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COMPILED BY

OFFICE OF THE ADDITIONAL DIRECTOR, INDUSTRIAL SAFETY & HEALTH,


PUNE












CASE STUDIES ON
INDUSTRIAL
ACCIDENTS







COMPILED BY
OFFICE OF THE ADDITIONAL DIRECTOR
INDUSTRIAL SAFETY AND HEALTH, PUNE

















































































Preface
We know that many stories of accidents, near-misses, and accidents waiting to happen go untold.
According to Henrichs Theory of Accidents, for every one reportable accident there are 29 non-reportable
accidents and 300 first aid cases. On analysis for the causes of accidents, he further states that cause are- 88
% accident due to unsafe act, 8 % accidents due to unsafe working conditions, 2 % each due to physical
deficiency and natural disaster. Thus, unsafe act and unsafe working conditions are the main causes of the
industrial accidents. As much as the next years promise to be exciting for the industry, they also pose a
great challenge to the industry to maintain workplace safety and health. We must address this perception
and change the reality. While workers are at work place, it is important that they do not risk life and limb. It
is crucial that these workers go home safely after work.
This compilation of case studies on fatalities and serious accidents in the industries is initiated and put
together by the Office of The Additional Directorate Industrial Safety & Health, Pune. This booklet depicts
how the accidents occurred and provides valuable learning points on how they may have been prevented.
This booklet of case studies offers insights to all in the industry on how these tragic accidents occurred, so
that we may glean important, lifesaving lessons from the experience. In learning from our past mistakes,
we can and must prevent these mishaps from happening again. Together with your help, we can transform
the factory into safe and healthy workplaces for our workers.
Some human errors appear to be completely random. However, most errors are not random but are
system induced or systemic errors caused by the unsafe system of work. The book will use case studies to
demonstrate how and why they have occurred and what could have been done to reduce their likelihood of
occurrence or the severity of their consequences. However, the objective of the book is not simply to
reproduce case studies of systemic errors that have led to serious accidents. Rather, it is intended to
identify common features in the accidents and the way they are investigated, so that lessons may be
learned to prevent similar accidents in the future. There is another aspect of blame, which needs to be
considered. In the immediate aftermath of a serious accident there is a natural tendency, especially by the
management, quickly to suggest a cause by quite often the words it is believed the accident was a result of
workers error are heard. The accident investigation does not accept human error as inevitable but goes on
to reveal the underlying reasons. Organizations of the industries should look too closely at the system
faults which caused the accidents. Further accidents of a similar nature will occur because the underlying
causes have not been corrected. Apart from the human cost of future accidents in terms of loss of life, injury
and trauma, the long term cost to the organization in loss of production, customers and reputation will far
exceed the cost of correcting a faulty system.
It is crucial both to the prevention of major accidents with multiple fatalities which make the headlines, as
well as to the host of minor accidents leading to injury and disability, which rarely make the headlines, but
still cause untold human suffering.
Accidents could occur due to various reasons. It is not possible to cover case studies on all the types of
causes. However efforts have been made to cover cases studies based on commonly used machines,
processes, activities. They cover a variety of issues, ranging from accidents at Engineering Industries to
chemical industries. The cases studies include accidents on the power press machines- Mechanical, Electro
pneumatic, Hydraulic, machines like-pressure die casting machine, bagasse bale braking machines, lathe
machines, etc. The case studies are based on the causes like non provisions of guards, lack of maintenance,
unsafe system of maintenance work, unsafe material handling, unsafe working at height, unsafe working in
confined space, unsafe method of pneumatic testing of coils of heat exchangers. It also covers the
incidences like collapse of cement silos, sliding gate, boiler chimney, explosion of the reaction vessel, curing
oven etc.
The book comprises a wide range of case studies from various industries in order to show how systemic
errors have in the past led to catastrophic accidents. The use of these case studies also enables the more
technical subject matter in the book to be better understood. In order to change the future, the lessons of
history need to be brought to bear on the present. This is why the book draws so heavily on what has
happened in the past in the hope that some of the terrible accidents referred to in the case studies may
never be repeated.
The case studies in this booklet are presented in a typical manner. It provides you the information about
how the accident occurred, what were the observations made by the investigating officer, what went wrong
and also suggests the remedial measures.
Through a series of case studies and the lessons drawn from them, you will:
* Probe the methods of failure by which most industrial accidents occur,
* Investigate common components of accidents,
* Explore a common-sense strategy for systematic industrial operations,
* Determine the purpose of operating limits and the safe operating envelope,
* Review how alert, well-trained operators are developed,
* Examine the importance of investigating abnormal events,
* Realize the worth of continuing training,
* Analyze a case study in implementing the systematic approach.
The intention is that the reader can use the book to select an appropriate accident analysis methodology to
suit their analysis needs, and then use the practical guidance and case study examples provided to see how
the method works and then apply the method effectively. These factual cases studies are investigated by
the officers of Directorate of Industrial Safety & Health. The success of this booklet will rely on every safety
professional if they study each case thoroughly and take effort to prevent the accidents and not to create
another case study in future.
I express my sincere gratitude to the officers and staff of my office who directly or indirectly helped in
compiling this book.
Thank you!

M.N.Gadappa
Additional Director
Industrial Safety & Health, Pune

INDEX
SR.NO. A CASE STUDY ON

COMPILED BY PAGE NO
1. Electro pneumatic Power Press Machine Shri.R.P.Khadamkar 01
2. Mechanical Power Press Machine Shri.A.B.Pawar 03
3. Hydraulic Power Press Machine Shri.V.M.Yadav 05
4. Power Press Machine- Unsafe system of work during
maintenance work
Shri.R.P.Khadamkar 07
5. Pressure Die Casting Machine Shri.R.D.Kichamabare 10
6. Rotary Vacuum Dryer Shri.J.B.Kumbhar 12
7. Bagasse bale breaking machine Shri.R.D.Kichamabare 14
8. Lathe Machine-Non use of tight fitting clothing Shri.R.P.Khadamkar 16
9. Lathe Machine-Unsafe system of work during maintenance
work
Shri.S.G.Giri 18
10. Material Handling-Use of improper lifting mechanism Shri.N.A.Deshmukh 20
11. Unsafe Material Handling Shri.S.G.Phadatare 23
12. Unsafe Material Handling in a Sugar Factory Shri.R.B.Lakhe 25
13. Working at height-Falling through fragile roof Shri.S.G.Giri 27
14. Falling from a Platform without Railing Shri.Y.P.Patange 29
15. Working in Confined Space-In a vessel at a Chemical
industry
Shri.J.B.Kumbhar 31
16. Working in Confined Space-In a tank at a Engineering
Industry
Shri.R.P.Khadamkar 33
17. Working in Confined Space -In a tank at Edible oil Industry Shri.R.D.Kichamabare 36
18. Falling in quenching tank containing hot water Shri.T.M.Kambale 38
19. Heat Exchanger-Unsafe system of work during pneumatic
testing
Shri.R.P.Khadamkar 41
20. Extrusion Machine-Use of a kerosene burner near the
trough containing a highly flammable solvent-toluene
Shri.A.B.Pawar 45
21. Explosion of the condenser coil Shri.P.V.Adkar 47
22. Chemical Industry-Unsafe system of work while handling Di
Methyl di Sulphide.
Shri.V.M.Yadav 48
23. Explosion of the Reaction Vessel Shri.P.V.Adkar 51
24. Minor Fire causing tragedy Shri.P.V.Adkar 53
25. Explosion in the curing oven Shri.P.V.Adkar 55
26. Collapse of cement silo at Ready Mix Concrete plant Shri.V.M.Yadav 56
27. Collapse of sliding gate of the shed of the factory Shri.R.P.Khadamkar 60
28. Prevention of fall of Boiler Chimney Shri.P.V.Adkar 63
29. Driving Fork Lift Shri.N.A.Deshmukh 65
30. Explosion due to Ammonia gas leakage in a cold room.

Shri.V.M.Yadav 66
31. Chlorine Gas Leakage-Successful Disaster Management

Shri.V.A.More 69
A Case Study On 1
1.SERIOUS ACCIDENT OCCURRED WHILE WORKING ON ELECTROPNEUMATIC
POWER PRESS MACHINE
Compiled By
R.P.Khadamkar
Deputy Director
Industrial Safety & Health, Pune
------------------------------------------------------------------------------------------------------------------------------
A serious accident had occurred to a worker while working on the Power Press Machine in the factory
premises.

ABOUT THE ACCIDENT:
The factory is involved in the manufacturing of
the various press components required for the
automobile industries. The manufacturing
process for the job Piller Side Wall involves
various operations on C.R. sheets like-drawing,
trimming, restriking, piercing etc. The drawing
operation is carried out on the 400 T power
press.
The said power press was having loading side,
from where the job was loaded for drawing
operation and unloading side from where the job
prepared, was taken out. On each side of the
machine i.e, loading and unloading side, there
was a push button station. Thus there were total
two no. of push button stations. Each push
button station was having two push buttons.
When all push buttons were pressed, the stroke
of the power press machine was getting
operated.
The injured worker was employed through the
contractor as Power Press Operators. On the day
of incidence, the injured worker along with a
co-worker was entrusted with the work on 400 T
Power Press machine in the factory premises for
carrying out the drawing operation of the job
Piller Side Wall. Accordingly they started the
said machine. For carrying out the said job, the
work involved was as under. The co-worker was
working on loading side of the machine and the
injured worker was working on unloading side
of the machine. The co-worker was loading the
job on the die of the machine through the
opening in the punch and die of the machine by
hands from loading side. Then both of them
were operating the push buttons of the
respective stations provided to them. With this
the punch was coming down and the job was
getting pressed between punch and die of the
machine and punch was going back to T.D.C.
(Top Dead Centre). After drawing operation, the
injured worker was removing the job by hands
from the die of the machine and keeping near
the machine. They prepared about 700 no. of
jobs in the above said manner. While the injured
worker was removing the next prepared job
from the die of the machine, the punch of the
machine suddenly came down, while his right
hand was still on the die. As a result, his right
hand was caught and crushed between the punch
and die of the machine. The accident resulted in
the amputation of his right hand at level of mid
forearm.

OBSERVATIONS:
It was a Power Press Machine of capacity 400T.
The main motor is of 3 phase, 440V, 60 H.P.,
1440 RPM. The upper die fixed to ram forms
the punch and the bottom die is fixed to the
table i.e. bed. The size of punch and the die top
was about 1600 mm x 930 mm. The maximum
POWER
PRESS M/C



distance between the punch and die was about
400 mm, when the punch was at TDC. The
distance of the die top from the ground level
was about 820 mm. The front and rear opening
of the machine was of size of about 2840 mm x
1050 mm. The left side and right side opening
of the machine was of size about 800 mm x
1400 mm. On each side of the machine i.e.
loading and unloading side, a push button
station was provided. Each push button station
was having two push buttons. The loading side
and unloading side and right, left side openings
of the machine are not found provided with a
photo sensitive guard or any other guard for
preventing access to the punch and die, while
the machine is in motion.
For carrying out the drawing operation
of job on the power press machine, a job is to be
kept on the die of the machine from the loading
side through the rear opening with hands. When
the stroke of the machine operates, the punch
comes down and the job gets pressed between
the punch and die of the machine. As a result,
drawing operation of the job takes place. Thus
due to design, location, function, reciprocating
action of the punch, the portion between punch
and die is dangerous zone and constitutes the
dangerous part of the machine, when the punch
is descending.





WHAT WENT WRONG: 2

The accident had occurred, while the injured
worker was removing the next prepared job
from the die of the machine. The punch of the
machine suddenly came down, while his right
hand was still on the die. As a result, his right
hand was caught and crushed between the punch
and die of the machine. He was seriously
injured. Thus, there was access to the dangerous
parts of the machine, while the machine was in
motion. The above said dangerous part of the
machine ought to have been securely fenced by
providing an interlocking photo sensitive
safeguard to prevent access for any part of body
to it from all sides of the machine, while the
machine is in motion and also the safeguard for
securely fencing of the above said dangerous
part ought to have been constantly maintained to
prevent access to the dangerous part, for each
worker working on the machine. But the front
opening (unloading side), the rear opening
(loading side) and side openings of the machine
were not provided with any safeguard for
preventing access to the above said dangerous
part of the machine, while the machine was in
motion.

REMEDIAL MEASURES:
i) The dangerous zone between punch and die of
power press machine shall be securely fenced
from all sides by interlocking safeguard and
prevent access of any part of body and the
safeguard shall constantly maintained and kept
in position while the punch is in motion.

DANGEROUS
ZONE
DANGEROUS ZONE
ACCESSIBLE FROM
REAR SIDE
A Case Study On 3
2.SERIOUS ACCIDENT OCCURRED WHILE WORKING ON MECHANICAL POWER PRESS M/C
Compiled By
A.B.Pawar
Deputy Director
Industrial Safety & Health, Pune

------------------------------------------------------------------------------------------------------------------------------
A serious accident had occurred to a worker while working on the Power Press Machine in the factory
premises.

ABOUT INCIDENCE:
The factory is involved in the manufacturing of
the various press components required for
automobiles. The manufacturing process
involved various operations on s.s. sheet like,
blanking, forming, etc. The injured worker was
employed as a helper. On the day of incidence,
he was entrusted with the work on 150 T Power
Press Machine for carrying out the forming
operation. Accordingly he started the said 150T
Power Press M/C. For carrying out the said job,
the work involved was as under. He was
keeping the piece of s.s. sheet on the die of the
machine through the front opening of the power
press machine by his right hand. Then he was
operating the stroke of the machine by pressing
the foot pedal switch provided at the front side
of the machine. With this the punch was coming
down and the s.s. sheet was getting pressed
between punch and die of the machine and
punch was going back to T.D.C. (Top Dead
Centre). He was taking out the prepared job by
his left hand through the front opening. Then he
was again keeping another s.s. sheet for next job
and the process was repeated.
While he was keeping next job on the
die of the machine through the front opening,
the foot pedal switch got pressed by his foot,
unknowingly and the stroke of the machine got
operated. With this the punch of the machine
came down and his right hand was caught and
crushed between the punch and die of the
machine. He was seriously injured. The accident
has resulted in the amputation of the two
phalanges of the fore finger and middle finger
and part of the first phalange of the ring finger
of his right hand.

OBSERVATIONS:

I
It was 150T mechanical Power Press machine.
The punch was fixed to ram and the die was
fixed to the bottom table. The size of table was
about 600 mm length x 730 mm breadth. The
die was cylindrical having size of about 200 mm
dia x 140 mm height. The maximum distance
between the punch and die was about 120 mm,
when the punch was at TDC. The machine is
provided with the foot pedal switch at height
170 mm from the ground level.
For carrying out the operation for job on the
power press machine, a job was to be kept on
POWER
PRESS M/C
DANGEROUS
ZONE


For carrying out the operation for job on the
power press machine, a job was to be kept on
the die of the machine through the front opening
with hands. When operator presses the foot
pedal switch, the stroke of the machine operates.
As a result the punch comes down and the job
gets pressed between the punch and the die of
the machine, to form the required shape and
size. Then the punch goes up to the T.D.C. (Top
Dead Centre) and the prepared job is removed
from the die of the machine through the front
opening by hands.
Thus due to design, location, function,
reciprocating action of the punch, the portion
between punch and die is the dangerous zone
and constitutes the dangerous part of the
machine, when the punch is descending.

WHAT WENT WRONG?


4
The accident had occurred, while the said
worker was keeping the next job on die of the
machine by right hand. The stroke of the
machine got operated, while his right hand was
between the punch and the die of the machine.
Thus there was access to the dangerous part of
the machine, while the machine was in motion.
The above said dangerous part of the machine
ought to have been securely fenced by providing
interlocking safeguard of substantial
construction to prevent access for any part of
body to it, while the machine is in motion. But
the above said dangerous part of the machine
was not securely fenced by providing with any
safeguard to prevent access to it, while the
machine was in motion.

REMEDIAL MEASURES:
The dangerous zone between punch and die of
power press machine shall be securely fenced
by interlocking safeguard and prevent access of
any part of body and the safeguard shall
constantly maintained and kept in position while
the punch is in motion.














NO SECURE
FENCING TO
DANGEROUS
PART
A Case Study On 5
3.SERIOUS ACCIDENT OCCURRED WHILE WORKING ON HYDRAULIC POWER PRESS M/C
Compiled By
V.M. Yadav
Deputy Director
Industrial Safety & Health, Pune
------------------------------------------------------------------------------------------------------------------------------
A serious accident occurred to a worker, while working on the hydraulic power press machine in the
factory premises.

HISTORY:
The factory was involved in the manufacturing
of wheels required for cars, heavy motor
vehicles. In the plant there were rim line, disc
line and assembly line. The rims were
manufactured on the rim line and the discs were
manufactured on the disc line. The rims were
fed one by one to the inlet conveyor of the
hydraulic power press machine in the assembly
line. The discs were kept on the rim at the inlet
conveyor manually. Then the rim with disc was
fed to the hydraulic power press machine by
inlet roller conveyor. The hydraulic power press
machine was operated to press rim and disc
together to form a wheel.


ABOUT THE ACCIDENT:
The injured worker was employed through the
contractor and was working as an Operator. On
the day of incidence, the injured worker along
with other worker was entrusted with the work
on assembly line for manufacturing of wheels.

Accordingly they started the 30 T Hydraulic
Power Press Machine in the assembly line. The
Hydraulic Power Press Machine was having
parts like-a ram, a fixture, die tool, control
system etc. A fixture was fixed to the ram
provided at the bottom to form a punch, while a
tool was fixed at the top to form a die. The
punch was hydraulically operated. An inlet
conveyor was provided at the left side for
feeding rim and disc to the press machine. An
outlet conveyor was provided at the right side of
the press machine. For carrying out the said job,
the work involved was as under. A rim from the
rim line was fed to the inlet conveyor of the
press machine. The injured worker was keeping
a disc received from the disc line, on the rim
manually. Then other worker was operating the
machine from control panel to push rim along
with disc on the fixture inside the hydraulic
power press machine. Then he was operating the
press machine from the control panel. With this
the rim along with the disc was moving upwards
by the ram of the machine and the rim and disc
were getting pressed in between the tool (die)
and the ram (punch) to form the wheel. The ram
along with wheel was moving downwards
again. The wheel was then fed to the next
station for welding operation, by outlet
conveyor. The process was being repeated for
the next job again. They prepared about 300
such jobs in the above said manner. For next
job, the rim along with disc was pushed on the
fixture inside the hydraulic power press
machine. But, the injured worker felt that the
disc was not properly located on the rim. So, he
put his right hand on the disc through the front
opening of the machine to check and to confirm
it. By that time the other worker, who was
unaware about this, operated the hydraulic
power press machine from the control panel.
With this, the ram (punch) along with the rim
DANGEROUS
ZONE
HYDRAULIC POWER
PRESS MACHINE


power press machine from the control panel.
With this, the ram (punch) along with the rim
and the disc moved upward and the right hand
of the worker was caught and crushed between
the die tool and the job (disc on the rim). The
accident resulted into the amputation of two
phalanges of first finger and amputation of the
middle finger, ring finger and little finger of his
right hand completely.

OBSERVATIONS:
It was 30 T Hydraulic Press machine. The tool
of size 400 mm diameter fixed to the upper
portion formed the die and the fixture fixed to
the ram formed the punch. The rim together
with the disc formed the job wheel. The size of
the wheel was about 400 mm diameter x 160
mm height. The height of the fixture fitted to the
ram was about 1300 mm from the floor level.
The height of the disc of the wheel from the
floor was about 1460 mm. The distance between
the wheel top (disc) and the upper die tool was
about 150 mm. The size of the front opening
was about 550 mm x 700 mm. The ram was
operated by the hydraulic pressure of about 100
bars. For carrying out the said operation on
the 30 T hydraulic power press machine, a rim
and disc were to be kept on the fixture fixed to
the ram of the machine. The worker had to
check whether the disc is located properly on
the rim. When the auto cycle was started, the
punch along with the rim and disc moved up
and the job (the rim and disc) got pressed
between the punch and die tool to form a wheel.
Thus due to design, location, function,
reciprocating action of the punch, the portion
between punch (ram) and die (tool) was
dangerous zone and constituted the dangerous
parts of the machine, when the machine was in
motion.
6
WHAT WENT WRONG:

The accident to the worker, while he was
checking alignment of the disc on the rim by
keeping his right hand inside the job wheel and
tool die of the machine. Thus there was access
to the dangerous part of the machine, while the
machine was in motion. The above said
dangerous part of the machine ought to have
been securely fenced by providing interlocking
safeguard of substantial construction to prevent
access for any part of body to it, while the
machine was in motion. But the above said
dangerous part of the machine was not securely
fenced by providing with safeguard to prevent
access to it.

REMEDIAL MEASURES SUGGESTED:
The dangerous parts of hydraulic power press
machine shall be securely fenced by an
interlocking safeguard to prevent access for any
part of body to it, while the machine is in
motion.








NO
PHOTOSENSITIVE
GUARD
A Case Study On 7
4.A FATAL ACCIDENT WHILE REMOVING CLUTCH ASSEMBLY OF POWER PRESS M/C
DURING MAINTENECE
Compiled By
R.P.Khadamkar
Deputy Director
Industrial Safety & Health, Pune
------------------------------------------------------------------------------------------------------------------------------

A fatal accident had occurred due to unsafe system of work, lack of training, lack of instructions,
while carrying out maintenance of the 150 T Power Press Machine in the factory.

CONSTRUCTION OF CLUTCH:



The manufacturing process in a factory
involved use of an electro pneumatically
clutch operated 150 T Power Press Machine.
The machine had main parts like ram, bottom
table, power transmission system, electro
pneumatic friction clutch and brake unit,
pneumatic control system, electric control
panel etc. The clutch was air operated and
mechanically interlocked brake unit. When
clutch was engaged, the brake disengaged and
when clutch was disengaged, the brake got
applied automatically. The construction of the
electro pneumatic friction clutch and brake
unit was as follows. The clutch assembly was
mounted on the shaft and consisted a cylinder,
piston, inner disc, outer disc, brake facing
plate, clutch facing plate and brake holding
plate etc. The inner disc along with hub was
mounted on the shaft close to the flywheel.
The inner disc was provided with 18 no. of
guides located in circular position. High
tension springs were placed on each guide.
The piston and cylinder were mounted on the
shaft and fitted to a hub by using 8 no. of allen
bolts, such that the springs got compressed
between the back of piston and inner disc. The
clutch facing plate was mounted close to the
inner disc and brake facing plate was mounted
close to the outer disc. When stroke of the
machine was operated, the piston moves
forward by air pressure against the spring
tension causing brake to release and clutch to
engage. At the end of stroke the air pressure
releases and the piston comes back to its
original position due to spring tension. Thus,
under normal condition, when the clutch was
disengaged, the springs remain in compressed
state. A brake holding plate was fitted after the
clutch and brake unit. The check nuts are
provided outside the brake holding plate at the
end of the shaft.

ABOUT THE ACCIDENT:

WORKER HIT
BY CLUTCH
ASSEMBLY
POWER PRESS M/C
CLUTCH ASSEMBLY
8
incidence taking place, a problem of stroke
slipping on the said Power Press Machine was
reported. On examination, the Maintenance
contractor found that the gap between the
clutch facing plates increased due to wear and
tear of liners (brake, clutch facing segments).
As per his instructions, the brake/clutch facing
plate were removed and sent for replacing the
liners. On the day of incidence, it was decided
to carry out maintenance of the clutch
assembly of the 150 T Power Press Machine
so as to keep the clutch assembly ready,
before the brake/clutch facing plate was
received back. The Maintenance Supervisor
told the deceased worker to help him in
carrying out the maintenance work. He
initially removed air supply line, rotor seal
and solenoid valve. He brought a table near
the machine and removed the check nuts of
the clutch assembly by standing on the table.
Then he removed one allen bolt out of 8 no. of
allen bolts of the clutch assembly. Before he
opened the second bolt, he went to the
maintenance office for attending the phone
call. By that time, the deceased worker
climbed up the table for removing the allen
bolts.


While opening the allen bolt, the clutch
assembly got dissembled and the cylinder,
piston came out speedily and hit against his
chest and he fell down from the table. He was
seriously injured and died on the spot.

OBSERVATIONS:
The clutch assembly included a cylinder,
piston, inner disc, outer disc, brake facing


plate, clutch facing plate and brake holding
plate etc. The cylinder and piston were of cast
iron and weight about 40 Kg each. Out of 8
no. of allen bolts (size M16 x 66.6 mm
length), 6 no. of bolts are found in broken
condition. Out of 18 no. of high tension
springs (size 42.9 mm O.D. x 29 mm I.D. x
96.8 mm length), 4 no. of springs are found
broken and one spring damaged. The cylinder,
piston, springs, allen bolts are found lying on
the floor. Under normal condition, when the
clutch is disengaged, the springs remain in
compressed state and hold the cylinder and
piston close together by spring tension.

WHAT WENT WRONG?

The brake and clutch facing segments (liners)
got worn out and the gap between the clutch
facing plate increased due to excessive use of
the machine. As the machine was continued to
use with the excessive gap, out of 8 no. of
allen bolts, 6 no. of the allen bolts broke,
which remained inside the assembly. After
removing one allen bolt, the deceased worker
was removing the coincidently the remaining
allen bolt. As soon as he removed the allen
bolt, the spring tension released suddenly.
With this, the clutch assembly got dissembled
and the cylinder, piston of the clutch assembly
came out speedily and hit against the chest of
the said worker. As a result he was seriously
injured and succumbed to injuries.

It is revealed that-
i)Before opening the clutch assembly, tension
of the H.T. springs was not released by using a
puller or any other tension releasing

BROKEN
ALLEN BOLTS
BROKEN
SPRINGS

CYLINDER PISTON

arrangement and it was not ensured that
tension of the spring was released.
ii)At the time of accident the clutch assembly
was being dismantled on the machine itself
without removing it from the shaft.
iii)The machine was not maintained by timely
replacing the clutch, brake facing, without
allowing the gap between facings and discs to
increase excessively. The machine was
continued to use with the excessive gap,
causing 6 no. of the allen bolts to break. Thus
the systems of work were not safe.
iv)The precautionary notice showing
information and instructions in respect of
9
dismantling of the clutch were not displayed
near the machine. Also training about safe
system of dismantling the clutch was not
given to the workers to ensure safety.

REMEDIAL MEASURES SUGGESTED:

i) While carrying out dismantling of the
clutch, tension of the springs shall be released
by using puller and it shall be ensured that the
springs are in normal state.
ii)Only trained workers shall be required and
allowed to carry out such type of work.









































A Case Study On 10
5. SERIOUS ACCIDENT WHILE WORKING ON PRESSURE DIE CASTING MACHINE
By
R.D.Kichambare
Former Joint Director
Industrial Safety & Health

------------------------------------------------------------------------------------------------------------------------------

Accident Type: Caught Between
Type of Industry: Engineering
Size of work Crew: 4/600
Work Site Inspection Conducted: Yes
Designated competent Person on Site: No
Employer Safety and Health Programme: No
Training and Education for Employees: No
Craft/Type of Deceased Employee: Unskilled
Age and Sex: 19, Male
Time on the Job: A month
Time on the Task: 6 Hrs

Description of the Accident:
In a factory involved in manufacturing
Aluminum castings for automobile industry, a
worker working on one of the several Pressure
Die Casting Machines (PDCM), was crushed to
death. In the said factory there were several
PCDMs. One of them was of 800 MT capacity.
The cylinder heads were manufactured on this
machine. The machine had two large platens of
size about one square meter, carrying molds on
it. One on them was mounted on the tail stock, a
reciprocating die carrier of the machine and the
other was mounted on head stock of the
machine, a stationary die holder of the machine.
There was an interlocked guard on the machine
consisting of two cages made out of wire mesh.
One of the cages was a fixed one fencing the
moving parts of the tailstock of the machine.
The other was a reciprocating telescopic type.


The process involved,
inserting loose cores in to the die on the
tail stock,
spray the dies with a special kind of oils
for easy removal of the castings,
insert a loose sleeve on the die mounted
on the headstock of the machine,
pouring a molten aluminum metal into
the hopper of the injection cylinder of
the machine,
pull the reciprocating telescopic guard
to cover the open space into which the
die holding reciprocating tailstock
would move to close the dies, and set
the machine ready for injection,
operate two interlock switches ( push
buttons )on the body of the machine,
and actuate the injection operation,




11
The operation of two switches would actuate the
tail stock of the machine to move forward to
close the dies and the molten metal would then
get injected automatically in the die cavities.
After the injection of the molten was complete,
following was the sequence of the operation of
the machine.
The reciprocating tailstock of the
machine would automatically traverse
back into its earlier position,
Open the reciprocating guard on the
machine manually,
Remove the castings from the machine,
remove the loose cores from the
castings, and keep them into trolley for
further machining operations,
set the machine for the next cycle,
The cycle for the described sequence of
operations was of about 3 minutes. The closing
of dies would take hardly 5 seconds, after the
guard was set in its place. Four workers were
involved into the manufacturing of the
Aluminum Castings in the manner prescribed
above. Three of them were on one side of the
machine on which a control panel was installed,
on the pillar of the headstock of the machine
and another worker, a forth one was required to
work on the opposite side of the machine. One
of the three workers was the main machine
operator. His job was to spray the oil mist on the
dies when they were ready for closing and
injection, pour the molten metal into the
injection cylinder of the machine, operated two
interlock switches on the machine, to actuate the
closing of the molds, followed by injection. The
second would put the loose cores into the die
cavities, and the third worker would help
transfer the casting into the trolley, after it was
taken out. The job of worker on the opposite
side of the machine was to keep the loose sleeve
on the die, mounted on the headstock of the
machine.
On the fateful day, the sliding portion of the
interlocking guard (front gate) was not
functional, and the machine was being operated






without using the front gate of the guard. It
resulted in dies closing even before the sliding
portion of the interlocking guard was pulled
over to cover the opening into which the
tailstock-die would move. The activity of
manufacture had been going on this fashion for
over two hours, with proper coordination
amongst all four workers. At one stage, when
the main machine operator was about to actuate
the two interlock switches on the control panel,
the forth worker on the other side of the
machine noticed that the loose sleeve he had
kept on the die mounted on the head stock had
moved little away from its position. He
therefore, leaned into the opening between the
dies, and tried to set it right into its position.
However meantime, unaware of what the
worker on the side of the machine was doing,
the main machine operator pushed the two
switches on the control panel of the machine,
for closing dies for injection. As the tailstock
moved forward to close the dies for injection,
the worker on the other side of the machine,
who was leaning into the opening between the
dies to set the loose sleeve right into its position,
was caught with his upper portion of his body
between the moving tailstock and the headstock,
of the Pressure Die Casting Machine, and was
crushed to death on the spot.

Accident Prevention Measures:
An electrical interlock arrangement shall
be provided so that the molds cannot be
closed unless front safety gate is fully
closed and on opening the front safety
gate, the molds would stop
automatically,
A hydraulic safety shall be incorporated
with the front safety gate such that it will
prevent the tailstock mold plate forward,
on opening of the front safety gate,
The interlock arrangement so provided
shall be maintained in effective working
condition.








12
A Case Study On
6. SERIOUS ACCIDENT WHILE WORKING ON A ROTARY VACUUM DRIER.
Compiled By
J.B.Kumbhar
Deputy Director
Industrial Safety & Health, Pune
------------------------------------------------------------------------------------------------------------------------------
Serious accident took place in bulk drug manufacturing factory. One of the supervisor having
qualification B.Sc. & Diploma in Industrial Safety, and employed as Production Officer met with an
serious accident while he was working on Rotary Vacuum Drier (here after called as drier).
ABOUT THE ACCIDENT: --
On the date of accident, the work of draining out
Sodium Salicylate slurry from the drier was in
progress and two workers were working in this
area. At about 6.30 pm, it was noticed by two
workers working on drier that Sodium Salicylate
slurry in the drier had become thick and due to
this drain valve was choked up. They tried to
dilute slurry by circulating steam through drain
valve jacket but it was of no use. So, these two
workers requested IP to remove this choke up
by showering water in side the drier. So, IP
went on the drier platform and started
showering water in side the drier through its top
opening with the help of inch plastic pipe. At
that time, his right hand thumb came in contact
with the rotating blades (plates) of the stirrer
and it was caught & pulled in the gap between
the blades and the inner surface of the drier
body. This resulted in the on the spot
amputation of his right hand palm up to wrist.
He immediately rushed down to the ground
floor and requested other two workers to call for
vehicle. He then ran up to 100 m towards the
office. From there he was taken to local
hospital. He was given first aid and as per the
advice of local Dr., he was shifted to orthopedic
specialist for further treatment. His amputed
right hand palm was brought to hospital by
another vehicle at about 11 pm. It was checked
by Doctors and after examining the amputed
palm, it was concluded by doctors that it was
not possible to in plant the amputed part of his
right hand. This accident has resulted in to
amputation of right hand palm up to wrist.

OBSERVATIONS:- The said drier on which
the IP met with an accident is located in Sodium
Salicylate department. This drier is on the
platform and there is one centrifuge on the
ground floor adjacent to the platform. There is
1005 x 195 mm opening provided on the top of
this drier. Height of this top surface of this
opening from the working platform floor is 940
mm. There is one stirrer (shaft) fitted in side this
drier and it is connected to 10 HP,(1440 rpm )
electric motor through reduction gear box. On
this stirrer, blades (metallic plates) are fitted
alternatively. The minimum gap between the
inner surface of the drier body and the outer
diameter of stirrer plates is 5 mm. These stirrer
plates rotate in clockwise direction and its rpm
is 7. Depth of the rotating stirrer blades from the
top surface of the top opening is 150 mm. Body
of this drier is a jacketed vessel for circulation
of steam. On the bottom side of this drier, there
is one 4 inch drain valve. This drain valve is
also provided with arrangement for circulating
steam around it. One hose pipe is connected to
this drain valve and the other end of this hose
pipe is connected to centrifuge. This drier is
used to remove excess water from the Sodium
Salicylate solution. For this, Sodium Salicylate
solution is charged in to this drier by pipe line
and it is heated by circulating steam through the

jackets and simultaneously stirring/blending is
done. Then the slurry of the Sodium Salicylate
is drained out in to centrifuge through drain
valve by gravity.
WHAT WENT WRONG:- On this stirrer,
blades (metallic plates) are fitted alternatively
inside the drier body.. The minimum gap
between the inner surface of the drier body and
the outer diameter of stirrer plates is 5 mm.
These stirrer plates rotate in clockwise direction
with 7 rpm. Depth of the rotating stirrer blades
from the top surface of the top opening is 150
mm. It was essential to provide suitable inter

13
locking arrangement to the top lid of the drier so
that the drier will not start when the lid is open.
However, during inquiry with the IP, it was
revealed that there was no lid provided to the
top opening of the drier, when he met with an
accident.
REMEDIAL MEASURES: In order to avoid
such type of accidents in future, it was
recommended to provide suitable interlocking
arrangement to the top lid of the drier so that the
drier will not start when the top lid is open and
it will stop automatically if the top lid is opened
when stirrer is in motion.




A Case Study On 14
7. A Worker Gets Ripped to Death

By
R.D.Kichambare
Former Joint Director
Industrial Safety & Health
------------------------------------------------------------------------------------------------------------------------------
In a Sugar Factory, a worker got ripped to death while working on Bagasse Bale Breaking Machine.

Background:
A bagasse is, a left over sugar cane body, after
juice is totally extracted from it, in the process
of Manufacture of Sugar. The bagasse, is thus a
by-product of Sugar Factories. Every year,
several tonnes of bagasse is generated in Sugar
Factories. The storage of bagasse in loose form
is a great problem for the factories. It is
therefore, compacted into bales, on Bagasse
Baling Machines, while it is still moist.
Normally, the bales are of 1'x1'x1' ( one cubic
feet )size. After the bails are compacted on
Baling Machines, they are bound by steel cross
wires, in order that the bales do not easily open.
These bales are stacked in pyramid form, in
open in the Sugar factory compound, to be used
as a Boiler fuel, for the next Sugar Cane
crushing season of the factory.
For using the bagasse from these bales as a fuel
for boiler, it becomes necessary to remove the
steel wires on the bales and break the bales into
loose bagasse, in order
to ensure the efficient combustion of the
bagasse. This is done on Bagasse Bale Breaking
Machines.
The Bagasse Bale Breaking Machine consist of
two closely held spiked rollers, revolving in
opposite direction, housed in a open hopper.
The rollers are driven by a electric motor. The
rotary motion from motor is transmitted to the
spiked rollers by the pulleys and belt drives.
The bale breaking operation is carried out by
feeding wire bound bales on to the spiked
rollers, in the hopper of the Bagasse Bale
Breaking Machine. The spiked rollers, revolving
in opposite direction, hold back the entangled
steel wires, bound around the bagasse bales. It
further tears the bound bagasse bales into loose
bagasse. The loose bagasse falls on to the
running conveyer at the bottom of the Bagasse


Bale Breaking Machine, and the loose bagasse
is carried to the boiler, to be used as a fuel.
The steel wires which are held back, get
entangled on the revolving spiked rollers. These
wires need to be removed frequently to allow
the Bagasse Bale Breaking Machine, to work
efficiently for breaking the bagasse bales into
loose bagasse. The operators of the Bagasse
Bale Breaking Machine, were required to
remove the steel wires removed from the bales
and entangled in the spiked rollers.
The operators were allowed to remove it by
sitting over the accumulated heap of the bagasse
to the level of the hopper, around the Bagasse
Bale Breaking Machine, by using their legs to
remove the entangled wires.

Brief Description of the Accident:
On the day of the accident, as the operator was
sitting on the edge of the hopper, and was busy
in removing the steel wires of the bagasse bales
entangled on the spiked rollers, by his
legs, his legs was caught in the gathering in
spiked rollers, and the operators was pulled into
the hopper. With the result, both of his legs
were entangled in the spiked rollers, and his legs
got ripped into pieces.
As the alarm was raised by the injured operator,
the workers working around, immediately cut
off the electric supply to the Bagasse Bale
Breaking Machine, and tried to rescue the
injured worker. The body of the worker had to
be removed by dismantling the spiked rollers of
the Bagasse Bale Breaking Machine. However,
by the time the injured worker was rescued, he
had bled profusely through the rip injuries on
his legs, and succumbed to them.




Accident Prevention Recommendations:

i) The steel wires used for binding the Bagasse
Bales, should be removed, before the bales are
fed for being broken into the Bagasse Bale
Breaking Machine,
ii) A long chute, preventing the access of the
workers to the spiked rollers, with a closed but
15


interlocked hopper, should be provided on the
Bagasse Bale Breaking Machine, in order to
ensure that the access of the worker is prevented
to the dangerous revolving gathering in spiked
rollers, while they are breaking and opening the
bagasse bales.


































A Case Study On 16
8 .SEROUS ACCIDENT ON A LATHE M/C DUE TO UNSAFE SYSTEM OF WORK
Compiled By
R.P.Khadamkar
Deputy Director
Industrial Safety & Health, Pune
------------------------------------------------------------------------------------------------------------------------------
The serious accident to a female worker occurred, while working on the lathe machine in the factory
premises.

ABOUT THE ACCIDENT:

The factory is involved in the machining of the
components required for the manufacturing of
the automobile components like gears, cross
bars etc. The raw material is received in the
form of forged jobs of gears, cross bars from the
forging factories. The machining process on the
cross bars involved operations like facing of
cross bars on the lathe machines and making
holes of required size in the cross bars by using
drill machines.
The injured worker was working as a helper. On
the day of incidence, the injured worker was
entrusted with the work of facing operation of
the job-cross bars on the lathe machine.
Accordingly, she started the lathe machine. The
lathe machine was an electrical power driven
machine and having parts like head stock fitted
with chuck, tail stock, tool post, lead screw,
power transmission system and an electric
motor. The operation on the lathe machine was
as follows. The job is held in the chuck and a
tool is fitted to the tool post. When the machine
was started, the power from the electrical motor
is transmitted to the chuck and also to the
carriage through the transmission system. The
lead screw was having square threads and
provided at a height about 600 mm from the
floor. When the machine was started the job
along with the chuck started rotating and the
facing operation was carried out by using the
tool fitted in the tool post. The lead screw also
got rotated by a power transmission system,
while the machine was in motion. She carried
out the facing operation of about 30 jobs-cross
bars on the lathe machine. While she was
carrying out the facing operation for the next job
on the lathe machine, the loose end of her sari
i.e. padar got entangled with the rotating lead
screw. As a result she fell and hairs of her head
also got entangled with the rotating lead screw.
The supervisor rushed to the lathe machine and
stopped the machine and removed her. She was
seriously injured. The hairs along with the skin
of her head got detached from the skull. The
accident has resulted in the serious head injury
to her. Also part of the lobe of her left ear got
amputated.

OBSERVATIONS:

The lathe machine was of 3-phase, 415 V, 1440
R.P.M., 3.0 H.P. an electrical power driven
machine. The overall size of the machine was
about 2400 mm L x 500 mm B x 1200 mm H.
LATHE M/C
LEAD SCREW TO WHICH
HAIRS OF WORKER GOT
ENTANGLED



The lead screw was of 40 mm dia x 2400 mm
length and was having square thread on its
throughout its length. It was located at the
operator side at a height about 600 mm from the
floor. The power from the motor was
transmitted to the lead screw through the belt,
pulley, gear train. The lead screw rotated at a
speed about 30 R.P.M.

WHAT WENT WORNG:
It is revealed that- The lathe machine was
having moving parts like-chuck, lead screw,
carriage and parts of transmission system. The
serious accident to the worker had occurred, as
the loose end of her clothing i.e. padar of sari
got entangled with the lead screw of the lathe
machine, which was in motion. As a result, she
fell down and hairs of her head got entangled
with the moving parts i.e. lead screw. She was
seriously injured.
i)The injured worker ought to have been
provided with the apron or tight fitting clothing
to prevent loose clothing getting entangled with
the any moving parts of the lathe machine.
17
ii)Also, the injured worker ought to have been
provided with cap/ helmet on her head (with
hairs tied in a bun) to prevent the hairs of her
head getting entangled with the any moving
parts of the lathe machine.
But she was not provided with such or any other
type of the personnel protective equipments,
when she was required to work on the lathe
machine. Thus the systems of work in the
factory were not safe and involved risk to the
health and safety of the injured worker working
on the lathe machine.

REMEDIAL MEASURES SUGGESTED:
i)No female workers shall be required / allowed
on such type of machine, unless she has been
provided with the apron/ tight fitting clothing
and its use is ensured.
ii) No female workers shall be required /
allowed on such type of machine, unless the
hairs of her head are tied in a bun and she has
been provided with the cap to prevent hairs
coming out.


























A Case Study On 18
9. SERIOUS ACCIDENT ON LATHE M/C DUE TO UNSAFE SYSTEM OF WORK.
Compiled By
S.G.Giri
Assistant Director
Industrial Safety & Health, Pune
------------------------------------------------------------------------------------------------------------------------------
A serious accident occurred to a worker, while working on the lathe machine in the factory premises.

HISTORY:
The factory was involved in the manufacturing
of domestic pressure cookers. The process
involved cutting, pressing, turning operations by
using the machines like power press machines,
lathe machine. The lathe machine was electrical
power driven machine. The power from the
main motor was transmitted to the chuck
through the V- belt pulleys. A Forward/Reverse
switch having lever was provided at the front
side of the machine for starting the lathe
machine. For adjustment and setting of the
machine, V-belts were required to be removed.
After carrying out of the alignment of slider and
setting of the machine, the belts were fixed
again on the pulleys.

ABOUT THE ACCIDENT:
The injured worker was working as Lathe
Machine Operators. On the day of incidence, the
injured worker along with other worker was
entrusted with the work of the trimming of
pressure cooker lids on the lathe machines.
After the lunch, the operation for small lid was
to be carried out. Hence it was necessary to
carry out slider alignment and setting of the


lathe machine. For carrying out the work, the
belts from the main pulleys were to be removed.
The injured worker called the other worker and
asked to help in the setting work. The other
worker was working on the front side and the
injured worker was working at the rear side of
the lathe. At that time, while the injured worker
was trying to remove belt from the pulley by
rotating the main pulley of the machine by left
hand, the switch of the machine got operated by
the body of the other worker, unknowingly. As a
result, the motor and pulley started rotating in
reverse mode and left hand thumb of the worker
got caught in and crushed in the intake nip
formed between the belt and the third pulley.
The accident resulted in the amputation of his
left hand thumb.

OBSERVATIONS:
The lathe machine was electrical power driven.
The overall size of the machine was about 2370
mm L x 1000 mm B x 1100 mm H. The driving
pulley of size 100 mm dia was mounted on the
motor shaft. The driven pulley of size 400 mm
dia was mounted on the shaft, on which six
pulleys of different sizes were mounted. The


LATHE M/C
BELT PULLEY IN WHICH
THUMB CAUGHT


19

power from driving pulley is transmitted to the
driven pulley through a V-belt. The 3
rd
pulley
was of size 180 mm dia, from which power was
transmitted to another set of driven pulleys. The
extreme right pulley was coupled to the slider
driving pulley through a V-belt. A Forward
/Reverse switch was provided at the front side
of the machine, at a height of about 800 mm
from the ground floor. When the lever of the
switch was turned to left position, the motor
rotated in clockwise direction and when it was
turned to right position, the motor rotated in
anticlockwise direction. When the motor was
started, the power was transmitted to the set of
pulleys. The speed of first set of pulleys and
hence 3
rd
pulley was about 360 R.P.M. The
height of the 3
rd
pulley was about 1000 mm
from the ground floor. When the motor rotated
in anticlockwise direction, the portion between
the V-belt and the 3
rd
pulley formed intake nip.
A main ICTP switch was installed on the wall
near the machine, from where an electric supply
was provided to the Forward / Reverse switch.

WHAT WENT WRONG:

i)Before starting the said work, the electric fuses
of the main ICTP switch of the lathe machine No.2
ought to have been removed and kept in the
custody of the responsible person to prevent
starting of the lathe machine by anyone
unknowingly. But fuses were not removed and
not kept in possession of responsible person.
Thus the systems of work were not safe and
involved risk to the health and safety of workers
at work.
ii)Also, while carrying out the said work, there
was no supervision for ensuring that the said
work should be carried out safely.

REMEDIAL MEASURES:
i)Before starting such type of the work, the
electric fuses of the main switch shall be
removed and kept in the custody of the
responsible person to prevent starting of the
machine by anyone unknowingly.
ii)Such type of work shall be carried out the
under the supervision of the responsible person
to ensure that the said work should be carried
out safely.










LEAVER OF
FORWARD /
REVERSE SWITCH
OPERATED
ICTP SWTICH
FROM WHICH
FUSES WERE NOT
REMOVED
A Case Study On 20
10. A FATAL ACCIDENT DUE TO IMPROPER LIFTING MECHANISM
Compiled By
N.A.Deshmukh
Assistant Director
Industrial Safety & Health, Pune
------------------------------------------------------------------------------------------------------------------------------
A fatal accident had occurred, while handling a load body for loading it into the truck.

ABOUT ACCIDENT:

The premises was involved in the
manufacturing of load bodies required for
transport vehicles. The process involves the
fabrication of bodies and painting. Then the
load bodies were loaded on a truck with the
help of a monorail crane at dispatch section in
the factory.
The deceased was working as a
Supervisor. On the day of incidence, the
deceased along with four other workers
resumed their duties in third shift. On
resuming duties, they went to the dispatch
section to carry out the work as usual. The
work involved was as under. After fabrication
and painting the load bodies were brought to
the dispatch section. They fitted accessories to
the load bodies and carried out the touch up
painting of the load bodies. Then the truck
was brought to the delivery end of the
dispatch section. The deceased with the help
of other worker was loading the load body on
the truck. The process of loading the load
body into the truck was as follows-
The load body, which was ready for
dispatch was kept on the ground at the
delivery end of the section. The truck was
parked in reverse direction with its carrier
towards the delivery end. The monorail crane
was brought at the delivery end in the dispatch
section. A lifting tackle having two ends
provided with brackets with holes at each end
was hanged into the hook of the crane. Then
two polyester webbing slings were put into the
each hole of the lifting tackle in such way that
two loops were formed at each end of the
lifting tackle. The load body was provided
with J hooks welded to both sides. Two
loops of sling were being inserted into two J
hooks of one side of the load body and the
other two loops of the sling into two J hooks
at the opposite side of the load body. Then, the
load body was being lifted with the help of the
monorail crane. Then the orientation of the
load body was made proper by turning it
horizontally manually in hanging condition, so
that it could be properly fitted to the fixture
provided at the carrier of the truck. After
fitting a load body on a carrier, the loops of
the slings were being removed and the load
body was being dispatched. Then the
procedure was repeated for the next load
body. In this manner they loaded about 7 no.
of load bodies till 1.30 A.M.
At about 1.30 A.M., there was tea time so all
of them, except the deceased went for tea at
LOAD BODY
LOAD BODY
HIT


the open space near delivery end of the
dispatch section. But the deceased, a
Supervisor waited there for loading the next
load body. He hanged the load body to the
webbing slings inserted in the lifting tackle in
the above said manner and lifted it with the
help of the monorail crane to a height about
2.5 metre. He kept the load body in hanging
condition with the crane and he was going to
call the truck driver to bring the truck at the
delivery end for loading. While passing
beneath the hanged load body, when he turned
the load body by hands for making its
orientation proper, the sling slipped from the
J hook (driver side) of the load body. As a
result, the load body got tilted due to
unbalance and swirled clockwise and hit
against the head of the deceased. The workers
lifted the load body by crane and removed
him. He was seriously injured and was
immediately shifted to the Hospital, where he
was declared dead.
OBSERVATIONS:
The load body was fabricated by using the
m.s. sheet, angles, channels etc. The overall
size of the load body was about 5100 mm L x
2150 mm B x 2200 mm H and weight was
about 810 Kg. The load body was provided
with 8 no. of the J hooks along the
lengthwise to its both sides ( Driver and
Cleaner). The J hook was made of m.s. rod
of 12 mm dia and is of size 18 mm radius x 90
mm length. The J hooks were fixed to the
load body by welded joints. The J hook and
mud guard at drivers side of the load body
were found in damaged condition. The
polyester webbing slings were of having
capacity 1 T each. Each sling was of size 6000
mm length x 50 mm width x 12 mm thick and
21
was having loop of size 410 mm length at
both ends. The lifting tackle was of m.s. and
having size 2280 mm length and was provided
with bracket with circular hole of dia 60 mm
at each end. The monorail crane provided was
of capacity 1T. The crane was having
electrical power driven hoist and long travel.
WHAT WENT WRONG:

It was revealed that-The fatal accident
occurred, while handling the load body for
loading it to the truck. The deceased was
required to turn the load body in hanging
condition, so as to make its orientation proper
and to fit it on the carrier of the truck. While
handling the load body with the crane, the
loop of the polyester sling came out of the
open end of the J hook. As a result the load
body swirled due to unbalance and hit against
his head causing fatal accident.
The lifting mechanism including the
crane, lifting tackle, polyester webbing sling,
J hooks on the load body were being used
for handling the load bodies and loading it to
the truck for further transport of load bodies.
The load of the body is transmitted to every
parts of the lifting mechanism.
The load body ought to have been provided
with round hooks and the webbing slings
ought to have been provided with the hooks at
ends having spring loaded positive locking
arrangement to prevent the sling coming out
of the hooks of the load body, while lifting or
in lifted condition. But the lifting mechanism
i.e.J hooks, webbing slings without having
J HOOK
WITHOUT
LOCKING
any type of locking arrangement were
provided and used for handling the load
bodies, which caused the fatal accident to the
said worker.
22
Thus the arrangements in the factory in
connection with the handling, transport of
heavy articles like load bodies were not safe
and involved risk to the health and safety of
workers at work.

REMEDIAL MEASURES:
i) The lifting mechanism having round hooks
and webbing slings with hooks having
positive locking arrangement shall be
provided and used to prevent the sling coming
out of the hooks of the load body, while lifting
or in lifted condition.























LIFTIN
G
TACKL
E

A Case Study On 23

11.A FATAL ACCIDENT AT A FACTORY MANUFACTURING-ERW AND CEW STEEL TUBES

Compiled By
S G Phadtare
Deputy Director
Industrial Safety & Health, Pune
------------------------------------------------------------------------------------------------------------------------------
A fatal accident that took place at 16:45 pm with worker age 27 years, employed through a contractor

MANUFACTURING PROCESS:
Manufacturing of S.S. E R W (electric
Resistance welding) tubes is being carried on in
this factory. The steel role (coil) received at
factory is slit on slitting machine into the coils
of required width, depends upon the diameter of
tube to be manufactured. Then these slit coils
are loaded on trolley and brought to the tube
mill section. Then individual coil is lifted by
EOT crane and stored near tube mill machine.
Single coil is lifted by a local crane and loaded
on support of mill machine and locked by
locking plates. The operator who brings the slit
coils to mill machine ,also load the coil on
support of mill machine, with the help of fixed
crane near mill machine. Open end of coil is
taken to further process of formation of tube by
ERW process. Loading of coil on support of
mill machine and locking it as per the
photographs attached no.1 to 5

ABOUT THE ACCIDENT:
On the date of accident, the crane operator
joined duties in second shift. According to him
his duty was to bring slit coil from trolley to
mill machine by EOT crane, then load the coil
on slit loader of mill machine by a local crane (2
ton capacity) and lock the coil with locking
plates. After joining duties he brought 4 slit
coils by EOT crane (7.5 ton) to mill machine no.
1. Out of these 4 coils, he loaded one coil on
machine and started the tube formation process.
Each coil is weighing appx.1.35ton

At 16.45pm, to load the second coil on machine
(position of both coils is shown in photograph
no 6), operator removed the locking plates and

was loading coil on slit loader, the coil dashed
against the foundation of mill machine .Due to
which the chain holding the coil slacken, the
coil was unbalanced and one end of chain came
out of hook as spring loaded locking
mechanism was not working.(photo no.7) The
coil fell on one side, on the deceased worker
who was doing cleaning work near the
machine.(Photo no.8). He was pressed below
the coil. Immediately the crane operator, with
the help of EOT crane, lifted the slit coil and
injured worker was taken out. He was put in
ambulance and taken to hospital where he was
declared dead.

WHAT WENT WRONG:
After verifying the locking system of hook, it
was observed that the spring loaded locking
system, which prevents the chain coming out of
opening of hook, is not working. As such after
dashing the coil to the machine foundation,
chain was slacken and easily came out of hook
and the coil fell on one side on deceased. The
said crane was got examined by a competent
person declared under Factories Act 1948. He
was again asked to carry out the examination of
the said crane and give his observations.
Accordingly he had given his observations,
which supports the cause of accident.

REMEDIAL MEASURES:
It shall be confirmed that the spring loaded
locking system, which prevents the chain
coming out of opening of hook, shall be
working.




24




A Case Study On 25
12. SERIOUS ACCIDENT DURING MATERIAL HANDLING DUE TO UNSAFE SYSTEM OF WORK
Compiled By
R.B.Lakhe
Deputy Director
Industrial Safety & Health, Pune


In one factory worker met an serious accident, while loading the M. S. Plates on the platform of the
truck, sustaining serious head injury which proved fatal. This accident occurred due to adoption of
unsafe system of work.

ABOUT ACCIDENT:
On the day of accident, the deceased worker,
had attended the duty at 8.30 am as usual along
with three coworkers And the work of loading
the M S plates (size 5m.x 1.25m. x 6mm ) in
the truck was being carried on in the stored yard
of the factory.
In store yard of the factory, there are various
types of material such as M S bars, angles,
channels, pipes including M S Plates and on the
said day the work of loading of m s plates was
to be completed, which was started with the
help of JCB loader for lifting the plates,
employing four workers.
The system and arrangement of loading the M S
plates in the truck was as follows.
The plate which was to be loaded in the truck
was being made holes lengthwise at a distance
of one meter from both the ends of the plate by
gas cutter. Then the wire rope ( 5/ 8 ) with
Dshackle was bolted in both the holes and the
plate was lifted vertically by JCB ( power-76
hp. ) 6 inch above the height of platform of the
truck (4 ft.) and was being dropped on the
platform which was falling horizontally with
huge sound on the platform with most of the
portion outside the platform of the truck in
imbalance position Then the four workers were
used to push the plate inside, on the platform so
as to load it completely on the platform.
It is marked that, the JCB which is used
specifically for digging purpose was used for
lifting and loading the heavy plates resulting
into the said fatal accident.
On the day of accident, the deceased worker,
along with his coworkers started the work of
loading at 9 am. and completed the loading of
one M S plate till 9.30 am. under the
supervision of Supervisor Shri S Y Pansare. As
there were total 12 Plates the supervisor,
thought that loading may consume more time if
plates are loaded one by one and therefore
second time two plates were taken at a time,
which were made holes by gas cutter and wire
rope with Dshackle was bolted to both the plates
and was lifted vertically by the hand (bucket) of
JCB and dropped on the platform of the truck.
The plates fell horizontally on the platform in
such a way that most of the portion ( 75 %) was
outside the platform. Immediately after falling
the plates, the deceased worker who was
standing there itself, started loading the plates,
along with three coworkers by pushing the said
plates inside, on the platform and while doing
so, the plates which were in imbalance position
due to maximum portion outside, fell on the
body of the workers. However the other
coworkers escaped miraculously and the plates
fell on the back of the deceased sustaining
serious head and neck injury. The other workers
nearby rush to the spot. However the deceased
worker was profusely bleeding. He was
immediately taken to Hospital. However Doctor
examined and declared him dead.

SPOT ANALYSIS :
The spot examination, work system of loading
the plates , working of JCB, Position of lifting
plates, position of truck platform , working
position of the deceased worker etc. revealed the
details which are as follows-

1) Machine / Mechanism : JCB Loader
2) Make : BEML Ltd.
3) Bucket Capacity of lifting soil : 1 cu m.
4) Power : 76HP
5) Operating height : 5.8 m.
6) Size of wire rope with D shackle : 5/8 inch


7)Dimension of M S plate : 5m x 1.25m x 6mm
8)Weight of one Plate : 300 kg
9)Size of loading platform of truck: 5.3 x 2.4 m.
10)Distance of loading platform from ground
level: 4 ft.
11) Position of plates while lifting : Vertical
12)Position of plates after dropping on platform:
Horizontal
13)Portion of plates outside platform after
falling : 75 %
14)Plates lifted at a time : 2 No.
15)System of loading plates: Improper and
Dangerous
16)Arrangement for handling of plates : Unsafe
and Risky

WHAT WENT WRONG:
The lifting of heavy M S plates by JCB loader is
itself very dangerous act since it is not meant for
lifting plates but for the use of digging the soil.
Further for loading the plates after falling in
imbalance position on the platform of the truck,
the workers should not have allowed to push it
inside , on the platform of the truck unless stable
position of the plates was ensured which was
not done and resulted into the said fatal
accident.

26
Secondly, the arrangement used in connection
with handling that is lifting the plates was done
by JCB loader which is at all not meant for the
said purpose.
The Management should have provided and
carried out the said work of lifting and loading
by making the arrangement of suitable crane to
ensure the health and safety of the workers at
work and further by adopting the proper system
of work that are safe and without the risk to
health, which could have prevented the said
accident.

REMEDIAL MEASURES :
1)The suitable crane with adequate lifting
capacity shall be provided for lifting / handling
the heavy M S plates.
2) The plates shall not be lifted vertically and
dropped down from the distance which is
dangerous to cause accident.
3) The proper system of lifting and loading
shall be adopted to ensure safety and absence of
risk to the health of the workers.
4) The workers shall be well acquainted and
properly trained to carry out the loading of
heavy plates.
5) Protective wears like safety shoes, helmet,
hand gloves shall be provided to the workers.

Case Study On 27
13. FALLING THROUGH THE FRAGILE ROOF
Compiled By
S.G.Giri
Assistant Director
Industrial Safety & Health, Pune

------------------------------------------------------------------------------------------------------------------------------
An accident to a worker had occurred while walking on the A.C.Sheet roofing of the building in the
factory premises.

HISTRORY:
The factory was involved in the bottling of
foreign liquor. There was an old administrative
building having A.C.sheet roofing, inside the
factory premises. The cabins inside the building
were having false ceiling. The false ceiling was
at height of about 3150 mm from floor and
above it was the A.C.sheet roofing at height
2500 mm. A staircase is provided for going to
the terrace and roof. From terrace, one could
reach the A.C. sheet roofing by crossing the
parapet wall.

ABOUT THE INCIDENCE:

As it was the beginning of rainy season, it was
decided to check and repair the leakages in roof
of the administration building. The gaps
between the A.C.Sheets, J-hooks, cause the
rainwater to leak through the roof of the
building. So, the Factory Manager called the
injured worker and asked them to assist him in
the said work. They climbed up the roof of the
administration building by using a staircase
provided from outside to check and assess the
actual work to be carried out for rectification of
the leakages. Then they stepped on the
A.C.sheet roof of the administration building
and started observing the roof for leakages. On
completing the observation of one portion, they
were moving forward to check next portion of
the roof. In this manner they moved about 12
metre distance on the roof. While moving
further, the injured worker slipped. In the
attempt of balancing, when he held the
A.C.sheet of the roof by hands, it gave a way
due to load of his body and he fell through the
roof on the ceiling of the cabin, which was
about 2500 mm below the roof. As a result, the
ceiling of the cabin broke and he further fell
through a height about 3150 mm. Thus he fell
through a total height of about 5.65 metre and
was injured. The accident resulted into the
fracture of his spine.

OBSERVATIONS:
The administration building was of size of about
25 m length x 15 m breadth. The roofing was of
the Asbestos Cement sheet (A.C.sheet). The
minimum height of roof (truss level) from floor
was about 5.0 m and maximum height of roof
(ridge) was about 8.0 m from the floor. The roof
structure was consisting of trusses and purlins.


The A.C. sheets were fixed to the purlins of the
roof structure by 'J' hooks and nuts. For
checking and observing the roofs,worker was
required to pass over the A.C. sheet roof to a
distance about 12 m. The cabin beneath the
broken A.C.sheet is having a metallic grid with
panels of heat resistant material like asbestos
fixed in it.

WHAT WENT WRONG:
The roofing of the administration building was
of the Asbestos Cement sheet (A.C.sheet),
which was a fragile material. The injured
worker was required and allowed to pass over
the A.C.sheet roof for carrying out the
observation of roof for assessment of work.
When, he slipped and held the A.C.sheet, it gave
way and he fell through the height of about 5.65
m and the accident occurred. It is further
revealed that-The injured worker was required
and allowed to stand, pass over the A.C.sheet
roof, without providing him any suitable
ladders, duck ladders, crawling boards.

REMEDIAL MEASURES:
Whenever the person / workers are required to
stand, passed over and carry out any work on
the A.C.sheet roof, or roof of the fragile
material, through which they were liable to fall,
i)They shall be provided with suitable and
sufficient ladders, duck ladders, crawling
boards and



28
ii) A safety net shall be provided beneath the
fragile roof, while carrying out the work at roof.

iii)A permit to work on the fragile roof, by a
responsible person of the factory.












A Case Study On 29

14. FATAL ACCIDENT WHILE WORKING ON A PAPER MACHINE.
Compiled By
Y.P.Patange
Assistant Director
Industrial Safety & Health, Pune
------------------------------------------------------------------------------------------------------------------------------
Fatal accident to one worker took place in paper manufacturing factory, while he was working on paper
machine.

ABOUT THE ACCIDENT:-
The deceased worker was working in this
factory through contractor, since last 5 years.
On the date of accident he had reported on duty
at 8 am to work in first ship. There was no
electric supply from MSEB from 3.30 am to
8.20 am. After the supply was received, the
paper machine was started. At about 8.40 am,
the deceased worker had climbed on the
platform near the MG cylinder to remove the
chock up of the water shower pipe. After
reaching on the platform, he had requested co-
worker to operate the water shower valve
located on the ground floor. Accordingly, the
co-worker operated the valve and then went to
control panel which is located at about 15 feet
away from the spot of accident. The deceased
then started the work of removing chock up by
hammering on the outer surface of the water
shower pipe. While doing so, he probably lost
his balance and fell on the moving felt and was
trapped in 200 mm gap between the felt roll and
the suction box. There is no eye witness to this
incidence. Co-worker, working nearby, noticed
that there is fold on the felt cloth, near the
suction box. He suspected that the deceased
worker might have fallen on the moving felt. So,
he immediately stopped the paper machine and
rushed to the platform along with two other
workers. On reaching there on the platform,
they noticed that the deceased worker was
trapped on the felt and injured. He was found
lying in unconscious condition, in the 200 mm
gap between the felt roll and the suction box.
Seeing this, they realized that it was essential to
cut the felt for removing him from there.
Accordingly, the felt was cut and he was
removed from the felt and shifted to hospital
where he was declared dead.

OBERVATIONS: The paper machine is used
for making paper by recycling waste paper. At
the centre of this machine, there is machine
glaze cylinder/drier (here after called as MG
cylinder). Below this MG cylinder, there is 400
mm X 1980 mm long touch roller. Next to this
touch roll, there is felt roll, one guide roll,
stretcher roll, felt roll, suction box/vacuum box
and two washing rolls. One 1980 mm wide felt
(belt) is passing over from these rolls. This felt
passes between two washing rolls to touch roll
below the MG cylinder. From there, it passes
below the felt roll and then from the bottom of
the guide roll to the stretcher rolls. It passes to
from the bottom of the next felt roll and then to
the suction box. From suction box it reaches the
washing rolls. In this way it keeps on moving
continuously.
There are three platforms at 3050 mm height
from the ground level, provided on three sides
of the machine and are extending from MG
cylinder to washing cylinders. Pipe railings are
provided on the outer side of these three
platforms. On the inner side of these platforms,
there are moving parts of the machine, like
rotating washing rolls, felt roll, stretcher roll,
moving felt, etc. However, there is no
railings/fencing provided on inner side of these
three platforms, so as to avoid access of the
worker to these moving parts of the paper
machine.
There is 200 mm gap between the felt roll and
the suction box and height of the felt roll and
suction box from the platform level is about 300
mm. Adjacent to this felt roll there is one 25
mm pipe water shower which extends from the
ground level to the top of felt roll vertically.
From there, it passes horizontally over the felt
and extends up to the other end of the felt.


30
Height of this shower pipe from the platform
level is 500 mm.
Workers are required to go to these platforms
for adjusting the felt rolls, removing chock up of
water shower, changing felts, greasing of
bearings etc. They do this work by standing on
these platforms.
This machine is power operated machine fitted
with two 50 HP electric motors. Power of these
motors is transmitted to rolls through belt
pulleys fitted on common shaft, then to gear box
and from gear box to MG cylinder through
sprocket and bevel gears. It was revealed that
normally speed of the felt is about 30 m/min.

WHAT WENT WRONG:-

There are three platforms at 3050 mm height
from the ground level, provided on three sides
of the paper machine. Two platforms are
extending from MG cylinder to washing
cylinders and are on either sides of the moving
felt. There is 200 mm gap between the felt roll
and the suction box and height of the felt roll
and suction box from the platform level is 300
mm.


Adjacent to this felt roll there is one 25 mm m.s.
pipe water shower which extends from the
ground level to the top of felt roll vertically.
From there, it passes horizontally over the felt
and extends up to the other end of the felt.
Height of this shower pipe from the platform
level is 500 mm. Workers are required to go to
these platforms for adjusting the felt rolls,
removing chock up of water shower, changing
felts, applying grease to bearings etc. There are
pipe railings provided on the outer side of these
three platforms. On the inner side of these
platforms, there are moving parts of the
machine, like rotating washing rolls, felt roll,
stretcher roll, moving felt, etc. All these moving
parts of the paper machine are dangerous parts
of this machine by virtue of its position and
construction and they are accessible from the
platform level. It was essential to fence these
dangerous parts by safeguards of substantial
construction while the parts of machinery they
are fencing are in motion or in use. However, it
was revealed that on the date of accident, there
were no fencing (railings) provided on inner
side of these three platforms, so as to avoid
access of the worker to these dangerous
(moving) parts of the paper machine. This has
resulted in to fatal accident.

REMEDIAL MEASURES:-
In order to avoid such type of accidents in
future, following remedial measures are
recommended:-
i) Suitable railings/ fencing shall be provided on
all the three platforms from the inner sides, so as
to avoid access of the workers working on the
platform.
ii) Wooden planks of the platform shall be
replaced by metallic checker plates so as to
avoid slipping of the worker standing on the
platform.
iii) Railings on the platform from the passage
side which is weak, shall be got suitably
repaired.




A Case Study On 31
15. A FATAL ACCIDENT WHILE WORKING IN CONFINED SPACE IN A CHEMICAL FACTORY.
Compiled By
J.B.Kumbhar
Deputy Director
Industrial Safety & Health, Pune

------------------------------------------------------------------------------------------------------------------------------
A fatal accident had occurred while working in a confined space in a chemical factory.

HISTORY:
The factory was engaged in the manufacturing
of various types of resins using raw materials
like benzoic acid, soya fatty acid, pentaery
thritol, glycerol, phthalic anhydride, toluene
diisocynate and solvents like xylene /
toluene/acetone etc. The manufacturing
process was as under:
The above mentioned raw materials except
solvents were taken in 10 metric cube kettle &
stirred together at 200 to 230 degree
centigrade temperature by heating with the
help of thermic fluid heater. Water of reaction
was removed to get polymer. At required time
(about 6-8 hours), after getting right polymer,
reaction mass was cooled to 80 100
0
C. At
this temperature, solvent was added to get
required solid content of either 70 % or 55 %
as per customers requirement.

ABOUT ACCIDENT:
On the day of incidence, it was decided to
charge 10 m3 vessel with old prepared alkyd
resin (having solid content 90 %) and
subsequently dilute it with solvent.
Accordingly 3 no. of workers started charging
vessel/ kettle with the help of 50 kg drums.
The kettle was charged with about 350 kg of
material. As the material was viscous, it was
taking time to charge. After emptying few
drums of resin in to the vessel, while they
were charging the resin with next drum in the
vessel through its man hole, the plastic drum
slipped from their hands and fell down in the
vessel. In order to remove the drum, those
workers placed one bamboo ladder in the
vessel. Bottom of this ladder was rested on
one of the blades of the stirrer in the vessel.
One worker entered in the vessel with the help
VESSEL IN WHICH
WORKER FELL



entered into the vessel, he felt uneasy.
Therefore, he immediately came out from the
vessel. Then other worker entered in to the
vessel using the ladder. However, while
climbing down on ladder, he fell in to the
vessel. When the first worker saw it, he
entered in the vessel to rescue him from the
vessel. But he also fell down in the vessel. In
the mean time, the Occupier along with other
workers rushed to the vessel. By the time they
reached the vessel, the third worker was trying
to enter in the vessel. But he was stopped from
doing so.

RESCUE OPERATION:
Immediately, the intimation regarding the
incidence was given to the nearby hospital so
that they could arrange for respirator and
ambulance and also to the Police & Fire
Brigade. Meanwhile, the DISH Officers, when
came to know about the incidence, contacted
the concerned fire brigade personnel and took
the feedback of the incidence and immediately
directed the members of the MARG from the
concern Industrial Area for rescue operation.
After reaching the spot, a person from the
medical team of the hospital tried to enter the
vessel, however, as soon as he entered, he felt
uneasy and therefore he came out from the
vessel. By the time police and fire brigade
people arrived at the spot, most of the material
was removed from the vessel / kettle by the
other workers. The material in the vessel was
sticky and it was necessary to enter the vessel
and remove both the workers. The fire brigade
person was unable to enter in the vessel after
wearing breathing apparatus, as the size of the
man hole was only 17.5 inches diameter. Fire
brigade personnel wanted to cut vessel, but
could not use the gas cutter as there was risk
of fire/explosion due to xylene vapours
present in the vessel and it would have created
problem to both the workers, who were
trapped in the vessel. Then, it was decided to
make hole at the bottom side by using grinder.
Accordingly a hole of size about 22 inches X
24 inches was cut at the bottom of the vessel
by fire brigade persons. The worker who had
fallen on his


32

back, was in unconscious condition and
shifted to Hospital. He survived and recovered
after treatment. Other worker, who had fallen
on face into the vessel got lot of resin stuck to
his face that made breathing difficult for him.
He died due to suffocation caused by vapors
of xylene in the vessel.

WHAT WENT WRONG:-
The size of the vessel in which these two
workers had entered was 4.5 m high X 3 m
diameter and was having man hole of size
about 17.5 inches at the top side. All the
openings provided for various types of pipe
lines were closed. Portion inside the vessel
was a confined space. This vessel was
containing vapors of xylene mixed in the
alkyd resin which was charged in it. Xylene
was toxic substance and having 100 ppm
TLV.
(i)The vessel was not checked for contents of
vapours before the two workers entered in it.
(ii)A certificate from the competent person,
based on the test carried out by him that the
space was reasonably free from dangerous
gas, fume, vapour or dust was not obtained
before those two persons were
required/allowed to enter the confined space
in the vessel.
(iii)Belt securely attached to a rope and
breathing apparatus were not provided to these
two persons before entering confined space.

VESSEL CUT OPEN
FOR RESCUE OF
WORKER
A Case Study On 33
16. SERIOUS ACCIDENT WHILE WORKING IN CONFINED SPACE
Compiled By
R.P.Khadamkar
Deputy Director
Industrial Safety & Health, Pune
------------------------------------------------------------------------------------------------------------------------------
A serious accident causing burn injuries had occurred while working in a tank, a confined space.

HISTORY:
The factory was involved in the manufacturing
of the equipments like s.s. tanks required for
brewery, pharmaceutical and chemical
industries. The manufacturing process for tanks
was as follows. The raw material was in the
form of s.s. coils, pipes etc. The s.s coils were
uncoiled on a de-coiling machine and coated
with a thin PVC film for protecting the surface.
The sheets were cut to required sizes and shapes
on plasma cutting machines. The blanks were
formed by carrying out TIG welding operation.
These blanks were used to form dish ends &
cones. The shells were formed on plate bending
machines. These components were then
assembled together by welding to form a tank.
The tanks were provided with manhole, drain
pipe, nozzles as per design. The tanks were
polished and cleaned from both inside and
outside. After testing and inspection the tanks
were packed and dispatched.
The polishing and cleaning process was
as under. The tank was kept in horizontal
position on the rotator stand. One worker carries
out polishing of the welded joints by a portable
electric grinding machine and removes the thin
film from the outer surface of the tank. Other
worker enters the tank through the manhole
provided on one dish end. He takes electrical
light inside the tank so as to view inner surface
of the tank. Then polishing was carried out of
welded joints at inner surface and the film
coated on inner surface was removed. It was
necessary to remove stains formed on the inner
surface by the film. The stains are removed by
applying a cleaning solvent with the help of
cotton cloth. Thus the cleaning process was
completed.

ABOUT THE ACCIDENT:

The injured worker was employed through the
contractor and was working as a trainee. On the
day of incidence, the injured worker along with
a fitter was entrusted with the work of polishing
& cleaning of the tank. Accordingly they started
carrying out the said work. The tank was kept in
horizontal position on the rotator stand. The
fitter was working on outer surface and the
injured worker was working on inner surface.
The injured worker connected supply cables of
halogen lamp (500W) and portable electric
grinding machine to the extension board and
S.S.TANK
MANHOLE THROUGH
WHICH WORKER
ENTERED


34
switched on its electric supply. Then he took the
halogen lamp, the grinding machine and entered
into the tank through its manhole. He kept the
glowing lamp in the tank and started polishing
of the inner surface. He removed the film from
the inner surface of the tank. After finishing this
work, he came out of the tank. Then he took a
can containing about 1.5 litre of the cleaning
solvent, cotton cloth and again entered the tank.
He poured the cleaning solvent on the cloth and
started wiping the inner surface for removing
stains. Due to the halogen lamp (500W), the
inner surface and inside air became hot. The
vapours of the cleaning solvent, which was
volatile chemical, were formed and got
accumulated inside the tank. While the injured
worker was carrying out further cleaning work
inside the tank, the vapours of the cleaning
solvent inside the tank caught fire and caused a
flash of fire. Due to this, he received burn
injuries to his hands, legs. He came out of the
tank through the manhole. In this accident, he
received about 20-25% burn injuries. After the
treatment at the hospital, the worker recovered
from the injuries.
OBSERVATIONS:
The tank was of stainless steel (SS-316) and
cylindrical in shape. It was mounted
horizontally on a rotator stand. The size of the
tank was about 1600 mm dia x 4300 mm height.
One dish end was provided with a manhole of
size 450 mm dia, inlet of 125 mm dia, a nozzle
90 mm dia and a nozzle of 85 mm dia. The other
dish end was provided with a drain of 50 mm
dia, an overflow pipe of 150 mm dia. The height
of the rotator stand was about 800 mm. The
halogen lamp used for lighting was of rating 240
V, 500 W. It was not of flameproof
construction. The material safety data sheet
indicated that the cleaning solvent was
composed of ketones having flash point less
than 18
0
C, which was volatile and highly
flammable solvent. The capacity of the plastic
can used for handling the cleaning solvent was
of 5 litre. A piece of cotton cloth was found in
burnt condition inside the tank.

WHAT WENT WRONG:

The incidence of flash of fire occurred, when
the worker was working inside the tank, which
was a confined space. The cleaning solvent
composed of ketones having flash point less
than 18
0
C, which was volatile and highly
flammable solvent. The temperature of the inner
surface of the tank and inside air got raised due
to heat generated by the halogen lamp of rating
240 V, 500 W. As a result the vapours of the
cleaning solvent were formed and got
accumulated inside the tank. The vapours of
highly flammable solvent formed flammable
mixture with the air. The halogen lamp of non
flameproof construction was a source of
ignition. It caused flash fire of the flammable
mixture formed by vapours of the highly
flammable cleaning solvent with the air.
It is revealed that the solvent- The said worker
was required and allowed to enter the tank, in
which the vapours of the cleaning solvent were
formed and got accumulated during the process.
(i)The control measures were not taken for the
prevention of accumulation of the vapours of
cleaning solvent inside the tank.
(ii) No test were carried out for ensuring the
space inside the tank free from dangerous
vapours and no certificate of fitness was
obtained from the competent person.
(iii)The said worker was not provided with a
self contained breathing apparatus and was not
wore with belt securely attached to a rope, the
INSIDE
TANK
BURNT
COTTON CLOTH
CLEANIN
G
SOLVENT
NONFLAMEPROO
F LAMP

free end of which to be held by a person outside
the tank.
(iv)The highly flammable vapours of the
cleaning solvent were formed and got
accumulated inside the tank. No lamp or light
other than of flameproof construction ought to
have been permitted to use inside the tank. But
the said worker was not provided with a lamp of
flameproof construction. He was required and
allowed to use a halogen lamp of 240 V, 500 W,
which was of ordinary construction.
REMEDIAL MEASURES SUGGESTED:
i)The workers shall be provided with a self
contained breathing apparatus of adequate
oxygen supply capacity.
35
ii)The lamp/light of flameproof construction
shall be provided and used while carrying out
such type of work.
iii)The space inside the tank shall be got tested
and certified by the competent person to ensure
that it is free from the dangerous vapours/gases.
iv)The worker shall be provided with a belt
securely attached to a rope, the free end of
which is held by a person outside the tank.
v)The tank shall be continuously purged with a
suitable inert gas. The arrangement shall be
done so that vapours are not accumulated inside
that tank or work area.



































A Case Study On 36
17. FATAL ACCIDENT DUE TO ASPHYXIATION WHILE WORKING IN CONFINED SPACE
By
R.D.Kichambare
Former Joint Director
Industrial Safety & Health

____________________________________________________________________________________

Accident Type: Asphyxiation
Type of Industry: Chemical
Size of work Crew: 4/150
Work Site Inspection Conducted: Yes
Designated competent Person on Site: No
Employer Safety and Health Programme: No
Training and Education for Employees: No
Craft/Type of Deceased Employees: Unskilled
Age and Sex: 19 Male, 22 Male, 23 Male,
Time on the Job: 5 months
Time on the Task: 20 Minutes,

Description of the Accident:
In a factory involved in manufacture of Edible
Oils, one worker got injured and two other
workers died of asphyxiation in a pit, a confined
a space, in the effluent treatment plant of the
factory. The factory was primarily involved in
refining the edible oils manufactured elsewhere,
and in its packing on the factory premises. The
process comprised of decolourisation and de-
odourisation of the edible oils bought out from
external sources. Several materials, such as
special earth, Caustic Soda, Sulfuric /
Hydrochloric Acids, were used in the process.
There was a effluent plant in the open premises
of the factory, to treat the effluent generated in
the process. One of the places where effluent
was collected for further treatment, was a
collected a pit flush with the land level
admeasuring 8 feet long, 2 feet wide, and 6 feet
deep. A power driven agitator arm to churn the
effluent in the pit was installed on the pit. Also
there was a transfer motor driven pump installed
on the edge of the pit. There was access ladder
constructed, on one of the walls of the pit to
facilitate the workers to enter the pit, should
there be a need. The pit was covered by a
removable wire-mesh cover.
On the day of the accident, the Supervisor from
the maintenance department of the factory
instructed a worker to enter the pit to clean the
foot-valve of the pump installed on the pit, as it
was not pumping out the effluent properly, for
transferring into another tank for further
treatment. One of the workers therefore
removed the wire-mesh cover on the pit and
entered the pit by the access ladder provided on
the pit. After entering in the pit, as he started
walking towards the foot-valve of the pump
which was in one corner of the pit, he fainted,
became unconsciousand fell into the slurry in
the pit. Noticing him fall, another worker near
the pit entered the pit. He started rescuing the
unconscious worker by lifting him bodily and
tried to push him out of the pit.He succeeded in
pushing the unconscious worker outside the pit.
However, in the process, he too became
unconscious and fell into the slurry in the pit.

37
However, in the process, he too became
unconscious and fell into the slurry in the pit.
This prompted another worker outside pit to
enter the pit to rescue the unconscious worker.
He entered the pit by the access ladder. He tried
to lift him bodily and push him out of the pit.
However, while doing so, he too became
conscious and fell into the slurry into the pit. A
group of several workers then attempted to
remove the two unconscious workers with the
help of ropes. They were successful in removing
them. However they had succumbed to the
injuries sustained by inhaling the foul gas in the
effluent in the pit and one to fall conscious first
had survived.
The inquiries revealed the pit contained about
one and a half feet deep content of the effluent.
The effluent was viscous and appeared slurry
like. The effluent had remained in the pit for
quite some time. A Hydrogen Sulphide gas had
generated into it because of the anaerobic
decomposition of the unused reactants, from the
process. The gas had remained trapped into the
slurry. When the workers entered the pit the
slurry got vitiated and the trapped Hydrogen
Sulphide gas bubbled out, from the slurry. It
was inhaled by the workers who had entered the
pit and they were overcome by it. The worker to
enter the tank first, survived as his exposure to
Hydrogen Sulphide gas was probably less than
those who entered the pit later.

Accident Prevention Measures:
No person shall be required or allowed to enter
any confined space such as any pit, in which any
gas, fume, or vapour is likely to be present to
such an extent as to involve a risk to persons
being overcome thereby, until all practicable
measures have been taken to remove any gas,
fume, or vapour, which may be present, so as to
bring its level within the permissible limits and
unless-
(a) a certificate in writing has been given
by a competent person, based on a test
carried out by himself that the space is
reasonably free from dangerous gas,
fume, or vapour, or
(b) such person is wearing suitable
breathing apparatus and a belt securely
attached to a rope the free end of which
is held by a person outside the confined
space.















A Case Study On 38
18. A FATAL ACCIDENT DUE TO FALLING IN A QUENCHING TANK CONTAINING HOT WATER
Compiled By
T.M.Kambale
Assistant Director
Industrial Safety & Health, Pune
------------------------------------------------------------------------------------------------------------------------------
A fatal accident occurred while working at the quenching tank of the heat treatment furnace in the
factory premises.

HISTORY:
The factory is involved in the manufacturing of
the Aluminium castings components. The
process was as follows. The raw material in the
form of Aluminium ingots are melted in furnace
oil fired furnaces. The molten metal was
transferred to the LPDC machines (Low
Pressure Die Casting Machines), where
Aluminium castings were formed. These
castings were subjected to fettling operation for
removal of burrs, risers. Then these jobs were
sent to heat treatment section. The heat
treatment operation involved two processes-
Heat Treatment-Solution and Heat Treatment-
Aging. After heat treatment, the jobs are
checked and dispatched.
The Heat Treatment-Solution plant was
having a platform at a height about 3.0 metre
with three openings in it. Electrical resistive
furnaces were installed in each opening. Each
furnace was provided with a separate
underground quenching tank with its top open,
which was right below the furnace. The
quenching tank contained full of water in it. A
gate was provided to the furnace at its bottom.
Two manually operated loading trolleys were
provided beneath the platform. Rails were
provided along the tanks, on which trolleys
moved. Two cylindrical baskets mounted one
above the other were provided to each furnace
in which jobs were charged, which was further
loaded to the furnace. A hydraulic mechanism
was provided for the movement of the gate and
basket. The Heat Treatment-Solution process
was as follows.
The baskets containing the jobs i.e.
Aluminium castings were kept on the loading
trolley. The gate of the furnace was opened and
the baskets were loaded into furnace from its
bottom. After closing the gate Operator started
the heating cycle. The temperature of the
Aluminium castings reaches to 480
0
C. The
furnace was kept on hold at this temperature for
another 2 hours & the heating cycle was
stopped. The workers pushed the loading trolley
forward and the quenching tank became open.
Then operator opened the gate of the furnace
and lowered the baskets to dip it into the
quenching tank containing water, with the help
of hydraulic mechanism. After holding the
baskets into the quenching water for 5 minutes,
the baskets were again lifted up. The loading
trolley was now again moved on the quenching
tank and the baskets were kept on it. The trolley
along with the baskets wais then moved forward
and another loading trolley along with baskets
containing next batch of jobs was taken below
the furnace. When the hot jobs were quenched
into water, its temperature rises. Part of the
water got evaporated. The water was added into
the tank to make up the water lost. The
temperature of the water in the quenching tank
remained about 75
0
C. The process was
TROLLEY
QUENCHING TANK
BENEATH IT


39
repeated for next batch.
ABOUT THE ACCIDENT:
The injured worker was through the contractor
and was working as helper in the factory. On the
day of incidence, the injured worker along with
the other worker was entrusted with the work at
the quenching tanks of the Heat Treatment-
Solution section. The work involved was as
under. When the jobs were ready for quenching,
they were pushing the trolley forward by legs.
After quenching the trolley was brought back on
the tank by them and the basket containing jobs
was kept on trolley. Then they were moving
trolley out and sending it for next process. Then
again they were keeping next batch, on another
trolley for the heat treatment process. The
heating cycle of the furnaces of the Heat
Treatment-Solution was started and continued.
At the time of accident, the jobs in furnace were
ready for quenching, so the operator asked the
injured and other worker to move the trolley
forward, so as to quench the jobs in the tank. So,
the other worker from left side and the injured
worker from right side of the trolley, started
pushing the trolley forward by legs. While
pushing the trolley, the injured worker lost
balance and fell into the quenching tank through
its top, which became open as the trolley moved
forward. As the tank contained the hot water
having temperature about 75
0
C, he received 84-
85 % burn injuries. He succumbed to burn
injuries, while under the treatment in the
hospital.

OBSERVATIONS:
The plant was having a platform of size about
5200 mm L x 11500 mm B x 3000 mm H.
supported by pillars formed by m.s. channels.
There are 3 No. of circular openings in which
cylindrical shaped electrical resistive furnaces
No.1,2,3 were installed. The furnace was
installed vertically in such a way that 2000 mm
of its length above the platform and 600mm of
length below the platform. A hydraulically
operated gate was provided at the bottom
portion of the furnace. A hydraulically operated
mechanism is provided for the vertical
movement of the baskets. Two baskets one
mounted above the other were provided for
charging the jobs and have total capacity of 500
Kg. Beneath the furnace, there was an
underground quenching tank having its top
open. The size of the tank was about 2400 mm
length x 2400 mm breadth x 3000 mm depth,
which contained water as a quenching medium.
There was a pair of rails, which was laid along
the tank. The front side of the compartment was
open through which there was an access to the
tank. The rear side was provided with a
removable m.s.bar (pipe) at a height about 900
mm. The left and right sides of the compartment
were provided with the m.s. bar at a height of
about 1050 mm. There was access to the tank
from lower portion of the bar provided at left,
right and rear sides. A water feeding
arrangement was provided to each tank. The
temperature of the quenching water remained
75
0
C. The loading trolley is manually operated.
It was formed by welding m.s. plate on the
frame of m.s. channels and is provided with 4
no. of wheels. The size of the trolley is about
2450 mm L x 2450 mm B x 150 mm H.

WHAT WENT WRONG:



The injured and other worker was required to
push the trolley forward & reverse over the
quenching tank of the furnace. When the trolley
was moved, the top of the quenching tank
became open. The temperature of hot water in
the quenching tank remains about 75
0
C during
the operation. Thus the underground quenching
tanks in the Heat Treatment-Solution Plant by
reason of its depth, situation, and contents were
a source of danger. The fatal accident to the
worker occurred while pushing the trolley over
the quenching tank of the furnace. The
quenching tank ought to have been securely
fenced by providing adequate guards for
preventing access to the quenching tank. But
there was an access to the quenching tank from
NO FENCING TO TANK
NO RAILING TO
TROLLEY
all sides.

REMEDIAL MEASURES SUGGESTED:
i) The portion below the platform shall be
provided with adequate fencing by using strong
metallic guards from both sides and remaining
portion of the front and rear portion shall be
securely fenced. The height of guard rail shall
not be less than 1 metre.


40
ii) The loading trolley shall be provided with
railings guard from all sides.
iii)There shall not be any access to any person
to the quenching tank, while in operations.
iv) Precautionary notices shall be displayed in
the language understood by the workers.
v) The temperature of the quenching water shall
be monitored by providing fixed temperature
metre near the respective tanks.
























A Case Study On 41
19. BURSTING OF HEAT EXCHANGER DURING PNEUMATIC TESTING
Compiled By
R.P.Khadamkar
Deputy Director
Industrial Safety & Health, Pune
------------------------------------------------------------------------------------------------------------------------------
A fatal accident had occurred, while carrying out pneumatic test on the core assembly of the plate type
heat exchanger in the factory.

HISTORY:
The factory was involved in the
manufacturing of welded Plate type heat
exchangers. The heat exchanger had main
parts like core assembly, shell, end covers.
The manufacturing process for plate type heat
exchanger was as follows. The s.s. plate were
cut to a circular shape with holes in it for
inlet/outlet on the automated press machine.
These chevron type plates welded to form a
cassette. Depending upon the capacity of the
heat exchanger, number of cassettes stacked to
obtain a plate pack and perimeter welded
together to form a cylindrical shape core. A
circular plate with hole was welded at upper
end of the core, on which a flange (top cover)
was welded. The top cover was provided with
two nozzles welded with a flanges-one for
inlet and other for outlet. The cylindrical shell
was welded with a bottom cover. The core
assembly was fitted in the shell.
During the manufacturing process, the core
assembly was being tested for leakage at
welded joints. The testing was being carried
out in three stages. Initially the core assembly
was pneumatically tested to locate and the
leakages were rectified. Then the assembly
was immersed into water and pressurized air
was passed through the assembly to find
further leakages if any and these leakages
were rectified. Finally, hydro test was carried
out.
The pneumatic test was being carried out as
follows. The core assembly was being
clamped between the top and bottom flanges.
Out of the two nozzles provided to the top
flange, one was closed by fitting a blank
flange and other was fitted with a flange
having nipple. Then pressurized air from a
compressor was being passed into the core
assembly by a hose connected to the nipple
through a valve. With this the core assembly
got pressurized and air came out from the
portion where, welding was not proper. Then
air was being released and leakage was being
rectified by welding and again procedure was
being repeated for finding further leakage if
any.

ABOUT ACCIDENT:
The deceased was working as a helper. On the
day of incidence, the deceased and other two
workers were entrusted with the work of
testing of the core assembly required for the
Heat Exchanger. Accordingly, for carrying out
the said work, they kept the circular shape
bottom flange on a cylindrical shell. The
bottom flange was already provided with 8 no.
of clits at its periphery. The clits were in the
form of pieces of m.s. pipe of size 35 mm I.D.
x 45 mm O.D. x 40 mm height. They provided
5 no. of clits to the top flange at its periphery.
For that purpose they used pieces of m.s. pipe
each of size about 35 mm I.D. x 50 mm O.D.
x 40 mm height and welded it to the periphery
of the top flange. The core assembly with the
top flange was placed vertically on the bottom
flange kept on the shell. They inserted 5 no. of
CORE ASSEMBLY
AFTER ACCIDENT

42
studs, each of size M 27 X 1000 mm length
through the clits provided to the top and
bottom flanges and put washer, nuts from both
ends. The core assembly was clamped by
tightening the nuts from both ends of the
studs. One of the nozzles provided on the top
flange was closed by providing a blank flange
fitted with nuts and bolts. The other nozzle
was fitted with a flange having a nipple by
using nuts and bolts. A rubber hose of dia
was attached to the pressurized air pipe line
and its other end was connected to the nipple
on the flange fitted on the top end cover
(flange) through a ball valve. One worker
opened the ball valve and passed pressurized
air into the core assembly. The deceased and
the other worker observed the core assembly
and checked for the leakages. They rectified
two leakages. Then, the ball valve was opened
again and pressurized air was passed into the
core assembly for checking further leakage, if
any. The deceased reported about the leakage
in the core assembly. It was necessary to stop
the air supply and release the air from the core
assembly for rectifying the leakage. So, one
worker went at the valve for closing it, while
the deceased along with the other worker were
observing the leakage spot at the core
assembly from opposite side. When he was
about to close the valve, 3 no. of the clits of
the bottom flange and 3 no. of studs gave a
way and the core assembly burst open. The
top flange along with few cassettes turned
rapidly in vertical plane. With this the
projecting portion of the bolt, fitted to the
blank flange on the nozzle at the top flange hit
and pierced in the head of the deceased
worker. He was seriously injured and died on
the spot. The other worker fell unconscious
due to impact of bursting of the core
assembly. He received minor injury.

OBSERVATIONS:
The core assembly of the Heat Exchanger
included the parts like-Plate pack, top flange
(end cover) and bottom flange. The plate pack
was of cylindrical shape formed by 132 no. of
s.s. circular plates welded together, each of
size about 800 mm dia x 0.8 mm thick. There
were two circular openings each of size 150
mm dia in each plate provided for inlet /
outlet. The plate pack was found burst open

and found expanded. The bottom flange was
of m.s. and of circular shape having size of
about 960 mm dia x 40 mm thick. It was
found provided with 8 no. of clits welded
equidistance at periphery of the bottom flange.
The clit is prepared from m.s. pipe and was of
size about 45 mm O.D. x 35 mm I.D. x 40 mm
height. The distance between the consecutive
clits was about 380 mm. Out of these 8
number of clits, 3 number of clits were found
gave a way. The top flange was of m.s. and of
circular shape having size of about 920 mm
dia x 90 mm thick. It was found provided with
5 no. of clits welded at periphery of the top
flange. The clit was prepared from m.s. pipe
and was of size about 50 mm O.D. x 35 mm
I.D. x 40 mm height. The distance between the
consecutive clits was not equal and it was
about 700 mm, 420 mm, 420 mm, 720 mm,
800 mm. Total 5 number of studs each of size
M 27 x 1000 mm length were used for
clamping the plate pack between the top and
bottom flanges. Out of these 3 numbers of
studs were found broken. The weight of then
core assembly was about 1200 Kg. Air at



BROKEN
CLITS
BROKEN
STUDS
NATURE OF
STUD
FAILURE
pressure 6 Kg/cm
2
was supplied to the core
assembly by using rubber hose x 12 metre
length through a ball valve. There was no
pressure reducing valve provided in the air
pipe line.

WHAT WENT WRONG?
i)The centres of clits were not aligned due to
unequal diameters of the top and bottom
flanges and also due to location of clits at
unequal distances. Hence studs did not remain
in vertical position, causing unbalanced force
on the clits exerted by pressurized air in the
core assembly and bending stress on studs.
Out of 8 numbers of clits 3 no. of clits of
bottom flange gave a way and 3 no. of studs
broke.
ii)Total 5 numbers of studs were used for
clamping the plate pack between the flanges.
Out of these, 4 numbers of studs were fitted
diagonally opposite and no stud was provided
opposite to the 5
th
stud. The unequal
tightening of the nuts caused bending stress to
act on the studs, which led to failure of 3
numbers of clits and studs.
Thus equidistant holes in the flanges or clits of
adequate strength ought to have been provided
for fitting studs. Also diagonally opposite
studs i.e. even numbers of studs ought to have
been used for clamping. Thus the clamping
arrangement for the plate pack of the heat
exchanger was not of sound engineering
design and construction.
iii) The core assembly was kept on a
cylindrical shell having size about 585 mm dia
x 360 mm height x 12 mm wall thickness. The
bottom flange was of 960 mm diameter. Thus
the core assembly was projecting outside the
shell and was not well supported. A stand of
sound construction ought to have been
provided for mounting the core assembly. The
pneumatic test of the core assembly of the
heat exchanger ought to have been carried out
with the core assembly properly mounted and
fitted on the stand, so as to prevent random
43
movement of the core assembly, in case it
burst open. Thus the mounting arrangement
for the core assembly of the heat exchanger
was not safe.
iv)For carrying out pneumatic test air at
pressure of about 6 Kg/cm
2
was supplied from
the air compressor through a ball valve. There
was no pressure reducing valve provided in
the air pipe line for reducing the pressure to
safe value for preventing the bursting of the
core assembly of the heat exchanger. The
safety valve, pressure gauge, pressure switch
ought to have been provided in pressurized air
supply system. Thus the arrangement for the
pneumatic testing of the core assembly of the
heat exchanger was not safe.
v) The Safe Operating Procedure (SOP) for
pneumatic testing of the core assembly of the
Heat exchanger was not found displayed near
the test area.

REMEDIAL MEASURES SUGGESTED:
i)The clamping arrangement for the plate
pack of the heat exchanger shall be of sound
engineering design and construction.
ii) The pneumatic test of the core assembly of
the heat exchanger shall be carried out with
the core assembly properly mounted and
fitted on the stand / fixture, so as to prevent
random movement of the core assembly, in
case it burst open.
iii) The pressurized air supply system
consisting a safety valve, pressure gauge,
pressure switch shall be provided close to the
core assembly subjected to the pneumatic
testing. A pressure reducing valve shall be
provided in the air supply line before the
system. The air pressure for testing shall be
maintained to the minimum required safe
value for preventing the bursting of the core
assembly of the heat exchanger.
iv) A Safe Operating Procedure (SOP) for
pneumatic testing of the core assembly of the
Heat exchanger shall be displayed and
followed invariably.







NATURE OF
STUD
FAILURE
PNEUMATIC TESTING OF CORE ASSEMBLY OF THE SUPERMAX PLATE TYPE HEAT EXCHANGER 44



CLITS (8 NO) ON THE BOTTOM FLANGE

320 MM DIA

CLITS (5 NO) ON TOP FLANGE





FORCE ON CLIT

TOP VEIW


CORE ASSEMBLY TURNED
IN VERTICAL PLANE

CORE ASSEMBLY PLATE TORN



NIPPLE INLET OUTLET
BOLT PIERCED
STUDS M27 (5 NO) IN HEAD OF WORKER
NOZZLES
TOP FLANGE
920 MM DIA

PLATE PACK




BOTTOM FLANGE
960 MM DIA


SHELL



NIPPLE BLANK
FLANGE FLANGE



BROKEN CLITS
& STUDS
A Case Study On 45

20. SERIOUS ACCIDENT WHILE HANDLING THE HIGHLY FLAMMABLE SOLVENT

Compiled By
A.B.Pawar
Deputy Director
Industrial Safety & Health, Pune
------------------------------------------------------------------------------------------------------------------------------
A fatal accident had occurred while carrying out the manufacturing process for rubber hose, in which
use of a highly flammable solvent was involved.

HISTORY:
The factory was involved in the
manufacturing of rubber hoses required for
automobiles. The manufacturing process was
as follows. The raw rubber and chemicals
were mixed in a rubber mill to obtain sheets of
rubber compound. The rubber compound
sheets were sent to the extrusion machine,
where inner tube of the rubber hose was
prepared. Then braiding of polyester yarn was
formed on the inner tube on the braiding
machine. After carrying out surface treatment
by using toluene, the reinforced inner tube
was subjected to co-extrusion process for
outer formation. The rubber hose so obtained
was then cut and mounted on the mandrel.
Then vulcanization is carried out and hose was
extracted from the mandrel. The hose was
then packed and dispatched.
The extrusion machine used in the said
process included extrusion barrel provided
with a screw inside it. The screw was driven
by the electric motor through a gearbox. The
barrel of the machine was provided with a
straight head and the cross head at its outlet
called die head block. The braided inner tube
passes initially through a toluene trough and
through the straight head, while the rubber
strip was fed to the screw conveyor, which
passes it to the cross head to form outer over
the braided inner tube. The die head block was
required to be heated initially to maintain a
rubber flow. In the factory, heating of head
block was carried out with the help of a
portable kerosene burner. Once, it was heated
initially, further heating took place due to
friction of screw and a rubber. A trough (tank)
of capacity 15 L containing toluene was
mounted on the stand. The stand was portable


and was kept adjacent to the die head block of
the extrusion machine, while carrying out the
outer formation. The water cooling
arrangement was provided for the cooling of
the extruded rubber hose. Then the hose was
applied with a powder to prevent sticking.

ABOUT ACCIDENT:
The deceased worker was working as an
operator. On the day of incidence, the
deceased worker along with four workers
working as helpers were entrusted with the
work of co extrusion process on Extrusion


EXTRUSION M/C
TROUGH CONTAING
TOLUENE
DIE BLOCK

46
machine for the formation of different sizes of
rubber hoses. Accordingly, they started
carrying out the said work. The work involved
was as follows. The deceased worker fitted the
die head block for the job and carried out
setting. One worker ignited the kerosene
burner and started heating of the die head
block by a kerosene burner. Then the deceased
worker asked another worker to pour toluene
into the trough. While the worker was
carrying out heating of the die head block with
the help of kerosene burner, the other worker
was pouring toluene into the trough with the
help of a 20 L capacity drum manually. At
that time, the flame of the kerosene burner
reached to the toluene in the trough and
toluene in the trough and a drum caught fire.
Due to this the drum flew up and the burning
toluene splashed over all of them and they
received burn injuries. The fire was
extinguished immediately within 5 minutes
with the help of extinguishers. They were
shifted to the Hospital, for the treatment. The
deceased worker received about 50% burn
injuries and he succumbed to burn injuries
while under the treatment in the Hospital. The
other workers received about 30%, 40%, 4%,
15% burn injuries and were discharged from
the hospital after the treatment.

OBSERVATIONS:
A rectangular m.s. trough (tank) of capacity
15 litres and having size about 1200 mm
length x 150 mm width x 175 mm depth was
kept on the m.s.stand of height 800 mm. The
trough is not found fastened with the stand.
The sludge of rubber solution is found
accumulated at the bottom of the trough. The
top of the trough was found open and the
cover provided is not found fixable. The
kerosene fired burner was found used for
heating the die head block.

WHAT WENT WRONG?
The trough containing toluene was having its
top open. The vapours of highly flammable
solvent-toluene formed flammable mixture
with the air. The flammable mixture received
a source of ignition from the open flame of the
kerosene burner. As a result, flammable
mixture formed by toluene with air caught fire



The fire reached to the drum, which flew up
from the hands of the worker. The burning
toluene splashed over all of them and their
clothes caught fire and they received burn
injuries.
It is revealed that-
i)The precautions were not taken to prevent
initiation of ignition from sources such as
open flames from kerosene burner. The highly
flammable solvent toluene ought not to have
been handled unless the kerosene burner is
stopped or taken away from the work place to
prevent the initiation of ignition from the open
flame from the kerosene burner.
ii)The precautionary notice showing
information and instructions in respect of
toluene, was not displayed near the machine
to ensure safety of workers at work.
iii)Also, while carrying out the said work,
supervision was not provided on the work to
ensure safety of workers at work.

REMEDIAL MEASURES SUGGESTED:
i) The open flame kerosene burner shall not be
used, where highly flammable solvents like
toluene are being used.
ii)Precautionary notice showing information,
instruction in respect of toluene shall be
displayed near the machine. Such work shall
be carried out under supervision of a qualified
supervisor.


KEROSENE
BURNER
A Case Study On 47
21. EXPLOSION OF CONDENSER COIL
Compiled By
P.V. Adkar
Former Joint Director
Industrial Safety & Health


An explosion occurred in the ice manufacturing factory in which 5 workers and the occupier got severe
burn injuries. One worker later succumbed due to his burn injuries in the hospital. The factory was
existing since 5 years and there was hardly any accident except minor ammonia gas leakage.
ABOUT INCIDENCE:
In this factory, for the refrigeration cycle with
use of Ammonia as a refrigerant, there were two
sets of condensers out the factory building. One
set of the condensers was located close to
factory building where the air flow was poor.
The occupier decided to shift this condenser to a
new place to get better cooling effect. There
were 3 coils (10 U bends, 20 Pipes) for this
condenser. It was decided to convert existing 3
condenser coils to 6 coils by cutting in between
to have (5U bends, 10pipes in each). This work
of shifting and installation was allotted to a
contractor. The total job was fabrication work
involving various valves, fittings liquid & gas
line header fitting etc. The fabrication work was
completed in open area & then the condenser
tubes were tested for leakage by using
compressed Nitrogen gas.
Then, the condenser was mounted at the new
location. Both the headers & valves were fitted.
It was again necessary to check for leakage after
new assembly. Then contractor asked one of the
workers to bring either Nitrogen or Carbon-di-
oxide cylinder from supplier. Without testing
the content gas of the cylinder, it was connected
to one of the condenser pipe in series. Only the
inlet valve of this condenser was open & all the
other valves including the outlet valve of this

condenser were closed. The gas was released
from the cylinder at14 kgs/cm
2
. There was
immediate explosion of the condenser tubes
which resulted into burn injuries to 6 persons.
They were immediately admitted in the hospital.
One of them, later succumbed, to his injuries on
the same day,
WHAT WENT WRONG:
During inquiry it was revealed that the gas
cylinder used was of oxygen instead of
Nitrogen, and also ample quantity of
compressor oil was noticed inside the condenser
tubes. Hence, when the oxygen came in contact
with the oil, there was an explosion. The
contractor could not identify the Oxygen
cylinder hence caused this incidence.
REMEDIAL MEASURES:
1.Before the use of any gas from the cylinder,
its properties, hazards, suitability shall be
carefully studied by responsible person
supervising the job.
2.The pressure vessels, with its fittings
(including Pipes) shall be tested, hydraulically
only for leakage.
3.Oxygen cylinder should not be used for
pressure testing work.




A Case Study On 48
22. Fatal Accident due to Splashing of DMDS (Di Methyl Di Sulfide)

Compiled By
V.M. Yadav
Deputy Director
Industrial Safety & Health, Pune

------------------------------------------------------------------------------------------------------------------------
An fatal accident that took place in a factory to a worker while working in DHDS ( Diesel Hydro De
Sulfurisation ) complex at HGU (Hydrogen Generation Unit) plant in a Refinery due to splashing of a
chemical named Di methyl di sulfide on his body.

Incident :-.
On that particular day, the worker,a
maintenance technician, alongwith his
colleagues from maintenance dept. went to
HGU( Hydrogen generation Plant) in DHDS
(Diesel Hydro De Sulfurisation) complex to
connect a metal drum containing @225 litre
(240Kg) of chemical named DI Methyl Di
Sulfide (DMDS) to the drum unloading
manifold already provided on the first floor in
HGU section . This drum was placed on this
floor for connecting with the help of a crane.
This chemical was required to be decanted
under nitrogen atmosphere. For this purpose one
manifold was provided on the first floor with a
arrangement of provision of connecting two
hose pipes , one for nitrogen line and another
hosepipe for liquid decantation. The nitrogen
inlet pipe was connected to the nitrogen header
having pressure of 5 kg/cm through a rotameter
and a valve to control it.
This worker and his colleague put the barrel on
the stand in vertical position, opened the
threaded caps (corks) from the two openings(
one od & another of ) of the drum and
connected the nipples with valve and hose pipe
to these two openings. They tilted the barrel and
kept the stand & barrel in horizontal position.
Then they connected the other free ends of the
hosepipes to the respective pipelines. While
these connections were going in, all the four
valves on these two lines were closed. Then the
said worker opened the valve near the near the
drum on N2 line and after that opened the
second valve on the manifold of N2 line. As
both the valves on the N2 line were opened, N2
gas with a pressure of about 2 kg/cm entered
the drum and the drum got pressurized.


At that moment the other workers who were
nearby, heard some sound from the barrel so
they told the said worker to get away from the
barrel, but because of this excess pressure , the
drum got opened up at the seam of the top dish
(cover) and the inside DMDS chemical splashed
on the body of the worker who was in front of
the barrel. Some of this chemical also splashed
on the body of other worker who was nearby..
The said workers clothes got soaked in DMDS
and he inhaled the vapours of DMDs. He
himself immediately rushed to the bathroom on
the ground floor , opened the water showers and
stood below the showers.

He was feeling drowsiness and within 5 to 10
minutes, he became unconscious and fell down.
Other workers took him to factory medical
centre .Doctors examined him, gave first aid and
then he & other worker both were shifted to
nearby hospital. But the said worker died in the
hospital after 2-3 hours. Other worker was in
hospital for about 5-6 hours for treatment and
then he was discharged.

Manifold

Process requirements in HGU section in brief
The DHDS plant was in the stage of start up
after a gap of about months because of a shut
down taken in the plant. The new catalyst was
charged in to the reactor no.73-T-
02.(hydrogenator).The Pre-sulfiding activity
was going as new catalyst was loaded in 73-T-
02. A sr. Process Engineer (from Process
analysis & design) was monitoring the sulfiding
activity. At about 12.05 a.m.on 30/5/08 first
recycle gas sample of PDS (pre desulfurisation)
was collected and sent to the lab. As per this
Process Engineer, in this sample the H2S
content was NIL whereas it should have been @
2000 ppm. Also meanwhile in the DMDS
storage tank(73-D-O8), the drum (DMDS) level
was dropping fast. So he advised to unload one
DMDS barrel in DMDS storage tank(73-D-O8)
.The storage capacity of this tank no. 73-D-08 is
500 litres. Accordingly Incharge of Maintenance
Dept , as per request from process dept. issued
hot work permit for shifting the DMDS barrel
on the first deck (floor) in HGU section to the
crane operator & cold permit to his assistants
make the nipple and hosepipe connection with
the manifold.
After getting the information from the
maintenance dept. about the connections being
made to the manifold , the process department
operators starts unloading DMDS as per the
process requirement.
The procedure followed by process dept. for
unloading DMDS from the barrel to the DMDS
storage tank (73-D-O8 ) located on the ground
floor is as follows
i)Stop the DMDS transfer pump(This pump
transfers DMDS from the TANK 73-D-O8 to
the reactor.)
ii) Reduce the blanketing nitrogen flow to 2
Nm3/Hr by watching the rotameter reading.
When the DMDS pumps are on , the N2 flow
rate is kept at @ 5 Nm3/Hr.
iii).Open N2 blanketing valve on the drum then
open audco valve on manifold slowly.
iv)Open the DMDS unloading valve on the
DMDS drum then open two audco ball valves
on the manifold and one on Tank 73-D- 08
v) See the DMDS level in Guage Glass.



49
vi) Slowly unload the DMDS to DMDS storage
tank (73-D-O8)
vii)Once the entire contents of the drum is
emptied , close the loading point valves & drum
hose connecting valves.
viii)Maintain nitrogen flow for purging to
normal 5 Nm3/Hr

Properties of Di Methyl Di Sulfide:-
As per the various material safety data sheets of
DMDS referred, properties of this chemical are
as follows, The M.S.D.S. obtained gives the
following relevant information
Name of chemical : dimethyl disulfide
CAS No. : 624-92-0
UN No. : 2381
Appearance: pale yellow liquid
Odour : special foul smell
Boiling point: 110 c
Flash point: 24 c
Relative density : 1.06 (water=1)
Data on Routes of exposure: The substance
can be absorbed into the body by inhalation and
by ingestion
Effects of short term exposure: The substance
is mildly irritating to the skin and is irritating to
the eyes and the respiratory tract. The substance
may cause effects on the central nervous system.

Observations at the site of accident and
findings:-
The accident took place in HGU section at
DHDS complex on the first floor. On the first
floor , a 1 pipe vertical manifold having
connections of two pipes of dia and 1
with audco make ball valves is provided. A
line coming from the nitrogen header
passing through a rotameter and a valve having

Bulged DMDS
barrel
a pressure of 5 kg/cm2 is connected to the top
of the manifold. The bottom of the manifold is
connected to the DMDS storage tank ( 73-D-08)
which is located on the ground floor by means
of a 1 line. On this site near the manifold at
first floor , the drum was lying burst open .The
top cover of the drum had opened out from its
seam joint alongwith connected nipples and
valves and was thrown to some distance towards
the manifold. The bottom & shell of the drum
was thrown back from the manifold. The
bottom of the drum had become bloated or
swollen. The N2 valve provided on the top
cover was in full open condition, whereas the
liquid valve on this cover was in closed
condition.


There was not a single pressure guage provided
on the N 2 line. The flow of N2 was being
controlled by adjusting the flow through a
rotameter with the help of a valve. I alongwith
two Engineers from the said factory provided a
pressure guage on the N2 line after the
rotameter to find out the correlation between
flow rate and pressure. It was found that when
the flow is 3 nm3/ hr , the pressure is @ 2
Kg/cm2. The markings on the rotameter were
also not visible. The maximum N2 pressure
requirement for this HGU section was 1.5 to 2
Kg/cm2. The nitrogen which was being received
from the N2 header was having pressure of 5
Kg/cm2. No pressure reducing valve was
provided on this incoming n2 line from the
header before it enters the HGU plant to reduce
the pressure from 5 kg/cm2 to required 1.5
kg/cm2. It was also found that , no personal
protective wears such as rubber apron, hand
gloves, goggles, face mask etc. were

50
provided to the maintain ace persons who were
carrying out the job of connecting DMDS barrel
to the manifold. Considering the toxic properties
of DMDS mentioned above, these personal
protective wears were required to be given to
the workers.


What Went Wrong:--
i) A pressure reducing valve on the nitrogen line
before it enters the HGU section to restrict the
nitrogen pressure below a safe value to avoid
overpressurising of the barrel was not found
provided.
ii)A pressure guage after the manifold audco
valve on nitrogen line to know at what pressure,
the nitrogen is being allowed to enter into the
barrel was not found provided.
iii)Suitable personal protective wears to the
maintenance workers while carrying out the
DMDS barrel connection considering the
hazardous nature of this chemical were not
found provided.
Remedial Measures:
Following remedial measures are suggested to
avoid recurrence of such type,
i)A pressure reducing valve to reduce the
pressure of incoming N2 gas to a safe
minimum value , sufficient for maintaining
inert atmosphere inside the plant shall be
provided.
ii)Fittings such as pressure gauge, safety valve
shall be provided on the nitrogen line.
iii)Suitable personal protective wears shall be
provided to the maintenance workers while
carrying out the DMDS barrel connection.
iv)Proper supervision , instructions and training
shall be given to the workers involved in
handling of hazardous chemicals.


Top cover of
barrel
A Case Study On 51
23. AN EXPLOSION OF REACTION VESSEL USED WITHOUT EXAMINATION
By
P.V. Adkar
Former Joint Director
Industrial Safety & Health



A big explosion was caused as no care was taken to examine equipments on shifting at new place.

HISTORY:
An explosion of reaction vessel took place in the
chemical factory causing burn injuries due to
spurting of chemical on the bodies of six
workers ,and proved fatal in case of one worker.
The factory manufacturing Hydroxyl
Ethyledene Di Phosphoric acid (HEDP) was
shifted from its old place to new place in the
chemical zone area. The reaction vessels, glass
condensers, and all other accessories were
required to be transported to new place located
about 50 Kms from previous place. Hazardous
chemicals like acetic acid, Phosphorous tri
chloride, Butanol were used in the process.

ABOUT INCIDENCE:
On the day of accident, 275 kgs of acetic acid
was taken into the jacketed reaction vessel from
overhead tank and was heated by steam in the
jacket. Afterworlds 215 kgs of Acetic acid and
230 Liters of Phosphorous tri chloride, was
transferred by air pressure into two different
overhead tanks. When the temp had reached
65
0
C Acetic acid and Phosphorous tri Chloride
were passed into the reactor slowly through two
different pipes lines. The reaction being
exothermic the temperature reached to 75
0
C at
that points, vapours of acetyl chloride were
passed to glass condenser to liquefy and the
condensate was passed into another reaction
vessel containing Butanol. The condenser outer
body tubes and tubes inside it, used for the
water circulation were of glass. The both
reaction vessels were installed on first floor. The
feeding of Phosphorous tri chloride was stopped
after 8 hrs. Afterwards when condensate Acetyl
chloride was stopped passing into the reaction
vessel of Butanol, rubber piece was introduced




in the flange joint and workers were operating
the reflex valve to take condensate in the
Reaction vessel at that moment worker saw
vapours in the condenser joining U shape glass
tube for reflex arrangement. Within no time the
reaction vessel exploded and the stirrer along
with its lid was thrown upward upto 15 meters
and entangled in the structured ( lid downwards
,weighing about 750 kgs.) the hot chemical
spurted on the body of 6 workers working
nearby causing serious burn injuries. One
worker expired in the hospital. Complete roof
and equipments were damaged.

WHAT WENT WRONG?
1. Before actual operation of the condenser glass
tubes and water tube inside it were not tested for
leakage of water at elevated temperature.( Water
was circulated at normal temperature to test the
leakage; when leakage was not detected.)
however , the leakage caused at elevated
temperature.
2. Inspite of the fact that if vapours of Acetyl
chloride come in contact with water there is a
violent chemical reaction causing evolution of
HCL fumes with large amount of heat, glass
was used for condenser body and inner water
circulating tubes.
3. It was found that the condenser was not tested
at different temperature circulating water of
leakage.
During transport, crack was remained
undetected. At raised temperature, the water
leaked and came in contact with Acetyl chloride
fumes causing violent reaction emitting very
high heat. It caused more leakage and as reflex
valve was opened water went directly inside the
reaction vessel causing violent reaction with 90


kgs of Acetyl chloride causing tremendous heat
and hence the explosion. During design proper
material for condenser would have averted the
said accident.
(The author personally visited the National
Chemical Laboratory Pune, where small
experiment was requested & arranged to be
carried out in Lab, by adding drop by drop 5 cc

52
of water by pipette in 10cc of Acetyl chloride
taken in test tube , when temp of 15
0
C raised in
10 sec. and lab was filled with HCL gas. This
will give idea to the readers about the amount of
heat and violent reaction.)
REMEDIAL MEASURES: Graphite
condensers were used afterwards instead of
Glass which was more fragile.





A Case Study On 53
24. MINOR FIRE CAUSING TRAGEDY
By
P.V. Adkar
Former Joint Director
Industrial Safety & Health



A major accident occurred in a factory in Maharashtra which Involved hospitalization of about 65
workers and as well as loss of lives of two employees. The hospitalisation period varied from 4 days to
one week. The accident involved a minor fire and at the time, when attempts were being made to
extinguish the fire it was not realized that the consequences would be so terrible. In fact there was hardly
any property damage because of the fire and not a single person received burn injury. Yet two persons
lost their lives and sixty five persons had to be admitted to hospital.
ABOUT INCIDENT:
It was a chemical factory manufacturing dyes
and intermediates. It was situated in a remote
village. There was a horizontal blender mixer
with a motor driven stirrer. In this factory, in the
morning the mixer was charged with raw
materials through the small opening provided on
the top for the purpose. The operator who was
working on this mixer switched on the motor
and the Z-arm stirrer started rotating. The
operator was satisfied that mixing of the
material, which was in the powder form, was
going on smoothly. There was some time to
complete this batch. After some time however
he noticed some smoke coming out through the
loosely closed top opening. This was unusual.
He immediately stopped the motor and opened
the cover of the opening. To his horror, he
found that the material inside had caught fire. In
fact, it was not exactly fire where flames are
jumping but it was only a smouldering fire.
Some material had started slowly burning. The
operator shouted for the chemist who in turn
called the fire brigade officer of the company.
The Fire Brigade officer had recently joined the
company. He had just retired after a long
meritorious service from the fire brigade of a
big city. After joining the company, he had
immediately ensured that the factory is well
equipped with necessary fire fighting
equipments. As soon as he got the message, he
immediately rushed to the spot. He surveyed the
scene. It was a minor fire. No cause for panic.

He asked others to stand aside and with a dry
chemical powder extinguisher started covering
the smouldering material with the dry chemical
powder. He was bending over the mixer opening
and, with the extinguisher in hand was fighting
the fire. Within no time, the extinguisher was
exhausted but the fire had not been
extinguished. The material was still burning.
Smoke, dust, fumes were still coming out.
The fire brigade officer took the second
extinguisher and continued to fight the fire. The
machine operator and the chemist were on the
platform giving him all the help they could.
Obviously this was not a usual scene and there
was some commotion attracting attention of
everybody who was in the factory. Almost
everybody came to the hall and gathered in the
small place. To them it was an interesting sight.
Three persons were busy in fighting
smouldering fire and the fire refusing to get
extinguished. Smoke continuing to come out.
Anxiety writes large on the faces of the three
who were fighting the fire. There was no reason
for the workers, who had gathered there, to run
away. After all, there were no flames, no danger
of a major fire breaking out. Apparently
everybody was enjoying the scene. The fire was
really refusing to die. The second extinguisher
was exhausted, the third one, the fourth one.
The perspiring fire brigade officer bravely
continued his fight and the onlookers in the
hall the continue enjoying to watch the fun. This
went on till all the extinguishers were


exhausted. The material in the mixer continued
to burn. But after some time there was no more
material in the mixer to burn. All the material in
the mixer had been burnt in the fire. The fire
thus automatically died down. All the three
persons busy on the platform heaved a sigh of
relief. They were completely exhausted by their
efforts. There was nothing more to watch, so the
workers went back to their work. Everybody
was happy and relaxed. There was no reason to
imagine that a big tragedy was about to strike.
AFTER EFFECTS:

After three or four hours the fire brigade officer
was the first to report to the doctor that he was
not feeling well. The doctor examined him and
realized that he needs to be admitted to the
hospital. The nearest hospital was the civil
hospital about 20 kilometers away. By the time,
a vehicle could be arranged the operator had
also taken ill. The chemist also was showing
same symptoms. All three were put in the same
vehicle. On way to hospital, the fire brigade
officer died. Another died in the hospital. When
these three serious patients were being taken to
hospital the workers who had, by then, gone
home started reporting to the doctor. When
workers, one by one started reporting to the
doctor, it was realized that there was a major
emergency. Arrangements were immediately
made to shift them to the civil hospital at the
district headquarters. About 65 persons were
required to be hospitalised and treated. They
were in the hospital for varying period from 4
days to a week.

54
WHAT WENT WRONG?
First: When the fire brigade man decided to use
the dry chemical powder extinguisher on the
burning material, he was trying to starve it of
oxygen by covering it with powder from the
extinguisher. He was not aware that there was
already highly oxidising chemical in the burning
material and hence it did not require any oxygen
from air. Thus the sophisticated extinguishers
were of no use to fight this fire and the material
continued to burn. Secondly, when the material
was burning it was giving out toxic gases viz.
oxides of nitrogen. Unknowingly the three
persons fighting fire were inhaling the toxic
fames. Those workers who were watching the
fun were, of course, blissfully unaware about
the toxic fumes they were inhaling. The fumes
were of oxides Nitrogen which do not have
irritating effect like chlorine. Otherwise
everybody would have remained away.
Moreover oxides of nitrogen have delayed effect
and hence the delay in the symptoms of
sickness.

COULD THIS BE AVERTED?
Instead of using a sophisticated DCP
Extinguisher a bucketful of water or two could
have extinguished smouldering fire within no
time Moreover question of any toxic exposures
(and the tragedy) would not have arisen. In spite
precautions taken for prevention of accidents,
major emergency can occur and one should
prepare to tackle the emergency to keep the
damage to the property and to life to the
minimum The above accident, illustrates the
need for the proper on-site emergency plan
studying all hazards and contingencies in
details.






A Case Study On 55
25. EXPLOSION IN THE CURING OVEN
By
P.V. Adkar
Former Joint Director
Industrial Safety & Health


A fatal accident took place in grinding wheel manufacturing factory, due to an explosion of the curing
oven. The moulded grinding wheels kept on trolley rack were loaded in the oven. Initially the only
electric heating system was provided as the heating media. But two years before the accident, LPG gas
heating system was fitted as an option to electrical heating system due to power shortage. The accident
took place while switching over the system from electrical heating to gas heating. The oven was not
provided with the explosion flaps.
ABOUT INCIDENCE:
On the day previous to the day of accident at
about 11p.m., the loaded oven was started on
gas heating system. An automatic arrangement
by solenoid valve was provided to cut off the
heating after reaching the set temperature. It was
observed by the supervisor that after about 4
hours of heating and even after attaining the set
temperature the heating was on, due to some
defects in gas system. On the day of accident, at
about 8.30 a.m. the first shift supervisor switch
over the system to gas heating. He also found
same defect hence continued heating by
switching over to electrical heating. At about 11
a.m., the Assistant Manager tried to detect the
defect in the system. To check the defect in the
system it was put on to gas heating from
electrical. He tried to the set value of set temp to
145
0
C from 140
0
C, when suddenly, the oven
exploded and Assistant Manager and the
supervisor were thrown away. They received
serious injuries but in case of supervisor it
proved fatal.
WHAT WENT WRONG?
Investigation revealed that after switching the
system to electrical from gas and in case failure
of solenoid valve, gas can leak inside the oven


causing explosive mixture. In such situation gas
detection and alarm system was not provided to
give warning. The leakage of gas was caused
between 8.30a.m.to 11.00a.m.when gas system
was turned off. When Asst. Manager started the
gas system the spark at burner exploded the air
fuel mixture. In the process of curing of
grinding wheels no flammable vapours were
evolved. The main cause of accident was not
maintaining the solenoid valve in order.
REMEDIAL MEASURES:
1.Leak detector and alarm appliance
arrangement may be fitted to detect the leakage
of gas in the chamber on switching over system
to electrical
2.Solenoid valve shall be inspected and well
maintained.
3.Arrangement to trip electrical heating system
in case of leakage of gas.
4.Explosion flaps arrangement shall be provided
on the oven.





A Case Study On 56

26. Fatal Accident due to collapse of a Cement silo in a Readymix concrete Plant

Compiled By
V.M. Yadav
Deputy Director
Industrial Safety & Health, Pune
-----------------------------------------------------------------------------------------------------------------------------------------

The accident that took place in a factory due to the collapse of a silo used for storing cement, on a
cement bulker which was parked near the silo. Three persons who were inside the bulker died in this
accident.

About the Incidence

In this factory the manufacturing of ready mix
concrete is being carried out by mixing
cement, fly ash, sand, khadi and water in
proper required proportions, The production
of concrete was stopped since @ 9.00 pm
previous night. The plant was in closed
condition as there was no production going
on. One bulker came at the entrance of factory
at @ 1.30.a.m. to unload loose cement which
it was carrying in to the silos. Stores Incharge,
asked them to bring the bulker inside and to
park it near the silo no.2 in reverse direction.
Accordingly the Driver parked the truck in
reverse direction keeping a distance of @ 8-10
ft from the silo. Stores Incharge then went
near the silo and asked the cleaner of the truck
to make the necessary hose pipe connections.
After making the connections the unloading of
cement from bulker to silo no. 2 was started.
Normally unloading of one full bulker
(capacity 15-19 tonnes) takes @ one hour.
Stores Incharge stopped the unloading after 10
minutes as the production was not going on.
He wanted to check the level of cement in silo
no. 2 in the morning after any helper joins
duty and then restart the unloading. Stores
Incharge asked the cleaner to disconnect the
pipe and asked the driver of the bulker to shift
his vehicle little bit as one more fly ash bulker
was expected to come for unloading. This fly
ash bulker came at @ 3.15 a.m. It was parked
near to this earlier cement bulker, was
unloaded in fly ash silo no.3 as per the
instructions and supervision of Stores
Incharge. This fly ash bulker left the plant at
@ 4.35 a.m. Then at about 7.30 a.m. Stores
Incharge and other workers in the factory
heard a loud sound in the factory. He came out
of his cabin and saw that the silo no. 2 has
fallen on the bulker which was parked near the
silo in the night. After going closer to the
bulker he saw that the silo had fallen mainly
on the cabin of the bulker and the cabin was
almost became flat. Then police and fire
brigade was called. As the silo was full with
cement, it was cut from the side and some
cement was removed from it and then with the
help of a crane the silo was lifted and three
bodies were removed from the driver cabin.

Observations:



1.A huge silo had fallen on the cabin of a truck
(bulker) which was parked near to it.


2.Some front portion of the cement tank on the
tanker had plunged in the ground because of
which the tail portion had got lifted in the air
3)A small pit was created because of the
collapse of the silo in the soil below the silo
4) The Silo legs twisted & Shell/cone of the silo
has fallen on the Cabin
5)3-persons who were sleeping inside the cabin
died as silo had crushed the cabin.
6)3-Nos of silo leg top end to lug base plate
fillet weld joint sheared-off from the lug base
plate.
7)1-No silo leg top end to lug base plate fillet
weld joint remained intact.
8)Some of the foundation bolts sheared off from
base plate location.
9)Threads of Some of the Foundation bolts
sheared off.
10)Some foundation bolts were seen in broken
condition and some were in bent condition.
11)Lugs along with base plate, gussets & pad
plates remained intact.
12)The bracings of the legs were also twisted /
bent.
13)The bracings of the legs were also twisted /
bent.




57


The details of the silo which had collapsed
A)Silo Details:
a) Service : Cement
b) Capacity : 200T
c) Shape : Circular
d) Dimensions :

I) Diameter : 4000mm
II)Shell height : 12000mm
III)Bottom cone height :700mm
IV)Top Cone Height : 400mm
e) Support Type: Legs
f) Qty Of Legs: 4-Nos
g) Leg Member Size ISMB- 350
h) Leg Height-4500mm
i) Foundation Bolt Size- 24
j) No. of Foundation Bolts on each Leg :
4Nos.

Observations /Findings:

a)Activities Happened Before Accident:
1)Silo was filled upto some height / capacity.
Exact Capacity not known
2)Cement unloaded for about 10-15Min from
this said bulker in the night & stopped
3)Complete Cement bulk tanker was not
unloaded.
4)In the absence of the helper to check the
exact filling level, the silo filling activity
was abandoned.
5)The Bulk tanker was parked near to fatal
silo.
6)There was movement of two bulk tankers
(cement bulk tanker & fly ash bulk tanker
near this said fatal silo in the night) near the
silo no. 2 structure.



What went wrong?

(a) Settlement of the Soil & Foundation:
i)Since there was a water tank below the
Centre Silo & above its foundation, there are
more chances of its leakage & additional load
created by it on the foundation.
ii)The leaked water from the tank might have
loosened the soil below the foundation
iii)After a period, the soil might have loosened
& allowed the settlement of foundation due to
cycle of Silo loading & unloading.



(b)Silo Legs & foundation Bolts Not Designed
Properly:
i) Since the Legs has been twisted & bent, it is
quite possible that they were not designed
properly to consider wind, seismic loading &
moments generated in empty & operating
condition.
(b)The Connection of the bracings & Legs not
done properly, the load was transferred to web
in inclined direction & not in Leg Axis plane.
(c)Since Gussets were not provided at base plate
& cap plate locations, the shearing/uprooting of
weld joint due to sudden loading would have
been avoided & would not have resulted in the
bending of the legs.
i) The base plate orientation was not correct
with reference to leg web orientation. This has
resulted in wrong location/orientation of the
foundation bolts.
ii)In the present condition, there is only one bolt
which is under Tension & one bolt under
compression. The other two will act as neutral.
iii)This would have resulted in the failure of the
Foundation Bolts.
58
iv)Broader Legs base or higher legs PCD would
have made the silo more stable & would have
avoided its tilting.
v)The broad PCD would have broader PCD
would have been achieved by welding the Legs
Flange on the Shell & not on the Cone.
(c) Non Functioning of Silo Pressure Relief
Valve:
i)Silos are deigned for the static pressure of the
connected blower.
ii)There is always a +ve pressure during the
loading.
iii)It might have happened that at the time of
Silo loading, if the silo was full & level was not
known to the operator, they must have realized
that the material is not going inside the silo &
must have stopped.
iii)The Silo must have been filled more that its
capacity.
iv)The air which must have come along with
material, could not be released due to non
functioning of the pressure relief valve (breather
valve).
v)This would have created some movement
inside the silo material & would have added an
additional load on one of the side & added on to
the moment & would have resulted into falling
of Silo.
(d) Dashing of the bulk tanker with the silo
structure.
i) The bulk tankers were parked in the reverse
direction near the silo no. 2
ii)They were moved two three times to make the
hosepipe connection with silo no.2 and then to
shift a little in order to make space available for
another flyash bulk tanker.
iii) It is possible that during this movement one
of this bulk tanker dashed the structure around
the conical portion of the silo.And as the silo
was full, this might have resulted in shifting the
centre of gravity and initiating the bending/
tilting of the silo adding uneven forces on the
leg supports.

Conclusion :
From the various probable causes for the failure
/collapse of the silo mentioned above it can be
concluded that there were lapses in providing
and maintaining a plant which was properly
designed and fabricated and following the


system of work in the factory that were safe and
without risk to the health of workers by
i) Not preventing the possible seepage of water
from the curing tank which he had provided
below the middle fly ash silo and thus not
preventing the possible settlement of the
foundation of silo no. 2
ii) Not providing a barrier metal guard of
adequate strength to prevent any direct dashing
of vehicle on the silo structure.
iii) Allowing to unload the cement from the
bulker when the silo level was not surely known
iv) Allowing to park a vehicle inside the factory
v)Not providing a silo having its legs, base
plates, cap plates, foundation bolts properly
designed and fabricated


59
vi)Not connecting of the bracings & Legs
properly ( the load was transferred to web in
inclined direction & not in Leg Axis plane ).
vii)not providing Gussets at base plate & cap
plate locations,( the shearing/uprooting of weld
joint due to sudden loading would have been
avoided & would not have resulted in the
bending of the legs).
viii)not providing the correct base plate
orientation with reference to leg web
orientation. (This has resulted in wrong
location/orientation of the foundation bolts.)





































A Case Study On 60
27. A FATAL ACCIDENT DUE TO COLLAPSE OF DOOR
Compiled By
R.P.Khadamkar
Deputy Director
Industrial Safety & Health, Pune
------------------------------------------------------------------------------------------------------------------------------
A fatal accident to a Security Watchman occurred, while closing the sliding gate of the factory shed.

ABOUT THE FACTORY:
The factory was involved in the manufacturing
of the various components required for
automobile industries. The plant included a
factory shed and different machines installed in
it. The factory shed was provided with a
manually operated sliding gate at the front side,
which was made up of m.s. having weight about
700 Kg. A guide roller support bracket having 4
No. of rollers was welded at left end of the
opening and a stopper in the form of a piece of
channel was fixed at the right end. The gate
was provided with wheels at its lower end. The
gate slides between the rollers such that a front
pair of rollers supports gate from front side and
a rear pair of rollers supported gate from back
side. The gate wheels moved on the rail
provided at the ground.

ABOUT THE INCIDENCE:

The deceased was working as Security
Watchmen through the Contractor. The nature
of their work was to guard the plant and keep
watch on the gate of the factory. On the day of
incidence, the deceased and other watchman
resumed duties at about 8.00 P.M. The plant
was in operation in a General Shift. After end of
the shift, workers and staff left the factory. Both
the watchmen switched off the light and closed
the internal doors. The sliding gate of the
factory shed was to be closed and was to be
locked as usual. As the gate was heavy, it was
required to be operated by both watchmen. The
front pair of guide rollers and right side roller of
the rear rollers of the bracket were broken and
hence the gate was required to be pushed
towards wall and then required to slide towards
right side. At about 9.30 P.M., the gate was
being closed by sliding it towards the right side.
The deceased was pushing the left side and
other watchman at right side of the gate. At that
time, while pushing the gate from left to right
side for closing, the welding joint of the guide
roller support bracket at the pillar broke. As a
result, the gate fell down on the bodies of both
the workers and they were seriously injured.
One watchman succumbed to injuries, while
under the treatment in the Hospital. The other
watchman received fracture injuries to femur of
his left leg.

OBSERVATIONS:
The sliding gate of the factory shed was
manually operated. The overall size is about
5000 mm L x 3000 mm H and having weight
about 700 Kg. It was fabricated by using m.s.
channels each of size 75 mm x 40 mm x 5 mm,
m.s.sheets of 14 guage. A guide roller support
bracket was having a plate of size 500 mm L x
250 mm B x 10 mm thick and fixed with 4 no.
of guide rollers on lower side. The size of each
guide roller was about 75 mm dia x 25 mm
SLIDING GATE
FALLEN ON
WORKER
61

width. The gate along with the guide roller
support bracket was found lying on the ground.
The front pair of guide rollers and right side
roller of the rear rollers of the bracket was found
broken. The bracket was found detached from
the pillar at the welding joint. The welding joint
of length about 300 mm was found broken and
was in rusted condition. A piece of channel
having size about 100 mm x 50 mm and is fixed
at the right pillar as a stopper.

WHAT WENT WRONG:


i)The front pair of guide rollers and right side
roller of the rear rollers of the bracket were





broken and hence the gate was required to be
pushed towards wall and then required to slide
towards right side. Both the workers were
required to operate the gate, which was heavy.
There was support from only one of the rear the
guide rollers and load of the gate was
transferred to the welding joint of the support
bracket with the pillar. As a result, the welding
joint gave a way, while both the watchmen were
operating the gate. The broken guide rollers
ought to have been replaced by new one,
immediately for preventing the transfer of load
on welding joint and for ensuring the safety of
workers at work. But rollers were not replaced,
whereas it was reasonably practicable.
ii)The welding joint between the guide roller
support bracket and the pillar got rusted and
hence became weak. It could not withstand the
load of the gate and gave a way. The welding
joint ought to have been checked for its strength
and ought to have been maintained by welding it
again to ensure the safety of workers at work,
whereas it was reasonably practicable.




REMEDIAL MEASURES SUGGESTED:
The sliding gate and its accessories shall be
maintained to ensure the safety of workers at
work.

GUIDE ROLLER
SUPPORT BRACKET
ROLLERS
BROKEN
OPENING WHERE GATE
WAS PROVIDED
PLANT 62



SLIDING GATE
BRACKET
GUIDE ROLLERS



WHEEL
G.L. G.L.

GATE
SLIDING GATE
500 MM X 250 MM X 10 MM THICK
BROKEN ROLLERS

3000 MM 75 MM DIA X 25 MM WIDTH
WELDING JOINT BROKEN


5000 MM TOP VIEW
OPENING SLIDING DOOR SLIDING DOOR
A Case Study On 63
28. PREVENTION OF BOILER CHIMNEY
Compiled By
P.V.Adkar
Former Joint Director
Industrial Safety & Health,



A very big tragedy has been averted due to excellent co - ordination and timely implementation of on
site plan. Incident of bending of Boiler Exhaust (Chimney) of Factory and its possibility of likely to fall
on Ammonia Tank installed in open area any time before it was safely removed. Had it fall down then
min 3 Kms area would have been badly affected!

ABOUT INCIDENCE:

The factory was engaged in manufacturing of
fruit syrup/crush like Mango, Orange Grapes
etc. All utilities for the plant were located at one
place like Refrigeration Plant using Ammonia
stored in the tank of 3 ton capacity. Steam
Boiler was installed nearby with huge exhaust
chimney, Compressors and electrical sub-
station. Due to change of fuel the effect on
chimney pipe wall and joints was unnoticed for
along time. Boiler Exhaust (Chimney) at factory
was observed to be bending on one side at 7.30
PM on that day. The chimney made of Mild
Steel, consisting of five sections had a total
length of 30.5 meters. The bend was
around 25 degrees. The bend was erupted near
the joint of 3
rd
and 4
th
section from ground. This
was due to corrosion defect which was earlier
detected in section 3 of the chimney.
Immediately after noticing the bend, factory
operations were stopped, as a precautionary
measure to avoid any safety hazard. The boiler
was de-pressurised. All the workmen were
present in factory were called at emergency
assembly point, after reconciling the headcount,
only utility operators were retained in factory
and all other workmen were released. All the
person present at site was provided with
Personal Protective Equipment ( PPEs) such as
CHIMNEY BENT
BY 25 DEGREES

safety shoes and helmets. Fire Brigade and
Police were communicated to arrive at site to
meet any possible safety risk. Directorate of
Industrial Safety & Health , took lead as a
Member Secretary of the District Crisis Group.
Directorate of Boilers, Pollution Control
Department, Local Administration was also
informed about the situation of the incident. An
ambulance and doctors were arranged to be
present at site. Ammonia tank was covered with
sandbags and PUF panels to minimize any


possible damage to the same. Two empty
ammonia tankers were arranged to carry out
transfer of ammonia from system to tankers, as
a contingency plan. To carry out repair of
Chimney, required height of crane was of
minimum 95 feet. The cranes available in town
were of maximum 75 feet height, and hence a
crane of required height was mobilized urgently
from nearby city. Crane wheel punctured two
times in journey .Once on the way to city and
second in the entry door of the factory. Before
starting the actual activities,



64
Crane crew was briefed about safety
requirements. All safety equipment viz safety
shoes, helmets, safety belt etc were provided.
The joint between 2
nd
and 3
rd
section from
ground was opened, by removing the bolts
between the flanges to bring down the top 3
sections. All top 3 sections were tied up with
crane before removing the bolts.
The defective 3 rd section of chimney was
removed and Section 4 was joined with section
2 to re-erect the chimney. Stability certification


was obtained from competent authority, after
inspection and ultrasonic testing of the chimney
sections. While doing the above activity there is
5.5 mtrs reduction in the height of the chimney
and this has been communicated to all
concerned Govt. Authorities It is decided to
fabricate this 5.5 mtrs portion and reinstall
during the annual shutdown of the boiler.
The Photographs shows i) Bended Chimney for
25
0
.ii) Crane Boom fall short iii) Crane of
adequate height. iv) All Agencies ready to
handle possible tragedy v) Covered Ammonia
tank.


Lesson learned:-
The Chimneys shall be critically inspected
periodically and shall be timely maintained.

AMMONIA
RECEIVER
COVERED BY
WOODEN PLANK
TIEING OF
PART OF
CHIMNEY
DEFECTIVE SECTION
OF CHIMNEY REMOVED
A Case Study On 65

29.FATAL ACCIDENT WHILE DRIVING A FORKLIFT
Compiled By
N.A.Deshmukh
Assistant Director
Industrial Safety & Health, Pune
------------------------------------------------------------------------------------------------------------------------------
Fatal accident took place in one of the factory which is engaged in manufacturing of soft drinks. One
fork lift driver met with a serious accident while he was taking his fork lift in the reverse direction.

ABOUT THE ACCIDENT:
Forklifts are used in this factory for shifting soft
drink bottle crates from one place to other or for
loading/ un-loading of crates. The above said
fork lift along with the driver was hired outside
agency on contract basis. The renovation work
of dispatch ramp by constructing it with RCC
was completed recently. On the date of accident,
at about 3.50 pm, the deceased worker was
taking his fork lift in reverse direction on the
dispatch ramp. At that time, one of the wheels
of his fork lift slipped from the edge of the
dispatch ramp and fork lift toppled down from
the 4 feet height on the road leading to the
empty bottle yard. Portion of his body below
chest was trapped under the fork lift. Workers
working nearby rushed for his help. It was
difficult to lift the fork lift and remove him from
there. So, another fork lift was brought to the
spot of accident and the deceased worker was
rescued by lifting the fork lift below which he
was trapped. He was immediately shifted to
Hospital, by ambulance of the factory in
unconscious condition .He expired on the same
day while he was under treatment in the
Hospital.

OBSERVATIONS:
On visiting the spot of accident, it was observed
that in this factory, there is one dispatch ramp
which is located outside the unloading bay. The
road of this dispatch ramp is straight road up to
certain distance and then there is taper portion
on this road. On the north side of this dispatch
ramp, there is another parallel road which is
leading empty bottle yard. There is level
difference on both these roads. The road leading
to the empty bottle yard is at lower level and
maximum height of dispatch ramp from this
road is 5 feet. One fork lift is seen lying near
this wall. One seat belt is found provided for the
driver on this fork lift. However, it was revealed
that the deceased worker was not wearing seat
belt when he met with an accident. Damage
marks are seen on the corner of the ramp at
about 4 feet from the road leading to empty
bottle yard.

WHAT WENT WRONG:
During inquiry, it was revealed that the
deceased worker was holding valid licence. It
was revealed that there was level difference of
about 5 feet on the ramp and the road leading to
empty bottle yard. Both these roads were
adjacent and parallel to each other. There was
no barrier wall or fencing provided along the
road edges connecting ramp and adjacent road
which was at 5 feet depth from the ramp. The
portion of the ramp was tapered and there was
possibility of increasing the speed of the fork lift
while descending from the ramp. On that day,
while the driver was taking his fork lift in the
reverse direction from the ramp and when he
had reached the tapered portion of ramp, he lost
control on the fork lift. As there was no fencing
provided in the edge of the road, his fork lift
toppled down from ramp to 5 feet deep adjacent
road.

REMEDIAL MEASURES:
In order to avoid such type of accidents in
future, it was recommended to construct one
barrier wall/ or suitable fencing all along the
edge of the two roads which were at two
different levels.


A Case Study On 66
30.EXPLOSION DUE TO AMMONIA GAS LEAKAGE IN A COLD ROOM

Compiled By
V.M. Yadav
Deputy Director
Industrial Safety & Health, Pune
-----------------------------------------------------------------------------------------------------------------------------------------
An explosion took place in a factory due to ammonia gas leakage in the cold room, while carrying out
the draining of oil from the accumulator, which was located inside the cold room.
HISTORY: In this factory the activities like
receiving milk from outside, pasteurizing it,
packing it in , 1 litre plastic bags and storing
it in cold rooms is being carried out. The
packed milk was being stored in the cold
rooms and to maintain the temperature inside
the cold rooms at @ 1-4 degree centigrade, a
ammonia based cooling system (refrigeration)
was installed in the plant.

Details of Ammonia Refrigeration System:
The ammonia refrigeration/ cooling system
consists of
i)An ammonia receiver in which about 400 to
500 kg of ammonia is stored at pressure of @
10-12 kg/cm2.
ii)An oil separator: separates the oil carried
over with the compressed ammonia which
comes from the compressor
iii)Cooling coil: cools down the ammonia gas
which becomes hot after compression and
converts in to liquid ammonia.
iv)Compressor: Receives ammonia at @ 2-3
Kg/cm2 in gaseous form , compress it to a
pressure of @ 10-12 kg/cm2.
v)Cooling fans: consists of a oil accumulator
which first separates the oil coming from the
pipelines , then a throttle/ expansion valve
which receives ammonia at a pressure of 10-
12 kg/cm2 and expands the ammonia
suddenly, so as to get a sudden pressure drop
and because of this effect, temperature of
ammonia drops to -4 C to 0 C. Then the
circulating fans consist of network of
ammonia tubes through which chilled
ammonia flows. The fan circulates chilled
ammonia in the cold rooms to maintain the
temperature at @ -1 to 2 C. The oil
accumulator was provided with a drain pipe at
its bottom ( length @1 ft and dia of )
ABOUT THE ACCIDENT
Since last 3-4 days before the occurrence of
the incidence, the cold room temperature was
not going down to the required temperature of
1-4
0
C.

So on the day of incidence, after resuming his
regular duty, the ammonia plant operator
informed maintenance department, that he
wanted to drain out the oil from the oil
accumulator which was located inside the cold
room. Maintenance supervisor asked one
worker to help the operator in his work. They
collected the necessary tools like spanner,
screw driver and hammer and went inside the
cold room. The Operator opened the drain
valve of the oil accumulator but as the drain
line was choked, oil did not come down. He
then removed the drain valve and put it aside.
Then the co-worker pierced a screw driver
inside the drain pipe from the bottom. As soon
as he did this, as the system was under
pressure, ammonia gas from the system started
leaking from the pipe. As there was no valve
on the drain pipe, it was impossible for them
to stop the ammonia flow. So, they opened the
doors of cold room and came out of the cold
room. Meantime the workers in the factory
were told to evacuate the factory because of
the leakage. Accordingly the workers went
outside the factory gate.
COLD ROOM

At @ 9.20 a.m., there occurred an explosion
inside the cold room and a momentary flash of
fire came out of the door. The walls of the
cold room were shattered. Because of the
pressure wave, some plastic crates were
thrown away. Five workers were slightly
affected due to ammonia gas and were
admitted to hospital. Three workers received
minor injuries. The Operator received minor
burn injury on his face and hand.
OBSERVATIONS:
The explosion had taken place in the cold
rooms. There were two adjacent cold rooms of
the size 30L X 20 B X 10H. and 27 L X
12 B X 10 H, which were damaged due to
the heavy impact of the explosion .The walls
of the cold room on the east side, south side
and north side had collapsed, cracks got
developed on the walls and two to three
columns of the cold room were damaged.
There were cracks on the ceiling of the cold
room also. The wall on the west side between
cold room and the adjacent laboratory was
shattered. A m.s. ladder which was located
near the cold room was dislocated and had
moved about 15 away from its original
position. The milk packing machine which
was located on the east side of the cold room
was damaged. The tube lights inside the cold
room were shattered. Some electrical wires,
cables were burnt.

67
Properties of Ammonia:
Ammonia is a colorless, corrosive gas with a
sharp, pungent odor which can be detected by
smell at low concentrations. The flammable or
explosive concentration of ammonia in air is
15-28%. If the ammonia concentration is in
the flammable range, a large and intense
energy source can cause ignition and
explosion.
Material safety data sheet of Ammonia
Physical state (gas, liquid, solid): Gas
Vapor pressure at 70F : 94 psi
Vapor density at 60
0
F (Air = 1): 0.62
Solubility (H20) : Very soluble
Stability and Reactivity
Unstable, Anhydrous Ammonia is an
irritating, flammable, and colorless liquefied
compressed gas packaged in cylinders under
its own vapor pressure of 114 psig at 70 F.
Ammonia can cause severe eye, skin and
respiratory tract burns.
It poses an immediate fire and explosion
hazard when concentrations exceed 15%;
therefore, area must be ventilated before
entering.
Anhydrous ammonia has an expansion ratio of
850 to 1. One litre of liquid will expand 850
times as a gas.
Cause of explosion:
The spot where the explosion took place were
two cold rooms of the size 30 x 20 x 10 ht
and 27 x 12 x 10 ht totally closed from all
the sides.

Ammonia gas started leaking in these closed
cold rooms as the worker pierced rod inside
the drain pipe of the oil accumulator which
was centrally located between two cooler
COOLING UNIT
COLD ROOM
DRAIN
VALVE

units. Ammonia gas kept on accumulating
inside the cold room and slowly pressurizing
the cold rooms.



This ammonia leak occurred and the lower
explosive limit of 15% was reached in the
confined space. When the doors of cold room

were opened, the air-gas mixture was then
ignited explosively by an ignition source such
as an unprotected hot tungsten filament of the
fluorescent tube (provided in the cold rooms)
which were broken because of ammonia gas
accumulation and the thermal stress because
of the sudden temperature difference.

WHAT WENT WRONG:
It was found that,
i)The oil accumulator was frequently required
to be drained to remove oil to maintain the
efficiency of cooling inside the cold room. It
was found that the occupier had provided the
oil accumulator inside the cold room. And
68

there was only one valve was provided on the
drain line. Minimum two valves ought to have
been provided on this line so as to reduce the
risk of ammonia leakage in case of failure of
one valve.
ii) Ammonia plant operator in order to drain
the oil from the accumulator removed the
drain valve
completely and pierced the rod inside the pipe
subjecting the ammonia system to a hazardous
situation of ammonia leakage in a confined
space.
The operator ought to have checked whether
the accumulator contains ammonia and its
pressure and he ought to have removed the
drain valve only after ensuring that there is no
ammonia in the accumulator.
The operator and other workers were not
trained to follow a system of work that were
safe and without risk to the health of the
workers by the occupier.
iii)The factory was not equipped with
necessary equipments like self contained
breathing apparatus to use them in a
hazardous situation like ammonia leakage.
iv)This work of draining the oil from the
accumulator and removing the drain valve of
accumulator which was a part of a ammonia
pressurized system was not supervised by a
trained and responsible person.
v) It was found that no safety instructions
were displayed in the workroom about
precautions to be taken related to ammonia
and other hazards.















ACCUMULATOR
A Case Study On 69
31. CHLORINE GAS LEAKAGE- SUCCESSFUL DISASTER MANAGEMENT

By
V.A. More
Former Joint Director
Industrial Safety & Health
-----------------------------------------------------------------------------------------------------------------------------------------
It was 11 pm and I was about to go to
bed ., all of a sudden phone rang, I lifted
the phone.
Is Mr.More is there! This is S.D.O. speaking
..voice was very disturbing ..
I am Sdo, speaking she reveled again. At present
I am near Chlorination near Highway and I am
along with the leaking chlorine tonners loaded
in the truck which are brought for neutralizing
purpose in the BMC chlorination plant. All
tonners were brought for unloading in
Chlorination plant. Plant people refused to
accept it hence they are standing in middle of
the road. Chlorine is slowly leaking from one of
the tonner. I dont understand what to do now?
Immediately the thought which came to my
mind was the area in which this disaster took
place is not under my purview of operation as I
am responsible for different Region. But on
humanitarian ground and being a member
Secretary of District Crisis group I took the
initiative to contribute the best of capacity to
combat Disaster. So I collected the basic
information from S.D.O.& Started thinking of
the further action.
It was surprising that these five Chlorine
tonners were dumped in for last twenty years.
Nobody has cared about these rusty filled
Chlorine tonners kept in haphazard manner at
Maharashtra Jeevan Pradhikarans incomplete
sewage treatment plant. In the nearby
community thousands of people were living.
Many were passing around it for several years.
There was huge pile of dirt and garbage got
accumulated around these neglected Chlorine
tonners.
It was rainy morning, white yellow fumes
started coming out from the one of the Chlorine
tonner. Fumes started spreading with the wind.
It created chaos among the nearby community.
People started suffering from eye burn,
breathing discomfort, coughing. After all it was
Chlorine! The monster that was trapped for two
decades suddenly escaped from the cage and
took horrifying image. Chlorine is much useful
but at the same time it is toxic also. Its safe
concentration in air is 1 ppm (1 part of 1 lack) If
it increases up to 100 ppm then the atmosphere
becomes threat to life. Due to this sudden
incident local people became panic. Everybody
recollected worst memories of Bhopal disaster.
Local administration seems to be unaware about
what to do. Somehow they came out of this
sudden shock and started acting on the situation.
Experts from the largest Chlorine manufacturer
were called. Also information was given to
DISH officer and District Collectorate.
Leakage started from 4 am of that day & was
not yet under control. At 8 am, expert panel
from Chlorine manufacturing Factory was
arrived. They connected necessary device to
collect leaking Chlorine and its destruction. Till
then 30 people got affected due to chlorine. All
were admitted in Hospital. As a precautionary
measure, around 3500 people were evacuated.
Gas destruction work was progressing safely
and slowly. Other four non leaky Chlorine
tonners were kept under observation.

N.D.R.F., was also called as stand-by.
District Collector, Resident District Collector,
Team of Experts Inspecting the
defective chlorine Tonner

Municipal Commissioner were personally
monitoring the situation. After rigorous efforts
of 24 hrs., gas was completely taken out from
leaky tonner and safely destroyed. Everybody
sighed in relief. Due to pressure of local people
and also from safety point of view, it was
decided to shift the remaining four tonners out
of the village.
But outside the village means where?
Nobody was having its answer. Discussion
happened at higher level authority and it was
decided to send these tonners to water treatment
plant as it is near highway. By the time we
could decide on shifting we observed that
unfortunately one out of the four remaining
chlorine tonners started leaking. We were
worried but still all the tonners were loaded in 2
trucks and their journey towards water treatment
plant began. This was done under the leadership
of SDO Madam.
The caravan of Chlorine tonner loaded
trucks along with police force, ambulance, and
other officers slowly reached to water treatment
plant chlorination plant at 8 pm. There was no
tension till this period ..
But all of a sudden one phone call came from
some where giving an order of not to accept
these tonners in water treatment plant.
Immediately everybody made about turn.
But where to go? And what to do?
As and when the caravan reached to near by
village or community the resident/villagers
made strong resistance to this caravan. Due to
this SDO was puzzled. All the vehicles were
stopped in the mid way near Chlorination plant
and highway and she called me.
70


Even though the leakage from one of the tonner
was not that much serious the situation was
critical. Slight raining started. I organized to
send one Safety Manager from region and
suggested a temporary measure of placing
tarpaulin over the leaky tonner. Keeping it under
the surveillance of experts, I suggested S.D.O.
Madam to go home. Then I started thinking
about what can be done on next day morning.
On that night itself, I called MARG
coordinators and other selected members of
MARG and gave required instructions. I
discussed with District Disaster Management
Officer and gave information about tomorrow
mornings action plan and became relaxed.
In the morning I reached to a village
situated opposite side of water treatment plant. I
took District Disaster Management Officer
along with me. Fortunately for the safety
reasons, those trucks loaded with Chlorine
tonner were shifted in the open space of godown
building situated on the right side of highway.
Commissioner, Municipal Corporation and
Tahsildar were present on the site. A huge
crowd of local people and nearby villagers was
gathered to watch the situation.
Tonners were inspected with the help of
experts. Leakage was found from vapour valve
of tonner. Valve was not operating. Whole body
and valve of tonner was badly corroded. Hence
it became necessary to take out Chlorine gas and
destruct it as early as possible. Again there was
a concern about other three tonners. But there
was no Chlorine leakage from it so far.
Fortunately management of one of the chemical
company in area took initiative to take them to
Caustic tanker summoned
for neutralizing Chlorine

their factory. Therefore it was decided to shift
these three tonners to their desired destination in
order to minimize hazard at that place. For that
the preparations ware made till 1 pm. These
tonners were loaded in two trucks and kept
ready along with police force and adequate
resources for immediate measures required in
case of emergency situation. By shifting other
three tonners to our tension and risk at site was
going to be reduced. But again suddenly after all
these preparations, factory has refused to take
the tonners. We felt once again in trouble.


Our situation was just similar to 26/11 where
Nobody was ready to accept dead bodies of
terrorist attack. We found ourselves in similar
situation for these tonners. Then we again
decided not to bother about three containers and
concentrate on leaking tonners.

It was not an easy task to destruct 900 Kg
Chlorine gas from one tonner. For that 30%
dilute caustic solution tanker was brought from
Chlorine Manufacturing Company. In the mean
time Oxygen cylinders became empty. Hence
oxygen cylinders from other region were
brought. By looking at the condition of valve of
leaky tonner, initiation of urgent action became
necessary.

71
We discussed together and decided to cut the
valve. It was a decision with great risk.
Anything could have been happened. As far as
my knowledge was concern, it was the first time
such a brave decision for destructing Chlorine
was taken. Even though it was a risky decision
but considering the panic created by this
chlorine during last 3 days in the area, it became
necessary to take some immediate steps to
destroy this Chlorine.
Then we started our off site disaster
management plan. Cutter was required to cut the
valve. Fire brigade was having pneumatic cutter.
One separate device was created to remove both
liquid and vapour valves. That means it was
decided to create separate arrangement and
Chlorine to be released in caustic solution
through metallic pipes. Capping was required to
be done immediately without any further delay,
after cutting the valves. But this work was so
risky and requires people having courage and
strength. It was decided to give this job to a
nearby group of expert.
Finally it was decided. . Everybodys
places were fixed.
Who will cut valve? Who will put cap?
How to close cutter? Who will stand where? etc.
was decided. Flag was posted near the vicinity
to get an idea about wind direction. As a
precaution, all the people were taken on
highway. Highway systems were also alerted.
Leaky tonner was in the truck and behind that
tonner caustic tanker was parked. All the people
in the nearby communities and villages were
alerted and instructed to close their doors and
windows. Ambulances were kept ready in all the
villages in the 4 5 Km range in the down wind
direction. Announcements were continuously
made on loud speaker. Everybody has taken
their respective positions. Limited people like us
were standing in the 25 30 feet distance on
opposite direction along with necessary PPEs.
Actually on the truck, near tonner, there
were five persons. One cutting person, other two
persons ready for capping and one person doing
video shooting. Every boy was equipped with
Leakage successfully
plugged & neutralization
process started

breathing apparatus. One person was doing
video shooting with his camera. Two other
person was in position ready for capping. Fourth
Person of Municipal Corporation was ready
with cutting machine. Wind was blowing
heavily. Flag was also swirling heavily due to
wind. I unnecessarily thought that the flag is
also trembling due to fear. Then that moment
came. ..Cutter started. Capping people took
their positions. Heart beats and curiosity of all
increased. Breathes were hold. Cutter has
through with his work in few moments and
Chlorine trapped inside started coming out with
large noise and huge pressure. Everybody
missed their heart beat for a while. On that
moment, except yellowish smoke, nothing was
visible in the truck. Cameraman lost his balance
fell down. Two persons who are standing for
capping succeeded in placing cap with great
efforts. Some part of Chlorine started going in
Caustic tanker. Something has gone wrong.
Hence to reduce effect of Chlorine in the
atmosphere, water spraying was started. One big
yellowish / white cloud got created started rising
in the sky in the wind direction. Everybody was
panic due to happenings on the site. One sudden
thought came in mind. What would have been
happened if they failed in placing cap? If
somebodys breathing suit felled? If wind
direction was



72
suddenly changed were the immediate
questions in mind
Till 6 7 pm in the evening Chlorine
transferring from tonner to alkali tanker was
continued. Some amount of Chlorine was sure
gone in atmosphere. But most of the Chlorine
was successfully destroyed. Everybody sighed
in relief.
Definitely this successful mission
completed by this team was not less than that of
the military persons fighting on the border. They
completed this off site disaster management
plan by keeping their lives under danger. They
gave relief and confidence to District
Administration.
On 15
th
August, Honorable Guardian
Minister and District Collector praised and
honored me along with all above mentioned
team members in District Collectors office.
This is called Team Work and off
course successful disaster management.





























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