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Fatima G.oup
Investiqation Team:
P^ge I of 22
Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017
Table of Contents:
Page 2 of 22
Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017
Page 3 of 22
Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017
Executive Summary:
The incident occurred at PFL site on January 29, 2017 at 04:20 a.m.
A contract worker (bag loader) got electrocuted and died when nine contract workers were
preparing for de-stacking activity of CAN product bags inside the Urea Bag store, using
Stacker#1.
The Stacker is an equipment with a conveyor belt to facilitate the transfer of product bags from a
stack to a trailer/ truck. It substitutes the manual loading of bags into the truck with a quick
operation hence saves time and manual effort. The height of the Stacker # 1 can be adjusted with
a mechanical hydraulic valve installed below the conveyor belt assembly as shown in the picture
below.
Manual Valve
At the time of the incident four de-stacking lines/ stackers were in operation for loading of CAN
product, two stackers were in NP PH&S area while the other two were in urea bag store. One
trailer of 1000 bags had already been loaded during the same night shift by using stacker# 1.
Workers were preparing the stacker for another truck when Muhammad Fiaz touched the
hydraulic valve for height adjustment of the stacker. An electrical phase voltage had appeared on
body of the stacker due to a disconnected grounding wire touching the phase wire inside the
industrial plug of stacker.
Muhammad Fiaz received the electric shock and got electrocuted at 04:20 a.m., the bag counter
(Khalid Rehman) immediately switched off the power supply by pulling the plug from main supply,
and other workers rescued him. His area shift in-charge called at medical center emergency
number and asked for ambulance and immediate medical assistance.
Medical Emergency response was quick and the patient received immediate medical assistance of
CPR and first aid at PFL medical center. His pulse and blood pressure was not detectable. He was
then moved to Nishter hospital at 04:45 a.m. and reached at 04:58 a.m. where he received the
necessary Emergency treatment and Resuscitation. He was declared dead at 05:30 a.m.
Detailed investigation was carried out by a multi-disciplinary team from PFL, FFL and TD under the
lead of Mr. Tofique Ahmed, Department Manager FFL - E&I.
Page 4 of 22
Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017
A ground wire inside the industrial power plug of the equipment had disengaged and touched the
phase wire inside the plug. This created a potential on the body of stacker, equivalent to the phase
voltage resulting in electrocution of the worker. There was no ELCB or external ground on the
stacker and distribution board.
He was wearing a pair of damaged and repaired safety shoes on a wet floor which provided easy
path for the electric current to pass through his body.
Recommendations (click here) are mentioned in the detailed report.
Page 5 of 22
Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017
Incident Description:
During the night shift on 29th January 2017, de-stacking activity of CAN bags placed in Urea Bulk
Store was in progress. One truck had been loaded from stacker # 1 and another from stacker# 6.
Stacker# 1 was being prepared for the next truck and hence moved from its initial position to the
next position where stacker height was being adjusted for the truck. At around 04:20 am, a bag
loader (Muhammad Fiaz) attempted to adjust the height of the stacker with a hydraulic valve when
he got electrocuted.
Reference flash report is attached as Annex 2.
Pictorial Depiction:
Top view of urea bag store is shown in Annex 1
Page 7 of 22
Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017
Picture # 4: Main supply Receptacle Socket from where the power was cut off after electrocution
Sequence of Events:
January 28th, 2017
10:00 pm: Night shift started at PH&S area. CAN bags placed in Urea bulk store had to be
de-stacked and loaded into trucks
10:15 pm: Truck #1 of 1000 bags started loading from stacker# 01. Height of Stacker# 1 was
adjusted 3 times during the loading.
10:20 pm: Truck #2 started loading from Stacker# 6.
04:00 am: Both loaded trucks left and Stacker #1 was shifted to the new location along with
electrical DB shifted from ground floor to CAN bags as shown in picture # 3.
04:15 am: Electrical supply was reconnected
Man Standing on the top of trailer truck asked to lower the stacker
04:20 am: Muhammad Fiaz attempted to operate hydraulic valve to adjust the height and got
electrocuted.
Emergency Response
Bag Loader shouted to cut off the supply
Power supply was cut off from the main receptacle by Bag counter Khalid Rehman
Initial rescue activity was performed by USLs and bag counter Muhammad Faraz present at
the incident location
04:25 am: Shift in-charge Alamdar Hussain called at 3535 Medical Centre
04:27 am: Medical Response Team arrived at location and took the affected person in the
ambulance
2nd Rescue attempt was made by the Medical Officer Doctor Azra Memon at Medical Center
Page 8 of 22
Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017
04:45 am: The affected person was shifted to Nishter Hospital Multan. Bag counter M. Faraz
and the dispenser Maqsood went along with the ambulance.
Treatment at Hospital
04:58 am: Hospital staff immediately received the patient and started the treatment
05:11 patient was registered at the hospital
rd
3 Rescue attempt was made by the Nishter Emergency Team
CPR and Emergency treatment was given while there was inconsistent pulse on the ECG
05:30 am: Muhammad Fiaz was declared dead by the Nishter Hospital Doctor.
Investigation Process:
o Profile of Injured Personnel
o Initial Evidence Collection
o Interviews
o Previous incidents history
o Inspection & Maintenance history
Page 9 of 22
Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017
Page 10 of 22
Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017
Interviews:
2nd Interview
Page 11 of 22
Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017
Electrical Team:
1. Operation people didnt follow the standing instructions passed verbally after 23rd Jan
instructions
2. Electrical protections are there to protect the equipment but ELCBs are not installed on 3
phase site wide.
3. We established ELCBs setup on single phase supply in 2009
4. This fault couldnt have been detected by the system as the cable was disengaged and
current path didnt form. MCBs installed couldnt trip.
5. Previous practice was to hire one electrical technician on daily wages for PH&S along with
the labor so that he may handle all the electrical tools and equipment to be used by the
operations team. That practice has been discontinued recently
6. It looks like that Operations team has mishandled the electrical receptacle
7. Short Circuit study has not been conducted for the electrical system at PH&S
These incidents are majorly because of lack of electrical safety consciousness of the
employees and colony residents.
2. Collective wisdom needs to be enhanced
3. ELCBs on 3 phase are already in our objectives 2017 which were prepared weeks before
this incident
Page 12 of 22
Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017
1. Operation people didnt follow the standing instructions passed verbally after 23rd Jan
instructions.
2. We have provided portable ELCBs for single phase supply
3. This fault couldnt have been detected by the system as the cable was disengaged and
current path didnt form. MCBs installed couldnt trip.
4. It looks like that Operations team has mishandled the electrical receptacle
5. We have lean and low skill manpower.
6. Only 4 engineers are looking after the whole complex
7. We have on call availability of electrical technicians
Eye Witnesses:
Page 13 of 22
Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017
1. I heard shouting of the bag loaders and rushed to remove supply from the main
2. Faraz rushed towards the stacker # 1 where incident had happened
3. I informed my shift in-charge Alamdar Hussain, who informed medical center
4. Faraz started giving first aid to the injured
5. Ambulance came at around 4:27 am.
6. Faraz went along with the ambulance to medical center and Nishter hospital
Medical Personnel:
1. Call at medical center was received at 4:25 am, it was attended by Maqsood Dispenser
2. He called me at same time and I rushed to medical center
3. The patient arrived at medical center at 4:30 am
4. He had no pulse and BP was not recordable.
5. We did CPR and emergency drugs
6. He was gasping (which is the last attempt of the brain for revival)
7. Upon asking about skin condition, she replied that I didnt notice the burns on hands or
feet because of the emergency condition. Our focus was on revival and CPR.
8. We dispatched him to Nishter Hospital along with the dispenser Maqsood.
9. Oxygen was applied inside the ambulance
Operations Management:
Page 14 of 22
Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017
4. After purchasing the coffin for the funeral of the deceased. I reached his house and stayed
with his father and family for 5 hours
5. I joined Namaz-e-Janaza along with PH&S and loading staff.
6. The direction of stacker was changed and DB lying in the way was moved on the bags
stack. The loaders asked the turner to lower the stacker height. As soon as the bag turner
touched the valve of the hydraulic system of the stacker he received Electric shock.
7. There is no ELCB for three phase system. It is only available for single phase system.
8. For portable lights and pedestal fans, use of ELCB is mandatory and is being practiced.
9. There are eight stackers. Six stackers are in working condition and one is under repair.
10. PM plan has been recently developed for stackers.
11. Stacker # 1 remains in continuous use. It is mostly used for urea bagging.
12. The PH&S team called the electrician of West area to visit Urea handling to check the
stacker preventability. But the electrician refused by saying that he is busy in start-up
activities.
Page 15 of 22
Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017
Key Findings:
1. No one got hurt or received the electric shock
2. There was short circuit inside the stacker # 6 receptacle plug due to tension in the cable
3. Resulting in damage of stacker # 6 plug and cable along with 4 sockets of extension board
Page 16 of 22
Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017
Key Findings/Observations:
Electrical Design
1. ELCBs are not installed on 3 phase circuits at the whole complex
2. ELCBs for single phase have been arranged in portable DBs since 2009
3. External Grounding for movable equipment like stacker is not available
Page 17 of 22
Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017
Emergency Response
1. Bag Loaders shouted to switch off the electric power and didnt touch the body of
electrocuted person until the power was switched off
2. Electric power was cut off immediately by Khalid Rehman
3. Khalid Rehman didnt inform at medical emergency number instead he informed his shift
in-charge Alamdar Hussain
Communication
1. Flash report was issued within 24 hours of the incident
2. Multi-disciplinary Investigation team was formed with PFL, FFL and TD participation for
RCA.
3. Incident was timely communicate to the coordination engineer who informed the line
managers as per protocol
4. Shift In-charge CAN PH&S didnt raise the level to inform the coordination engineer for
non-availability of electrical technician.
Mechanical Integrity
1. Mechanical Integrity of the equipment had not been ensured.
2. Preventive Maintenance schedule for stackers was developed in Dec 2016.
3. There is no PM regime for receptacle of portable equipment
4. Electrical DBs are inspected quarterly under PM Plan
Audits
1. Observations from internal and 2nd party PSM Audit need to be completed on war footing
2. Safety Audit quality is questionable as many workers were observed using damaged
PPEs in operational area
Page 18 of 22
Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017
Conclusion:
Direct Cause:
1. Grounding cable inside the Electrical Power Receptacle Plug of Stacker #1 found
disconnected and touching the phase wires which produced phase voltage at stacker #1
body
2. Muhammad Fiaz was wearing damaged and repaired safety shoes on a wet floor. The
right shoe sole was badly damaged and repaired
Root Cause:
Fault tree analysis was used as a method for finding the root cause, Ref. Annex 10
1. Electrical system design was not inherently safe, ELCBs are not installed on 3 phase
sockets
2. Failure at management level to control the use of damaged and repaired pair of safety
shoes at work
Contributory Factors:
1. Management control to ensure safety of portable electrical equipment does not cover all
types of portable electrical equipment
2. Operations shift personnel violated the written work instructions (Urdu) by operating the
stacker without electrical inspection
3. Previous history of frequent wire disengagement from the plugs shows mishandling of the
equipment which is a violation of written electrical safety guideline (Urdu)
4. After series of electrical related incidents, significant efforts to enhance electrical safety
were not made and necessary risk assessment was not conducted.
5. Electrical and Operations team has low percentage of experienced and skillful manpower
1. Management Commitment
Lack of inherent electrical safe design
2. Audits and Observations
Previous internal and 2nd party audit observations were not taken seriously for the whole
site
3. Risk Assessment & PHA
After repeated electrical related incidents at stackers risk assessment was not conducted
4. Contractor Safety Management
PPEs compliance was not up to mark
Page 19 of 22
Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017
Recommendations:
1. ELCBs must be installed for all the single and 3 phase sockets and portable equipment.
Responsibility: Unit Manager Electrical Target Date: 30-10-2017
2. Site wide campaign to be launched to inspect the safety shoes of all the workers at plant
site and ban the entry of labor with damaged safety shoes.
Responsibility: Unit Manager HSE Target Date: 15-02-2017
3. Additional external grounding shall be provided for all the bag stackers in PH&S area.
Responsibility: Unit Manager Electrical Target Date: 30-08-2017
4. The SOPs for stacking/ de-stacking activities and electrical guidelines for PH&S are
available but it must be a controlled document under IMS.
Responsibility: Unit Manager Electrical/PH&S Target Date: 28-02-2017
5. Toolbox talks are being conducted but attendance record must be maintained.
Responsibility: Unit Manager PH&S Target Date: 07-02-2017
Page 20 of 22
Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017
6. Effective Management Safety Audits shall be ensured in true spirit with focus on the
unsafe acts/ conditions, employees safety awareness and PPEs compliance
Responsibility: Unit Manager HSE Target Date: 28-02-2017
7. It has been observed that damaged shoes are available with contract workers while new
shoes are not used. All the re-used shoes at site shall be retrieved and disposed off.
Responsibility: Unit Manager Planning Target Date: 15-03-2017
8. All Portable electrical equipment shall be made part of the testing & certification regime
Responsibility: Unit Manager Electrical Target Date: 30-06-2017
9. Effective communication training for line managers shall be conducted
Responsibility: Unit Manager TTC Target Date: 30-04-2017
10. Mode of contract needs review to enhance safety of the job and contractor responsibility.
Responsibility: Plant Head / UM Planning Target Date: 15-04-2017
11. JSA for stacking & de-stacking activity has been developed by operations team but it
needs joint review of Electrical, Maintenance and Operation
Responsibility: Unit Manager PH&S Target Date: 28-02-2017
12. Electrical Guidelines for portable equipment need to be updated. It shall cover all the
portable electrical equipment including extension boards, DBs and receptacle plug etc.
Responsibility: Unit Manager Electrical Target Date: 30-06-2017
13. Non-standard electrical DBs shall be replaced with standard DBs having breakers and
ELCBs
Responsibility: Unit Manager Electrical Target Date: 30-12-2017
14. Training to improve the quality of MSA shall be conducted for all the auditors
Responsibility: Unit Manager HSE Target Date: 28-02-2017
15. Skill assessment shall be performed to identify the gaps for existing and required Skill
level.
Responsibility: Unit Manager TTC Target Date: 28-02-2017
Page 21 of 22
Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017
List of Annexure:
1. Top view of Urea bag store depicting the positions of equipment and worker
2. Flash Report # INJ-C-FAT-1-2017-PH&S Urea
3. Flash Report # NM-NM-8-2017-PH&S CAN
4. Flash Report # INJ-CFA-2-2017-PH&S CAN
5. Job Safety Analysis for Stacking & De-Stacking
6. Work Instruction for working on Stacker
7. Observations from Log Book - Wire disengagement inside receptacle
8. Shoes Receiving - Muhammad Fiaz
9. Shoes Receiving - Hafiz Nazar Abbas
10. RCA - Fault Tree Analysis
Page 22 of 22
i
s
s
o
A n.< r'. 3
Flash Report
0p...+lsemh - Contractor FtrllS
lncident Sub-
Category Contractor Fatality
Contractor labor was working inside urea product store for de-stacking of CAN product bags. Two
stackers were deployed for this purpose. After filling one truck, electrical cable was removed to set
Description / Details
up another truck. After truck set up, power resumed and stacker level adjustment was in process;
Of Incident
when a bag loading staff received electric shock from the body of stacker. The worker was rescued
after power cutoff by his coworkers and shifted to Medical Center.
Sadak Bashir
Report Target Date 10-Feb-17 RCA Team Lead
Technical Services
1. |(lnsp + Proi), 2. Khurram Bin Ata - UM (Planning),
RCA Team Members
3. Farrukh lqbal - SH (Lab.)
Approving Authority Abdul Nasir - PFL Plant Head
Remarks people from TD and FFL shall also join for RCA.
An'"<,r- ' 3
A Flash Report
U n"=,,JS=i=*b | 11"", Mr"",""d""r - N"",,n""]
tc""l-._"ltracltract-r
N"r" I Friends Associates
t u"tt lnr""
"r
[,"1d""t I l-pH& s cAN---l
O Description / Details
Of Incident
Earth leakage observed in Stacker No. 6 in crane yard when destacking of CAN product was in
progress. lmmediately stopped the job and informed to electfician for rectification.
f"*-"*.*;lt--;,;--_lF;'*f
I nCnteam MemOers ll Tayyab Rehman - Etectricat Engineer
Mahmood Paracha
Staff Engineer (NP)
Itl Remarrs ll
-
A r,'rcr r 9
Flash Report
0p..--*lser*h
lncident Sub-
Category
Contractor First Aid Case
A Helper got electric shock when he was trying to connect an electric kettle with extension board at
Description / Details New CAN Bag Store. He was immediately shifted to PFL Medical Center for first aid. He was alone
Of Incident in the store at the time of incident. The electric kettle was heavily modified and was not healthy,
earth wire was not connected durino this modification.
Report Target Date 31-Jan-17 RCA Team Lead Hyder Ali - UM (CAN/CN)
Rem arks
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lhe phys'rcal appearance ot ths bags.
1, Fallh.zard
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Oc Use of Stackers,
poriable ligbls, ELCB'S
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Eleclric Shock
. appliances cable is not damaged and
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6. Ensure be proper earhhg of he
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7. Check the ONiOFF starter switch ot
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8. Do not buch he electrical appliance
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9. Use Tdpod light only rvih the help of
ELCB
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lo Electflzl slatf lor he sanre.
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