ACCIDENT (INCIDENT) ANALYSIS

(INVESTIGATION REPORT)
Report No.: DGM (TPI-E)/A./2010/

Dt. 28-09-2010

Sub: Accident of Shri Hemrai, Sr.Tech. MRD

Type of Accident:
Reportable
Details of the Injured:
Name
: Shri Hemrai
Age
: 56
P.No.
: 140869
T.No.
: 32347
Designation: Sr. Tech.
Section
: Electrical

Date
: 28-09-2010
Shift
: A
Time
: 01:30 PM
Department: MRD
Location : Slag Processing Shop
DSO
: Shri B.S. Vashistha

Brief of the case (Accident/Incident):

Portable welding M/c connection job at Crane no.-3 at Slag Processing Shop was
assigned to Shri Hemrai. Circuit Breaker with 125A rating is mounted at incoming
side of the power pack panel, while Shri Hemrai was connecting portable welding
machine at the incoming side of the incoming CB of the power pack with the help of
screw driver, flashover occurred and the individual got super facial burn injury in
hands, neck & face. He was admitted at Main Hospital in the burnt unit.
During the investigation it was found that:
1. Heavy flash point found in incoming side of the CB in left & middle phase
terminals.
2. Both the lugs found in melted condition.
3. Screw driver found in melted condition.
As per the above findings, while connecting the leads of single phase portable
welding machine on the both incoming live terminals of CB with the help of screw
driver is the cause of flashover resulting in burn injury.
Immediate cause of Accident/Incident
Unsafe condition:
Unsafe Act:
1. Single phase load connected across 440V.
2. Supply taken from incoming of the CB.
Basic Causes of Accident/Incident:
Personal factors:
1. Lack of awareness
2. Carelessness
3. Lack of training
Job/System Factors:
Lack of Control:
1. Inadequate Systems & Procedures (SOPs/SMPs)
2. Lack of supervision / monitoring.

Recommendations:
1. Supply is never taken from incoming of the CB.
2. Awareness should be there for voltage level and their system before
connecting the leads.
3. Single phase to be taken from CB at outgoing side on OFF condition.
4. Proper supervision to be done.
5. Safety training should be given to individual.

(H.C. Chandniha)
Dy. Mgr.(TPI-E)
DGM(TPI-E)
AGM -Elect. (MRD)
CC:
1. DGM-I/C (EHT)
2. GM (E)