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General Information:
Plant
Department
Location
Nature of Accident
Reportable (Fatal)
04/11/2012, 3.30 PM
Employee Information:
Name
Category
Contractors Employee
Designation
Electrician
Age
29 years
3.
Background Information:
a) Capital Repair of Hot Strip Mill was planned from 30th Oct. 12 to 9th Nov. 12.
Accordingly the Mill was under shutdown since 30th Oct. 12 from 3.00 PM
onwards.
b) During capital repair many jobs were undertaken in the Mill.
c) Replacement (Retrofitting) of circuit breakers was also planned in 03T 11,
415 Volts Sub-Station at () 11 mtr. level, in Motor Room # 5 of Hot Strip Mill.
d) As per Purchase Order No. P35/024/4510016704, Dated 19th Jan. 12, M/s
Deepak Enterprises, Chas, Jharkhand was awarded the work of supply and
complete retrofitting of General Electric (GE) make circuit breakers. M/s
Deepak Enterprises had deputed a group of six (06) persons to execute the
job.
e) On 29th Oct. 12, visitors gate pass was made and the crew members were
allowed to visit the site to take measurement. After taking the measurement of
the panels, the crew members returned back.
f) On 3rd Nov. 12, the crew members again entered the plant on visitors gate
pass and started the job. On that day, 1 no. circuit breaker was successfully
replaced by the crew. (Fig. 1)
g) On 4th Nov. 12 (Sunday), it was decided to replace another circuit breaker at () 11 mtr. in 45-L panel of Hot Strip Mill also and the job was started at 12 pm.
Before start of the job, job briefing was given to the crew members by the area
in charge wherein it was explained that Section-I was without power and
Section-II (i.e. adjacent panel) was live. Because from live panel (Section II)
was feeding power to EOT Cranes of Slabbing Mill. Accordingly front and
backside doors of live panel were kept in closed and locked condition.
h) It was reported that, at 3.30 PM, a flashover had occurred in the backside of
live (Section-II) panel during the job and Late Irfan got electrocuted. Other
crew members informed the concerned officials about the incidence. Late Irfan
was unconscious and his body was lying half inside the live panel. (Fig. 2 & 3)
i) Immediately electrical shut-down was given for Section-II and the victim was
removed from the panel. The victim succumbed to his injury at site.
5.
Observations:
Based on interactions at site and discussions held with concerned officials, the
following circumstantial facts were gathered:
a) Proper Safety Protocol was not prepared keeping the sequence of activities and
job wise responsibility in view.
b) On 25th Oct. 12, a letter was given by the representative of agency to the
executing deptt. for seeking permission for retrofitting of circuit breakers. He
had given a list of six expert/ trained persons who were deputed to execute the
job.
c) Accordingly, visitors gate pass was issued and all six persons were allowed to
work in the site.
d) Process for issue of gate pass for six persons was not routed through Safety
Engineering Department.
e) There is no system to impart Safety Induction training to the persons engaged
for the job on turnkey basis (material supply and installation), before issue of
gate pass.
f) It was informed that the same persons had already executed similar type of jobs
in other departments.
g) Required Safety information was not shared with the crew members during job
briefing before start of job.
h) Locking arrangement of the live panel was not foolproof, because the crew
members opened the lock of live panel to execute the job conveniently.
i) It was informed that it was not possible to give shut down to live panel, because
it was feeding power to Slabbing Mill and there was no alternate power supply
arrangement to Slabbing Mill EOT Cranes.
j) Proper insulation barriers were not provided between live and dead panels.
k) Proper supervision was not provided by the contractor as well as executing
department.
6.
No physical barriers
between live and
dead panels.
Inadequate supervision
completion of job.
7.
Victim
was
electrocuted.
till
Cause of Incidence:
(a) Protocol for the capital repair jobs during the shutdown period was available
but job wise responsibility was not mentioned in the protocol.
Injury
(b) Process for issue of gate pass for six persons was not routed through Safety
Engineering Department.
(c) There is no system to impart Safety Induction training to the persons engaged
for the job on turnkey basis (material supply and installation), before issue of
gate pass.
(d) Victim was not wearing insulated hand gloves while carrying out electrical job
though he had carried out similar jobs in other departments.
(e) Job briefing was given to the crew members by the concerned officials before
start of job.
(f) Locking arrangement of the live panel was not foolproof, because the crew
members opened the lock of live panel to execute the job conveniently.
(g) Proper insulated barriers were not provided between live and dead panels.
(h) Proper supervision was not provided by the contractor as well as executing
department.
9.
10.
(a) An internal committee was constituted to enquire the fatal accident. The
members of the committee are as under:-
11.
Islam Nagar
Jugsalai
P.O. Jugsalai
East Singhbhum
Jharkhand
Permanent Address
Islam Nagar
Jugsalai
P.O. Jugsalai
East Singhbhum
Jharkhand
(Suresh Kumar)
AGM (Safety)
SAIL Safety Organisation, Ranchi
Section I
(Under Shutdown)
Section II
(Live)
Section-I
(Under shutdown)
Circuit breaker
replacement was
being done here
Section II
(Live)
Flashover
marks
Section I
(Under
Shutdown)