A. General observations on Incidents reported to PNGRB · 16.Periodic fire and safety mock drills, regular training of operational staff for proper operating procedure and keeping

A. General observations on Incidents reported to PNGRB:

1. Air tightness test prior to gas charging, at suitable pressure, will remove chance

of incidents to a large extent.

2. The N2 cylinder and its source to be thoroughly verified and checked for purity

before using the same for purging activity.

3. Proper odourisation with periodic tests to be carried out at various defined

locations on the network and at network extreme ends to ensure minimum

acceptable level. There have been cases of fire which have resulted because of

inadequate or very less odourization.

4. Develop and communicate a procedure of positive isolation, by closing the

isolation valve upstream of regulator, opening of union downstream of

regulator and plugging the regulator downstream.

5. Gas supply to be started by opening of DRS valves after ensuring that there is

no leakage or trapped air/oxygen.

6. It needs to be ensured that there is no gas at the location and all electric

supply is stopped before excavating.

7. In order to effectively handle fire incidents, the entities having bulk storages of

inflammable hydrocarbons should ensure the following:

8. Periodic technical and safety audit of its facilities.

o Periodic review and approval of Disaster Management Plan and its

implementation including mock drills covering range of scenarios.

o Effective and monitorable Work Permit System so that work can take

place only with prior written permit allowing access only to persons,

tools and equipments authorised under the work permit to designated

work area. Work to be carried out only under authorised supervision.

o Periodic fire and safety trainings of all concerned.

o Entity to ensure adequate fire water reservoir/storage of its own with

sufficient quantity of water at all times along with automated fire water

spray/ sprinkling system/foam/CO2 flooding system so that such

emergency situations can be handled promptly and effectively.

o MOU with nearby industries including periodic joint mock drills involving

district administration.

9. There shall be an Emergency Vehicle fully equipped with all necessary tools,

tackles to handle fire and safety emergency with trained man power equipped

with proper communication gadgets on round the clock basis.

10. The periodic checks of “o‐rings” and other parts of CNG filling equipment and

system should be carried out by entities resulting in making the system safe.

11. Regular checking of electrical installation/facilities of CNG station.

12. Regular checking at CNG stations so as to ensure that CNG kit has been

properly maintained/ CNG cylinder hydro tested as due.

13. The safety disc should be replaced with a new one of appropriate quality after

every hydro‐testing of CNG cylinder.

14. The CGD entities may organize awareness camps/ free CNG kit checking by

trained technicians regularly on rotation basis at their CNG stations.

15. Safety awareness should be created among drivers of CNG vehicles

particularly auto drivers and commercial vehicle drivers.

16. Periodic fire and safety mock drills, regular training of operational staff for

proper operating procedure and keeping records of mock drills at the filling

station.

17. Wide circulation of incident investigation report together with lessons learnt to

all concerned including PNGRB.

18. Pipelines and other associated facilities to be installed in accordance to PNGRB

regulations/guidelines.

19. Educating the consumers at the time of commissioning and awareness

programmes at regular intervals. Regular leak checking and integrity check of

gas delivery system not only outside the premises/house but also pipe, meter,

rubber pipes etc installed inside the house/flat.

20. The entity is advised to conduct periodic tests/ audits as per ASTM standards

by engaging the services of a PNGRB approved third party

21. Approved on‐site/ offsite emergency plan should be available in office/control

room along with updated phone nos./ email/ fax nos. / Mobiles/ addresses of

relevant local authorities, hospitals, fire & safety, police, emergency services

etc.

22. Improvement in design and automation so that relevant monitoring

parameters can be checked and critical parameters/ facilities/instruments etc.

can be operated and controlled remotely, wherever feasible/necessary. Such

automation would be of help in situations like rampage/blockage by mob,

wherein it becomes difficult to reach the site quickly for safe isolation of

critical valves.

23. All the isolation points need to be easily accessible, periodically checked,

cleaned and maintained so that same can operate during any emergency

scenario.

24. Records of safety & technical briefings, before carrying out pre‐commissioning,

commissioning, repairs and maintenance are to be maintained. A checklist and

written procedures to be provided.

25. Proper approved format with all relevant check points to be in place for pre‐

commissioning, commissioning, operation and maintenance activities.

26. Suitable online alarm facility will be provided in SCADA system when significant

pressure change occurs at the valve station instrumentation.

27. A solar lantern to be provided in the station so that light is available in the

night in case of failure of power from the grid.

28. To ensure an orderly and timely decision‐making and response process in case

of any natural calamity.

29. Prepare a security threat plan and action plan to meet the eventualities in

reference to ERDMP regulations.

30. The identification of potential impact on downwind air quality or downstream

water quality from an incidental release and possible danger to human, Flora

and Fauna and animal health and evaluate the consequences of such

occurrences based on scenarios such as most probable and worst case events.

31. The zones and maps shall be prepared highlighting the Incident prone areas of

the unit so that in case of an emergency it serves as a basis for taking the

action. This indicates the size of the area within which human life is seriously

endangered by the consequences of incident. This should also indicate the

location of assembly points and emergency control rooms. The map should

also have marked 24 wind directions to facilitate easy access in case of

emergencies.

32. Wind speed and direction should be recorded with the help of anemometer

and declaration of off‐site emergencies should be immediately communicated

to DDMA.

B. Recommendations by entities:

a. General

1. Warning mat with anti rodent properties to be used for 20 mm PE lines.

2. Route selection for laying of the domestic 20 mm PE pipe shall be such that

sewage system is not very near.

3. Proper back filling and restoration (compaction) of the boring pit and ends

shall be done.

4. RCC guard proper fixing with sand padding shall be done.

5. All AMC contractors are checking domestic connection for any gas leakage

with MMT and with soap solution at TF joint.

6. Company approved guidelines for destructive testing of electro fusion joints

is issued.

7. Good quality Electro fusion weld joint shall be applied by certified welder.

8. LPT of the network and walk through survey for gas leakage detection shall

be carried out as per the planning.

9. Hot work permit must be issued for carrying out any work on charged

network and the work is to be carried out in the presence of skilled

/authorized supervisor.

10. To hold tool box talk before starting of any activity on charged network.

11. O & M team/patroller shall ensure removal of flammable waste near the

installation and back filling of pits if any on commissioned network to

prevent incidents.

12. Better coordination with Utilities for any excavation work near the pipeline.

13. Safety clinics should be organized in residential areas/society to make

people aware of Do’s and Don’ts w.r.t. gas installations and network.

b. In case of fire on PE line:

1. Proper cordoning shall be done near the incident area.

2. Close the respective PE network isolation valves.

3. Ask general public to remain away at safe distance.

4. Divert traffic of the nearby road if required with the help of traffic police.

5. If required take help of fire brigade for controlling the fire.

6. In case of fire incident on network/installation; information shall reach to

HSE dept‐HO and signed copy of the preliminary incident report shall

reach to HSE dept within 24 hrs.

7. Display location hazard with safety guideline.

8. Ensure to replace rupture disc during hydrotesting of CNG cylinders.

ANALYSIS OF INCIDENTS

S. NO. CAUSES OF INCIDENTS NO. OF

INCIDENTS

1. NATURAL CALAMITY 49

2. SAFETY MANAGEMENT AND AWARENESS ISSUES 1588

3. THIRD PARTY DAMAGE 2116

4. EQUIPMENT FAILURE 1058

5. GAS LEAKAGE (OTHER THAN THIRD PARTY) 480

TOTAL 5291

Incidents reported under Level-2/Level-3 (Apr 1, 2012 to March 31, 2013)

Sr. No.

Entity Location Date and time

Type of Incident Causes

1. IGL Mayur Vihar III 02.09.2012 (21.00 hrs)

LEVEL 3 / MAJOR (Fatal Incident)

Sabotage and Arsoning

NH‐24 CNG Station 20.10.2012 (19.45 hrs)

LEVEL 2 / MAJOR (Explosion)

Explosion in CNG fitted vehicle

2. GSPC GAS Arihant Petroleum and CNG Station, Navsari

06.09.2012 (23.43 hrs)

LEVEL 2 / MINOR Equipment Failure (Fire Incident)

Vapi 22.08.2012 (12.50 hrs)

LEVEL 2 / MINOR Third Party Damage (Gas Leakage)

Kandari CNG Station

03.07.2012 (22.40 hrs)

LEVEL 2 / MINOR Natural Calamity/Heavy wind

Navsari 01.07.2012 (13.20 hrs)

LEVEL 2 / MINOR Third Party Damage

3. CUGL Panchakki Chouraha, Kanpur

04.08.2012 (04.30 hrs)


DRS Design fault by vendor

Shastri Nagar, Kanpur

20.03.2013 (09.15 hrs)

LEVEL 3 / MAJOR (Direct loss 20‐25 lacs)

Pilferage/Sabotage (Gas Leakage and Fire)

4. GAIL Vijaipur 29.08.2012 (19.25 hrs)


Safety management and awareness issues at construction site

5. MGL Goregaon (E) 16.11.2012 (07.30 hrs)


Explosion in externally corroded CNG cylinder

6. GUJARAT GAS

Rampura, Surat 29.12.2012 (10.15 hrs)

LEVEL 2 / MAJOR (Fire about 30 minutes)

Suspected Damage to Gas network by Third party Utility company

7. IOCL Dabsar 04.12.2012 (10.15 hrs)

LEVEL 3 / MAJOR (Fire about 30 minutes and Fatal Incident)

Equipment Failure (Fire Incident)

Hazira 05.01.2013 (10.15 hrs)

LEVEL 3 / MAJOR (Fire and Fatal Incident)

Under investigation

1. Incident at Kanpur (CUGL)

Date of incident: 04.08.2012

Time: 04.30 PM

Entity: CUGL

Location: Panchakki Chouraha, near Mall road, Kanpur.

Description:

A fatal accident took place on 4th August 2012 at CUGL Kanpur, and a project officer died on the spot in the accident. The accident took place at underground DRS at paanchakki chouraha when downstream MDPE commissioning was undertaken on 4th August 2012 at 430 PM.

The underground DRS is provided by the vendor was single stream of capacity 5000 SCMH. The lid of the underground DRS cartridge blew away due to pressurization inside and hit the engineer on his face standing above ground on the side of the pit leading to the casualty.

It is learnt from the investigation that quarter inch outlet vent present inside the cartridge remained open prior to the charging and hence when inlet DRS valve was opened, gas after reduction of pressure from 19 to 4 kg/cm2 got released inside the upper half of the cartridge (which was not designed to handle any pressure) and due to the pressure of released gas the lid of cartridge busted into the pieces and blew away. It was collective failure of the,

Design of DRS,

• which did not have inherent fail safe mechanism to release such vented gases from the cartridge of DRS.

• which could not hold the released gas inside the cartridge. Same could have been designed to handle max pressure in the system.

Vendor’s commissioning team,

• who did not mention of any such requirement on the signed commissioning format provided by them.

CUGL commissioning team,

• who did not adhere to commissioning procedure including venting of the assembly before Gas charging.

Cause:

• DRS Design fault by Vendor: Not a FAILSAFE design.

• Deviation from adopted procedure.

• Unidentified hazardous operation & compromise towards safety by CUGL team. The safety engineer was not called before start of commissioning.

Recommendations: • To be taken up strongly with Vendor for faulty DRS design and to own them the

responsibility.

• DRS to be preferably relocated and replaced by twin stream above ground installation.

• System to be in place to ensure checklist points on commissioning format itself and its compliance.

• System to be in place to ensure use of PPEs • Role clarity and accountability should be fixed to avoid recurrence in future. • Provision of vent line to safer location should be a part of DRS inherent design. • DRS cartridge should be designed to hold max. Pressure in the system. • Necessary statuary approval/standards should be pre‐requisite before installation of

these systems. • Pressure gauges provided inside the cartridge should be with isolation valves. • All the PGs should be visible for noting daily readings without the opening of

cartridge lid. • Quarter inch vents provided inside cartridge should be with double isolation valves

(block and bleed). • Installation should be with properly designed foundations and pedestals.

2. Incident at Mayor Vihar III (IGL)


Time: 2100 hrs

Entity: IGL

Location: MAYUR VIHAR III

Description:

At 18:45 Hrs. media flashed news that a person died due to negligence of local police who have setup a barricade/ check post during a routine exercise on road going from Kalayanpuri to Mayur vihar‐1 via Chilla Village. At 19:00 Hrs. local mob from Chilla village attacked police personnel deployed at the police check post. At 19:30 Hrs. station staff was updated by a customer who came for refueling at IFC‐2 CNG station regarding civic disruption. The station was shut down as precautionary measures and information was given to Mktg & Control room. Due to heavy barricading, IGL staff was not able to reach the site, thus telephonic updates started between the station staff and IGL control room staff.

At 20:30 Hrs. mob from Khoda Village went on rampage, taking advantage of the incident & started looting the nearby market. At around 20:30 Hrs. on understanding the criticality of the situation, Station technician isolated all the manually operated gas valves. Meanwhile the station manager collected the cash from all DSMs and secured it in the safe. This activity was completed by 20:45 Hrs. At 21:00 Hrs, Delhi Police personnel asked the station staff to leave the station premises as the crowd started moving closer. Station staff left the IFC‐II station and gathered at IFC‐I CNG station, which is approx. 800 meters away. Few of them remained near the barricades to assess the situation and continuously informed about the sequence of events till the IGL teams reached IFC‐I.

Marketing officers of IGL managed to reach IFC‐I at around 2145. The mob even tried to damage station safe box at IFC‐II, which was carrying a two days cash of around Rs. 11 Lacs, but could not succeed. At around 22:30 Hrs. control room team, fire & safety team could manage to reach to IFC‐II CNG station to take the stock of situation. Simultaneously, Pipeline department managed to close isolation valves as a precautionary measure. At 01:00 Hrs on 3rd Sept’ 2012. after ensuring the complete isolation of the station equipments, the whole team left IFC‐II on

instruction of Delhi Police team as the mob was again approaching the station. The team gathered at IFC‐I CNG station and finally dispersed.

Cause:

• Pilferage/sabotage

• Lack of job knowledge/ awareness.

Recommendations: • Awareness among employees and contract workers by means of case study to be

taken up by respective control rooms for handling such emergency situations efficiently.

• Frequency of training/Drills on emergency handling should be increased. The information system should be improved so that response time can be minimized.

• Since, approach to site locations under such circumstances is difficult, possibility of automation may be explored for remote operations from control rooms.

3. Incident at Vijaipur (GAIL (INDIA) LIMITED)


Time: 19.25 Hrs

Entity: GAIL (INDIA) LIMITED

Location: Vijaipur

Description:

Construction of a New Raw Water Reservior for the C2C3 Recovery project was being undertaken. For the execution of the said job, a batching plant was erected by the contractor for concrete works.

On the particular day i.e. on 29th August 2012, the victim along with other 4 / 5 fellow workers was engaged for shifting the cement bags, cut open the bags and pour the cement into the Batching plant. At around 19:25 Hrs. after finishing his day’s work the victim came out of the cement go‐down and was trying to cross the road to join his fellow workers. While crossing the road he might have slipped, lost his balance and came under the front wheel of the Concrete loaded Transit Mixer.

Cause:

• Due to heavy rain, the approach road and incident area was very muddy and slippery.

• Victim was standing very close i.e. on the turning of the road.

• The driver may not have been able to clearly see the victim, who on the left hand side of the vehicle.

Recommendations by the entity: • More Training and Awareness programmes on Safety should be conducted which

includes all categories of workers.

• Tool box talks should be conducted by each and every contractor with their workers before they proceed on to the work.

• Supervision may be increased i.e. the no. of supervisors/ safety personnel may be increased considering the nature of the work at different areas.

• Proper housekeeping at site should be maintained by the respective contractors.

• Regular monitoring of area. Illumination at site may be checked and if required, additional lighting should be provided.

• The speed of the vehicles should be observed and non‐compliances should be penalized.

Recommendations by PNGRB: • Even temporary roads at construction sites should be properly compacted & blind/sharp turns need to be avoided.

• Effort should be made to create separate movement paths/ pavements need to be created for workers at construction sites.

• Proper barricading wherever required along with warning/ safety boards to be displayed at construction sites.

4. Incident at Kanpur (CUGL)


Time: 9.15 hrs

Entity: CUGL

Location: Shastri Nagar, Kanpur.

Description:

On 16th march 2013, a contractor started the digging work near to MDPE and Steel pipeline for water line laying.

Since then contractor was digging on intermittent timings (i.e., stopping and starting) hence patrolling team gave instructions to the contractor for informing them and as well CUGL room prior to any digging activity near to gas line.

20th March 2013

• 09:00 am The said contractor again started the digging activity however this time he did not inform to the patrolling team as well to the CUGL’s control room.

• 09:15 am Damage to 125 mm dia MDPE line occurred during the digging activity with JCB (excavator) for water line laying.

• Upon seeing the Gas Leakage Contactor called officer (O & M) about the incident.

• They rushed to the spot and on the way instructed a plumber to close the Isolation valves at the immediate upstream and downstream from the damaged point of MDPE pipeline.

• Isolation Valve Closing Sequence :

♦ 9:30 Isolation Valve of 125 mm dia MDPE line in front of KMC (downstream)

♦ 9:40 Isolation Valve of 125 mm dia MDPE line in front of Kakadeo (upstream)

♦ 9:45 Being the only industrial customer M/S Quality laminator was instructed not to use the gas till further instruction.

♦ 01:30 PM Damaged section repaired

♦ By the time repair work was over gas was totally consumed by the domestic customers from the entire 15 Km network in isolated section.

♦ 01:35 PM After the repairing it was decided to insert Nitrogen from Ranjeet Nagar area TF point at 2 kg to check the leakage of joints done to repair work and 125 mm dia valve located in front of KMC hospital was opened to allow the Nitrogen to fill in the empty network.

♦ After ensuring no leakage it was decided to push/purge the nitrogen/air out from various points preferably from the risers of the domestic connection at following strategic points:

Lajpat Nagar Area: Hayderabadi Biryani (Commercial Connection). Farthest domestic connections (Domestic Connection). Ram Misthan Bhandar (Commercial Connection)

Ranjeet Nagar: From the TF joint where nitrogen was inserted.

Shastri Nagar: Farthest TF point of Gulmohar Apartment II. Sindhi Colony (Domestic Connections). Quality Laminator (Industrial Connections)

To start the purging 125 mm dia valve was opened in front of Kakadeo Thana to start the gas flow.

Teams deployed were instructed to carry out Venting/purging activity at each point after removing the regulator and for atleast 5‐10 mnts.

After verifying the connections, CUGL team went to check the venting, the incident took place.

Cause:

• Pilferage/sabotage.

• Lack of job knowledge/ awareness.

• Third Party Damage.

• Auto‐ignition

Recommendations: • Needs to be explored by visiting various CGD’s for developing SOP for breakdown of

MDPE pipeline. Hence firth the main line shall be fitted with end cap and Valve and this end cap of the main line shall be cut off to ensure proper purging.

• Possibility of having a earthing system at the end caps and Couplers and Isolation valves to be explored. At the same time this can be checked up with fitting supplier as well as with other CGD’s.

• System of lock out and tag out needs to be developed for averting any tempering during any maintenance or breakdown activity.

• Separate Line walkers (patrolmen) for MDPE network shall be hired to keep a check on unauthorized digging/tempering from third party.

5. Incident at Goregaon (E) (MAHANAGAR GAS LIMITED)


Time: 07.30 Hrs

Entity: MAHANAGAR GAS LIMITED

Location: Goregaon (E)

Description:

A CNG cylinder of a Water tanker vehicle while filling gas at Bharat Coal tar pump, Goregaon (E) busted. During this explosion, it caused minor injuries to 2 pedestrians, who were discharged after giving first aid and 1pedestrian received severe injuries and later on died in hospital.

Cause:

• Externally corroded CNG cylinder.

• Under investigation.

6. Incident at Dabsar (IOCL)


Time: 1700 hrs

Entity: IOCL

Location: Loopline terminal near Dabsar.

Description:

Around 17:30 hrs, the Chief Operations Manager informed that the Main pumps at Viramgam station has tripped on High discharge pressure in the Mainline and the shift operation personal are restarting the pumps.

Such trippings are inbuilt protection systems which are incorporated in the Pipeline Operation Logics whereby any effect which is in deviation from the normal operation parameters of either the pipeline, or of equipments or the effect of proceeding or succeeding pipeline installation, is captured and pipeline operation are tripped.

Undersigned contacted Viramgam control room for updates. As telephone of control room was continuously engaged, undersigned immediately contacted Sidhpur control room for operation parameters. Sidhpur control room informed that the suction pressure (upstream pressure)at the station has drastically come down to Zero kg/cm2. Now, Viramgam Control room rang and told that the pumps were started and stopped immediately as discharge pressuire was not increasing beyond 12 kg/cm2

The Central Dispatch, the body that controls day‐to‐ day operation of all the pumping installation on round the clock basis, took the decision immediately to take shutdown of the entire section of the pipeline and closed Motor Operated Mainline Block valves, remotely through SCADA command.

Around 18:15 hrs, information was conveyed by the maintenance personal that one villager from Dabsar village has conveyed to our Mainline Maintenance personal who was staying at Mehsana that there was heavy spray and leakage of oil from the Loopline Terminal at Dabsar. And a person is rushing towards Dabsar from Mehsana.

At the same time the same message was conveyed by mobile informing that one more person is also rushing towards the installation as he was only a few kilometers from that place.

After about 10 minutes, got the information that a person could see heavy smoke emanating from Dabsar loop‐line terminal.

IOCL team headed by COM Viramgam, CISF crew, foam tenders, Maint crew rushed towards Dabsar.

The undersigned activated the DMP from the control room along with Dy. Manager and started informing to all the members/ Bodies as per DMP.

Site personal informed that the Disaster Management Authority took supervision and Control of the incident and fire fighting activity started at Site with Fire fighting personal from Kadi, Ahmedabad, ONGC, IOCL.

The fire was brought under control around 22:30 and doused by 23:00 hrs.

District Authorities shifted 3 persons who were injured to the Hospital by Ambulance.

Cause:


• 2 motorcycles on the village road in charred condition.

• Heap of dry grass as well as presence of unwanted dery agricultural waste/ babool tree etc at a distance.

7. Incident at Hazira Terminal (IOCL)


Time: 12:30 hrs

Entity: IOCL

Location: Hazira Terminal.

Description:

On 05.01.2013 around 12:30 PM there was a thud and the floating roof of MS tank No. 4 having approx. 5000 KL blown off.

This was followed by fire on tank.

Immediately Gujarat State Office, neighboring industries and the local administration was informed of the accident.

The auto fire fighting system available at location was operated immediately and the sprinklers started on adjacent tank No. 3 & 5 for cooling. The monitor also operated on Tank No. 4 was on fire.

There are total 9 vertical tank farm area with 5 tanks of MS (Petrol) in a row and 4 tanks containing two SKO and two HSD in another dyke.

The tank No. 1 of MS was empty and no product stored in the tank. However, other tanks of MS have contained product.

Immediately, the neighboring industries rendered help and they deputed their fire tenders with fire fighting teams.

The local administration also reported by 14:00 Hrs. the Factory Inspectors arrived at site and requested all neighboring industries i.e., KRIBHCO, RIL, ONGC, GAIL, L&T, Essar, Adani, BPC, HPC, etc. to extend their help.

The tank wagons placed on 05.01.2013 at siding were pulled by Railways/ONGC immediately and placed at Sachin station safely.

ONGC provided water connection for providing water at IOC Hazira Terminal.

The District Collector has been taking the feedback on the situation and visited site at around 19:00 Hrs.

The DIG of police and the Police Commissioner also visited the site and reviewed the situation. The necessary help was extended by Police Department to cordon off the area and to maintain law and order.

Two Ambulances were positioned at the site.

The tank roof has fallen immediately on the approach road from tank No. 4 towards tank No. 5 and made it difficult for the fire tenders to approach for the same.

The Collector immediately suggested for the alternative ways to approach tank No. 5, the adjacent tank to affected tank No. 4.

It was decided that the team of officials from M/s Reliance, M/s Essar and the team of IOCL’s Gujarat Refinery shall start for firefighting immediately and the other industries shall provide backup to them.

After the continuous fire fighting, the replenishment of water started after 5 Hrs.

Under the disaster management the water tankers from different Municipal Corporations of Surat, Vadodara, Ahmedabad, Navsari, Valsad and Daman etc. also arrived at the site. The fire tenders from the neighboring industries like ONGC, GAIL, KRIBHCO, Reliance, L&T, Adani, Essar, etc. had arrived and were participating in the fire fighting.

Tank No. 5 got affected due to winds unfavorable direction.

Around 2300 Hrs the wind started blowing towards the tank No. 3 which is adjacent to other side of affected tank.

The fire was fought with great courage and all the efforts were made to ensure that the adjacent tanks are cooled.

The water was also replenished in the fire water tanks and the water was used judiciously for cooling purpose.

There were approx. 40 Nos. of fire tenders reported. Two truckloads of foam was also brought from other location as back up to douse the fire.

The fire fighting operation continued for the whole night.

On 06.01.2013 around 0700 Hrs the intensity of fire reduced in tank No. 4 and by the time the tank was melted and was reduced to the height of approx. 4 Meter with one side reduced to approx. 1.5 Meter height.

The fire intensity was further reduced at about 0900 Hrs in tank No.4 reducing the risk of direct heat on tank No. 3 & 5

The visit was made on 06.01.2013 morning by the Hon. Petroleum Minister, Shri Veerappa Moily along with Chairman and Director (M) of IOCL with OISD dignitaries.

The situation was ascertained as under control.

The fire fighters approached to the tank No. 5 from the top and douse the fire around 1300 Hrs.

On visibility and approachability during the round, 3 bodies have been recovered.

The flare on tank No.3 & 5 doused completely. The fire is confined in tank No. 4 with smoke and the intermittent fire is on 06.01.2013.

One mobile in broken condition was found at tank farm area which is handed over to police on 06.01.2013.

The effort of Terminal In‐Charge and his team was appreciated by District Collector on making all efforts in averting catastrophic disaster.

Cause:


8. Incident at Dwarka (IGL)


Time: 13.00 Hrs

Entity: IGL

Location: Nuovo Apartment, Sec‐10, Dwarka.

Description: • It was admitted by the Engineer In Charge (of G.I. Riser Maintenance) that the job was being

done without any permission or prior intimation to any person in PNG Control Room, G.I. Riser maintenance incharge or his concerned TPI (Third Party Inspector). He also stated that there was no riser maintenance job lined up on dated 22.06.2013. Still the job was carried by the contractor team without intimation and any supervision. However he refused to give any statement in writing.

• Based on the discussion with bystanders at the incident site, it was informed that the incident happened as the rope that was being used by workers broke and the person who was working fell down on the ground and got injured.

• The injured was taken to hospital where he succumbed to injuries.

• The incharge of G.I. Riser maintenance stated that there were four members in the team (including the deceased) working on that day in Nuova apartment for Riser testing and Painting Job.

Observation:

• It was observed that the yellow paint was found spilled on the ground i.e. at the base of the riser and no paint work was found done on riser from top to bottom. This implies that the worker fell down almost from the top of the building, which was 9 storeyed, which was confirmed by the security guard on duty.

Cause: • Based on the available information from site visit, the apparent cause is Equipment (rope)

failure.

• Since the job of ‘painting of riser’ was taken up by the Contractor team without the knowledge/ permission of concerned C/R and TPI, hence the safety precautions, checking of safety equipments & PPE’s could not be done before starting the job, that resulted in use of unapproved/unhealthy safety gadget.

Immediate Actions/Remedial Measures: • Meeting of all contractors, their authorised supervisors was called and all were

instructed to ensure compliance of safety systems at all levels, failure of the same shall lead to strict action as per contractual terms. M/s Shanvi Construction (the contractor who was carrying out work at the aforesaid incident site) was asked to explain for such serious lapse in executing the work and action they are taking to avoid such recurrence.

• Checking of all the safety gadgets, tools & tackles in all areas is carried out.

• Refresher trainings, briefings, case studies, discussions is taken up in Control Rooms, to educate and sensitise the staff.

Recommendations by entity:

• For critical activities like working at high rise building, a Three Tier safety Work Permit System may be followed involving representatives of PNG Control Room/PMC/TPI, and Fire & Safety department.

• Certified Practical Training programs for Working at Height may be arranged for all working staff of PNG.

Documents

A. General observations on Incidents reported to PNGRB · 16.Periodic fire and safety mock drills, regular training of operational staff for proper operating procedure and keeping