workshop on Understanding genesis of in-transit accidents, its mitigation measures & way forward 8-9 November 2019 Oil Industry Safety Directorate
workshop on
Understanding genesis of in-transit accidents, its mitigation measures &
way forward
8-9 November 2019
Oil Industry Safety Directorate
This presentation is for general informational and learning
purposes only and does not constitute or purport to render
advise. The views and opinions expressed in this presentation
are those of the author and do not necessarily represent official
policy or position. The material is intended, but not promised or
guaranteed to be current, complete or up-to-date. The author
assumes no responsibility for the content, accuracy or
completeness of the information presented.
Disclaimer
3
Our Job is to….
4
…….prevent this from happening
5
Our Job is to….
We work for you, with you, to make you more safeAUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
WE ADD SAFETY
In-transit Incident Statistics
.................Oil Industries-India
Oil Industry Safety Directorate
19 15 8 6 7
139
195
148
127
96
2014-15 2015-16 2016-17 2017-18 2018-19
TRANSPORT ACCIDENTS IN LAST FIVE YEARS
Transport (Fires) Transport (Accidents)
TRANSPORT ACCIDENTS
TRANSPORT FIRES
Oil industry Incident Statistics
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
0
20
40
60
80
100
120
140
160
180
2014-15 2015-16 2016-17 2017-18 2018-19
Transport Total IOCL 104 110 151 114 60
Transport Total BPCL 97 159 97 58 49
Transport Total HPCL 110 170 124 119 113
COMPANY WISE TRANSPORT INCIDENTS
Transport Total IOCL Transport Total BPCL Transport Total HPCL
IOCL
BPCL
HPCL
Incident Statistics
172
244224
164
12662
59
90 69
34
60
105
61 3227
50
80 73 63 65
2014-15 2015-16 2016-17 2017-18 2018-19
FATALITIES (TRANSPORT) IN LAST FIVE YEARS
Fatalities(Transport) IOCL BPCL HPCL
Incident Statistics
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
QUALITITIVE ANALYSIS
Oil Industry Safety Directorate
Qualitative Analysis
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
0
1
2
3
4
5
6
14-15 15-16 16-17 17-18 18-19
0.862068966
5.46875
1.282051282
0
0.970873786
Poor Road ConditionsFigures in %
Qualitative Analysis
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
0
5
10
15
14-15 15-16 16-17 17-18 18-19
4
13
6
3
6
Equipment failureFigures in %
Qualitative Analysis
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
0
10
20
30
40
14-15 15-16 16-17 17-18 18-19
Negligence by othersFigures in %
Qualitative Analysis
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
0
20
40
60
80
100
14-15 15-16 16-17 17-18 18-19
Negligence by TT driverFigures in %
QUALITATIVE ANALYSISOF IN-TRANSIT ACCIDENTS
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
0%
10%
20%
30%
40%
50%
60%
70%
80%
Negligence by TTdriver
Equipmentfailure
Natural Calamity Poor RoadConditions
Negligence byothers
QUALITATIVE ANALYSIS OF IN-TRANSIT ACCIDENTS
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
Negligence by TT driver65%Equipment failure
6%
Natural Calamity2%
Poor Road Conditions
2%
Negligence by others25%
Last Five years
Negligence by TT driver Equipment failure Natural Calamity Poor Road Conditions Negligence by others
90 % Negligence
Genesis and Mitigation
Oil Industry Safety Directorate
What is this Negligence?
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
ROAD ACCIDENTS IN INDIA – 2017Published by
TRANSPORT RESEARCH WINGMINISTRY OF ROAD TRANSPORT & HIGHWAYS,
GOVERNMENT OF INDIA ,
Published in July 2018
4,64,910 Accidents 1,47,913 Fatalities 4,70,975 Injuries
What is this Negligence?
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
Traffic rules violation %
accidents
%
Fatalities
%
injuries
Over-speeding 70.4 66.7 72.8
Driving on wrong side 6.3 6.4 6.4
Drunken driving/
consumption of alcohol &
drug
3.0 3.2 2.5
Use of mobile phone 1.8 2.1 1.7
Jumping red light 1.4 1.2 1.3
No violation & not known 17.1 20.3 15.3
ROAD ACCIDENTS IN INDIA – 2017 , GOVERNMENT OF INDIA ,MINISTRY OF ROAD TRANSPORT & HIGHWAYS,TRANSPORT RESEARCH WING-Published in July 2018
Why Over speed?
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
ROAD ACCIDENTS IN INDIA – 2017 , GOVERNMENT OF INDIA ,MINISTRY OF ROAD TRANSPORT & HIGHWAYS,TRANSPORT RESEARCH WING-Published in July 2018
74 % Accidents
due to Over speeding
Why Over speeding?
Are they gettingany direct/ indirectbenefit of overspeeding?
What makes the driver to drive fast? No. of tripsMorning Hrs.Benefit of low temperatureIs there any competition
MITIGATION
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
Tanker
• Design
• Licensing
• Maintenance
• Vehicle Tracking
• inspection
• Technical up gradation
Driver• Selection
• Training
• Motivation / Incentive Scheme
• Trip Monitoring
• Counseling
• Disciplinary measures
• Fatigue / sleepiness
Environment
• Driving safety Policy
• Roads
• Traffic density
• Weather
• Time of the day
• Parking location
Genesis and Mitigation
…………..Design/Safety features
Oil Industry Safety Directorate
Design & Safety features
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
The Petroleum (Amendment) rules, 2011. For POL tank trucks design OISD-RP-167 Pressure vessels for transportation of LPG -The Static and Mobile Pressure Vessels (Unfired) Rules 2016, IS: 2825, OISD-STD-159-LPG Tank Trucks - Requirements of Safety on Design / Fabrication and Fittings.
OISD-RP-157STANDARD FOR SAFETY IN TRANSPORTATION OF BULK PETROLEUM PRODUCTS
REAR CRASH GUARDSide guard for lateral protection
Design & Safety features
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
DESIGNThe Petroleum (Amendment) rules, 2011. For POL tank trucks design OISD-RP-167 Pressure vessels for transportation of LPG -The Static and Mobile Pressure Vessels (Unfired) Rules 2016, IS: 2825, OISD-STD-159-LPG Tank Trucks - Requirements of Safety on Design / Fabrication and Fittings.OISD-RP-157
STANDARD FOR SAFETY IN TRANSPORTATION OF BULK PETROLEUM PRODUCTS
Genesis and Mitigation
…………..Driver
Oil Industry Safety Directorate
What is this Negligence?
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
Training
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
Training
Outcome- Are we working on the root cause?
TRAINING-Emotional Quotient
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
पापा, धीरे चलाना गड्डी
Involve Family of TT crew in health check up ,safety
training
Sharing of Incident by Victim/family
member Video/live
TRAINING
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
1. DRIVING2. TRAFFIC RULES3. RISK INVOLVED4. EMERGENCY
• The properties of the material carried, • The handling method applicable • Use of the fire extinguishing
equipment • Emergency procedure to be followed.
• Safety measures against the Risk involved
• Fire extinguishing method/media
He should be aware of
Genesis and Mitigation
………….. Technology
Oil Industry Safety Directorate
MITIGATION-Technical Upgradation
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
Genesis and Mitigation
………….. Incentive and Punishment
Oil Industry Safety Directorate
Incentive and Punishment
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
Incentive and Punishment
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
Genesis and Mitigation
………….. Audit
Oil Industry Safety Directorate
Our Initiative
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
We audit and ensure …..
• Vehicle Tracking System(VTS)• Internal Valve with Excess Flow Check Valve
(IEFCV),• Rear & lateral under run protection in TTs,
• ‘Valve box’ & ‘Crash Guard’ to be provided forprotecting ‘valves / manifold
• Defining the size of parking area in LPG Plants,
• List of safety equipment to be carried by truckrevised to 20 from existing 5.
Way Forward
Oil Industry Safety DirectorateAUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
Way Forward
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
Strengthen the training mechanism
Behaviour base safety training
Ensuring healthy and safe life to drivers
Emotional touch in training
Unsafe behaviour of TT crew can result in….
The incident
Oil Industry Safety Directorate
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
FIRE INCIDENT AT
LPG PLANT IN
TANK TRUCK AT TANK LORRY DECANTATION FACILITY
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
Date & Time: 12th September, 2019 at about 10:23 hours
Location: Tank Truck (TT) at Tank Lorry Decantation Gantry
Injuries: Five persons reportedly received burn injuries and were admitted to thehospital.
Sequence:
1st batch of the LPG tank trucks were taken inside the plant on 12/09/2019 at07:00 hrs.
At around 10:00 hrs, 2nd batch of LPG tank trucks were allowed inside the plantfor the unloading operations.
The loaded LPG tank trucks are routed through Weigh Bridge for grossweighment and are positioned behind each bay awaiting their turn.
Tanker no. ‘A’ was positioned behind the TLD bay no: 02
THE INCIDENT
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
THE INCIDENT
Tanker no. ‘A’ was positioned behind the TLD bay no: 02
The driver of the truck then attached the male fittings on LPG liquid and LPG vapourpipeline manifold on the LPG tank truck.
In the meantime, TT no. ‘B’ and TT no. ‘C’ were placed behind bay no. 1 & 3respectively.
Similarly, loaded LPG TT’s were awaiting their turn by positioning behind the respectiveTLD bays undergoing fixing of liquid & vapour male fittings.
At 10:23 hrs, the driver of the tank truck no: ‘A’ (which is placed inside the TLD bay no:02, and connected to TLD LPG liquid and vapour LPG pipelines via unloading armsassociated with breakaway couplings) reverses the tank truck.
The unloading arms (liquid & vapour) are stretched to the maximum and rips the 2”threaded ball valve on the LPG liquid pipeline of the tank truck. Immediately liquid LPGfrom the tank truck starts to leak.
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
THE INCIDENT
Liquid LPG leak from the fully loaded tank truck enveloped whole of the TLD andadjacent area creating a thick white fog.
LPG vapours were seen travelling towards Motor Control Centre (MCC), DieselGenerator room, weigh bridge room, fire engine room and main gate.
Sprinkler in TLD was operated and dispersal of LPG using water monitors wasundertaken.
Around 10:50 hrs, the LPG vapour gets ignited which leads to Unconfined VapourCloud Explosion (UVCE).
The fire traced itself back towards the LPG source tank truck TT no: ‘A’ and started toburn with high intensity.
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
THE INCIDENT
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
THE INCIDENT
Bent Liquid LPG Breakaway Coupling inside TLD Bay: 02
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
THE INCIDENT
Damaged manifold valves of TT
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
THE INCIDENT
Sheared off LPG liquid manifold valve of TT
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
THE INCIDENT
The leaked TT which caused the incident
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
THE INCIDENT
Manifold valves & IEFCV’s of subject TT
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
THE INCIDENT
Internal EFCV of incident TT
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
THE INCIDENT
Internal Excess Flow Check Valve (IEFCV)
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
OBSERVATIONS
Operability of Breakaway Coupling
Breakaway coupling/ emergency release couplings which have beeninstalled in this Plant are not designed to release in backward/ reversedirection of the movement of the TT
Supervision of TLD
From the CCTV footage it is observed that the fitting of the unloadingarms and opening of the LPG valves from the TLD manifold LPGpipelines is done by the drivers and no intervention from the TLDoperators or supervision of officer.
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
OBSERVATIONS
Violation of SOP’s
a) Wheel chokes are not positioned.
b) Checking of integrity of the LPG arms connection.
c) The operator was not available at his work spot.
Breakaway coupling of the TLD unloading arm did not get activatedin reverse motion of the tank truck.
Failure of IEFCV operation of the TT due to the bending of internalshaft and housing of IEFCV.
Failure of shearing of IEFCV at the provided weak spot on the outervalve of the IEFCV.
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
RECOMMENDATIONS
Adherence to SOP’s for unloading operations by TLD
operators & drivers.
To ensure operators do not leave their work spot for any
reason unless the operation is completed.
To ensure Breakaway coupling mechanism works inboth directions.
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
QUESTIONS UNANSWERED
The identity of the person behind the wheel of the accidented TT couldnot be traced because of the lack of CCTV footage of TLD.
Since the affected TT was the 1st of the second lot to enter thepremises, why did the driver choose to park behind TLD bay: 02 andnot TLD bay: 01 or TLD bay: 08 (towards extreme ends).
Why did the driver move the vehicle after fixing the loading arms insideTLD.
Why the driver has not been traced, since he is the most criticalwitness in this particular incident.
58
AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD