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INCIDENT INVESTIGATION REPORT

Fatality at PFL Urea Bag Store

Investiqation Team:

Tofique Ahmed Department Manager E&l - FFL ( Team Lead)


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Sadik Bashir Technical Services Manager - PFL
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Taimur Ahmad Unit Manager Project - Technology Division

Syed Sarfraz Ali Unit Manager Projects & Inspection - PFL

Khurram Bin Ata Unit Manager Planning - PFL

Farrukh lqbal Section Head Laboratory - PFL


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Zain Ali Sr. E&l Engineer - Technology Division

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Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017

Table of Contents:

Executive Summary: ....................................................................................................... 4


Incident Description: ....................................................................................................... 6
Immediate Actions Taken: ............................................................................................... 6
Pictorial Depiction:.......................................................................................................... 6
Sequence of Events: ........................................................................................................ 8
January 28th, 2017....................................................................................................... 8
January 29th, 2017....................................................................................................... 8
Emergency Response ............................................................................................... 8
Treatment at Hospital............................................................................................... 9
Investigation Process: ...................................................................................................... 9
Profile of Deceased Person: ......................................................................................... 9
Initial Evidence Collection: ......................................................................................... 9
Receptacle Plug: ...................................................................................................... 9
Safety Shoes of Muhammad Fiaz: .......................................................................... 10
Interviews: ................................................................................................................. 11
Electrical Team: ......................................................................................................... 12
Eye Witnesses:........................................................................................................... 13
Medical Personnel: .................................................................................................... 14
Operations Management: ........................................................................................... 14
Previous Incident History: ............................................................................................. 15
Electric kettle incident ............................................................................................... 15
Key Findings: ........................................................................................................ 15
Earth Leakage in Stacker# 6 ...................................................................................... 16
Key Findings: ........................................................................................................ 16
Maintenance & Inspection History: ............................................................................... 17
Key Findings/Observations:........................................................................................... 17
Electrical Design ................................................................................................... 17
Personal Protective Equipment .............................................................................. 17
Job Preparation/ Risk Assessment .......................................................................... 17
Supervision & Monitoring ..................................................................................... 17
Emergency Response ............................................................................................. 18
Medical Emergency Response ............................................................................... 18
Communication ..................................................................................................... 18

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Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017

Mechanical Integrity .............................................................................................. 18


Job Safety Analysis ................................................................................................ 18
Hazard Effect Analysis .......................................................................................... 18
Training & Development ....................................................................................... 18
Audits .................................................................................................................... 18
Conclusion: ................................................................................................................... 19
Direct Cause: ............................................................................................................. 19
Root Cause: ............................................................................................................... 19
Contributory Factors: ................................................................................................. 19
PSM Elements Violated/Not Complied: ..................................................................... 19
Recommendations: ........................................................................................................ 20
List of Annexure: ........................................................................................................... 22

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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

Side view of Stacker # 1 with Manual valve highlighted in red circle

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.

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Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017

Investigation team found non-compliance of standard safe practices, lack of management


commitment for workers safety, absence of management control on movable and portable
equipment, gaps in inherent safe design of electrical systems and non-compliance of PPEs along
with major gaps in most of the PSM elements.

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.

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Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017

Incident Location Urea Bag Store Stacker # 1


Date and Time of Incident 29-01-17 @ 04:20 a.m.

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.

Immediate Actions Taken:


Other loaders/ workers (Zulfiqar & Zahoor) working in the area shouted for electrical power switch
off. Upon hearing the voices, Khalid Rehman (Bag Counter) present in the Shift in-charge urea
PH&S office rushed and disconnected the power supply from main receptacle.
Co-workers shifted Muhammad Fiaz to the nearby sand heap (available within the bulk store for
product floor housekeeping). Bag counter M. Faraz tried to rescue him by pumping his chest and
rubbing the feet. While medical center had been informed by the PH&S CAN shift in-charge
Alamdar Hussain, Ambulance arrived within 2 min of call. The effected person Muhammad Fiaz
was shifted to PFL medical center and later to Nishter Hospital Multan where he was declared dead
after resuscitation attempt.

Pictorial Depiction:
Top view of urea bag store is shown in Annex 1

Picture # 1: Depiction of Position of Workers


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Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017

Picture # 2: Last position of stacker inside the store

Picture # 3: Last position of the receptacle extension board

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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.

January 29th, 2017

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
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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

Profile of Deceased Person:

Name: Muhammad Fiaz


S/O: Muhammad Nawaz
Age: 27 years
Resident: Mattital Road Iqbal Nagar, Multan
Marital Status: Bachelor
Dependents: Father, Mother and one disabled brother.
He was on 15 days short sanction contractual labor with M/s Friends Associates.
It was revealed in interviews and feedback of his supervisors that Muhammad Fiaz was a
hardworking and honest guy. He had a good attitude towards work.

Initial Evidence Collection:


Receptacle Plug:
The stacker# 1 plug installed in the Distribution board was checked after the incident. Ground
cable inside the plug was found disconnected from its terminal end hanging between two phases
(yellow and red).

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Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017

Ground wire disengaged

Picture # 5: Receptacle Plug of Stacker # 1

Safety Shoes of Muhammad Fiaz:


Safety Shoes were found badly damaged from the sole and manually repaired from three places.
New shoes had been issued to the worker on 2-Aug-2016 with manufacturing date of Aug-2015
but he was wearing the repaired and damaged pair of shoes with manufacturing date of May-2010.

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Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017

Picture# 6 &7: M. Fiazs Pair of Shoes

Interviews:

Alamdar Hussain Shift In-charge CAN Handling

1. Khalid Rehman informed me about the incident.


2. I called the ambulance and coordination engineer. However, I didnt see the person.
3. Activity was being taken place near NP shed and urea handling. 04 stackers were being
operated. Two at urea handling and two at NP shed area.
4. No complaint was received regarding stackers. At the start of shift, electricians were called
to visit and check the stackers. East area Electrician visited and checked the stackers
being operated near NP shed area. Whereas, the West area Electrician didnt visit the
urea bag store site as he was busy in the start-up activities.
5. I didnt inform the coordination engineer regarding non availability of electrician of area
west (Mr. Naveed).
6. Mr. Iqbal Baig was on duty as Coordination Engineer. He visited the site after the incident.
7. Things to avoid the incident
a. A dedicated electrician should be available at PH&S to monitor the activity.
b. Equipment checklist should be developed

2nd Interview

8. Contacted Naveed at around 22:45 Hrs.


9. After the incident, Naveed also came to the incident site

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Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017

Electrical Team:

Muhammad Naveed Amjad (Electrical Tech)

1. He was on 12 hrs. shift duty. Came on duty at 1800 hrs.


2. He checked the same stacker two days on general check-up request from Operation.
Stacker was okay but one extension board was found faulty and its plug was removed.
3. Did not get any call from Handling regarding general check-up of Stackers.
4. He was not aware regarding any plan to check the stackers. Normally it is done by general
shift.
5. He did not see the problematic socket.

Hafiz Muhammad Shahid, Tech-III


1. Deputed in area west. Working in General Shift. Called on overtime for plant start-up
activities. Reached plant site around 23:45 Hrs.
2. No call from PH&S was received by him till 04:30 Hrs.
3. PH&S person reached their location to inform about the incident.
4. The injured person was already has been shifted.
5. Coordination Engineer announced on walkie talkie not to perform any kind of maintenance
activity on stackers.
6. Electrical system was checked in the presence of the top management.
7. The plug glands were intact.

Chaudhry Munir Ahmed - Unit Manager Electrical

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

Muhammad Aqeel - Unit Manager I&C (E&I Coordinator)

1. Similar Incidents have been reported related to electrical safety:


a. NP Lab electric shock to the Lab Technician
b. Short Circuit at PakArab School

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

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Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017

Salman Akhtar / Shahab Laghari- Electrical Engineers

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:

Zulfiqar, Bag Loader, Coworker and Cousin of Fiaz:

1. I was working with Muhammad Fiaz on the same stacker #1.


2. One helper standing on the top of the trailer truck requested the loaders standing below to
adjust the height of the stacker.
3. Total three persons were standing there, Zulfiqar, Zahoor and Muhammad Fiaz.
4. Fiaz tried to operate the hydraulic valve which had metallic body in contact with the
stacker metal structure.
5. He received electric shock and fell there and then on the valve
6. We shouted to isolate the electricity from the main source
7. Fiaz didnt get time to get away from the stacker and stayed there till the power was cut
8. Socket was removed by bag counter Khalid
9. This was our 4th consecutive night however, this was the first night of Muhammad Fiaz

Zahoor, Bag Loader, Coworker:

1. I was working with Zulfiqar and Muhammad Fiaz on stacker #1.


2. One helper standing on the top of the trailer truck requested the loaders standing below to
adjust the height of the stacker.
3. Fiaz was standing behind us but he was quick to respond and went to adjust the valve
4. He touched to operate the hydraulic valve which had metallic body in contact with the
stacker metal structure.
5. He received electric shock and fell there and then on the valve
6. We shouted to isolate the electricity from the main source
7. Fiaz didnt get time to get away from the stacker and stayed there till the power was cut
8. Safety Shoes were provided to us in Aug-2016 and the condition is good.

Muhammad Faraz, Bag Counter, Coworker

1. When bag loaders shouted that someone received electric shock


2. Khalid came out of the shift in-charge cabin and cut off the supply while I rushed towards
the stacker #1
3. We shifted Fiaz to the nearby sand inside the urea bag store
4. We removed his shoes, rubbed his feet and hands. I tried to pump his heart by pushing
5. Ambulance arrived very quickly and he was shift to Medical Centre
6. I remained with him all the time in medical center and ambulance

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Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017

7. His breathing was visible till Eid Gah (Half way)


8. Nishter Hospital staff attended the patient immediately and registered him meanwhile.

Khalid Rehman, Bag Counter, Coworkers

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:

Dr. Azra Memon, Medical Officer

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:

Muhammad Iqbal Baig, Coordination Engineer


1. Ammonia and Nitric Acid startup was in progress
2. Bag de-stacking activity was in progress and in my knowledge
3. No one contacted me for stacker inspection
4. I received call for incident at 04:32
5. Alamdar Hussain had already informed medical center
6. I reached incident site at 4:40 am.
7. I then informed Abdul Jabbar, Raja Fawad, Abdul Rauf in the said sequence
8. Altaf and Alamdar were already there
9. Ambulance had reached at the incident site and Dispenser Maqsood was pumping his
heart at the chest
10. Dr. Azra had been called and she attended the patient at Medical center
11. After a few minutes he was sent to Nishter Hospital
12. This incident happened after one truck of 1500 bags from stacker #1 had already been
loaded.

Abdul Jabbar Ch., UM PH&S


1. I received the call at 04:41 am from shift in-charge and Coordination Engineer.
2. I reached directly to Nishter Hospital at around 05:00 am.
3. Doctors were pumping his chest. After 20-25 minutes of efforts doctor declared him dead.

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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.

Previous Incident History:


During the month of January, Two Incidents related to Electrical safety had been reported in PH&S
area

Electric kettle incident


On 16-Jan-2017 a Helper (Hafiz Nazar Abbas) received an electric shock when he was trying to
connect an electric kettle with extension board at New CAN bag store. He was immediately shifted
to PFL Medical Center for first aid. He was alone in the store at the time of incident. The electric
kettle was heavily modified and was not healthy to use, earth wire was not connected during
modification.
(Flash Report, Ref. Annex 3)
Key Findings:
1. Electric Kettle was found modified and in unhealthy condition
2. Single phase Industrial Plug (Receptacle) was attached to the kettle.
3. Grounding wire had not been connected to the body
4. Sealing had been done with silicon
5. Hafiz Nazar Abbas and Amjad Saleem were using this kettle since 5 or 6 days
6. It was originally under the ownership of Abdul Razzaq (CAN PH&S - Pouring Operator),
Sharif Ahmed and other shift operators since more than one year.
7. Safety shoes of Hafiz Nazar Abbas were in really bad shape with steel toe exposed and
repaired at several places
8. Safety shoes of Hafiz Nazar Abbas were issued by contractor in April-2016 with
manufacturing date of Jan-2016 but he was wearing safety shoes with manufacturing date
of May-2012. Ref. Annex 9

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Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017

Picture # 8: Electric Kettle from 16-Jan-2017

Picture # 9: Safety Shoes of Hafiz Nazar Abbas

Earth Leakage in Stacker# 6


On 23-Jan-2017 Earth leakage observed in Stacker #6 placed in crane yard when de-stacking of
CAN Product was in progress. Immediately stopped the job and informed to electrician

(Flash Report, Ref. Annex 4)

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
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Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017

4. Due date for detailed report is 3-Feb-2017 and is awaited.

Maintenance & Inspection History:


1. Preventive Maintenance schedule for stackers was developed in Dec 2016.
2. There is no PM regime for receptacle of portable equipment
3. Electrical DBs are inspected quarterly under PM Plan
4. Electrical log book of last 3 months was reviewed
5. There were several observations regarding the Stackers plug wire disengagement within
the plug
6. On 12-Jan-2017, Stacker # 1 receptacle plug wire was reported disengaged inside the
plug and was rectified by electrical technician Ref. Annex 7
7. There were more observations of stackers receptacle plug wire disengagement on
3-Jan-2017, 4-Jan-2017 and 17-Dec-2016 Ref. Annex 7

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

Personal Protective Equipment


1. Overall PPE compliance in PH&S area is not up to mark and there is no control on use of
damaged PPEs (safety shoes)
2. Contractor provides safety shoes to the contractual workers once in a year, record is
available
3. Damaged and repaired safety shoes of Muhammad Fiaz (deceased) and Hafiz Nazar
Abbas was one of the major contributors in both the incidents

Job Preparation/ Risk Assessment


1. Written and approved work instruction (in Urdu) is available to perform the de-stacking
activity and using the stacker. Ref. Annex 6
2. It had been clearly mentioned in the instructions not to start the stacker or perform
stacking/ de-stacking activity without electrical inspection for leakage current in the body.
3. Electrical team has also issued guidelines in Urdu for safe use of portable equipment.
4. Verbal instructions had also been given to the operations and electrical team after 23rd
January 2017 incident, to check and inspect the stackers before doing de-stacking activity
after every movement/ relocation of stacker.
5. Removal and re-installation of receptacle plugs is the responsibility of Bag counters
6. This job in urea bag store was started without inspection by electrical technician.

Supervision & Monitoring


1. Similar problem was detected on 12-01-2017 where it was found that a wire is
disconnected inside the stacker #1 cable plug. PTW was issued and the problem was
rectified
2. Frequent complaint of the wire disengagement inside the stacker plug indicates
mishandling of the stacker and extension board cable / cable plugs.
3. Job was being supervised by the bag counter Khalid Rehman
4. Khalid Rehman had gone to the shift in-charge room for truck gate pass preparation at the
time of incident.

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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

Medical Emergency Response


1. Ambulance arrived within 2 min of the call
2. The dispenser on duty came along the ambulance and tried to give first aid on the spot
and then timely took into the ambulance and shifted to medical center
3. Necessary Emergency Medicines were available in the medical center
4. Pulse and B.P. of patient was not detectable
5. Patient was shifted to Nishter hospital Multan

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

Job Safety Analysis


1. Formal JSA had been conducted on 10-May-2016 for Stacking & De-stacking activity
Ref. Annex 5
2. Safety instructions in the form of written and approved guidelines from Operations are
available
3. Electrical department has provided safety guidelines for portable equipment.

Hazard Effect Analysis


1. Hazards involved in the de-stacking activity were identified and written guidelines were
issued.

Training & Development


1. Training records are not being maintained for contractual /loading labor.
2. Tool box talk record is not available

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

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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

PSM Elements Violated/Not Complied:

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
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Incident Investigation Report (Fatality at PFL PH&S) 02-Feb-2017

5. Line Management accountability & responsibility


Lack of control on PPEs and mishandling of equipment
6. Policies and Principles
Safety was given less priority than the production
7. Incident Investigation
Previous instants of mishandling of stacker cable were neither highlighted nor reported
8. Safety Personnel
Focus on MSA quality and contractor management was not ensured
9. Procedures and Performance standards
Written and approved work instructions for Stacker were not followed
10. Effective Communication
CAN shift in-charge didnt inform the coordination engineer about unavailability of
electrical technician for inspection of the stacker
11. Motivation & Awareness
Team seems demotivated, focus needs to be put on the motivation development
12. Quality Assurance
There was no standardization of electrical cables, plugs and extension DBs on the
Stackers
13. Mechanical Integrity
Preventive maintenance and inspections of the equipment along with checklist was not in
place
14. Management of Change - Personnel
Depletion in skilled manpower has not been managed

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

I Reporr Code ll tNJ-c-FAT-t-m17-pHAS Ura Report A Receiving Date 29-Jan-17

Incident Type Safety lncident Category I nlury

lncident Sub-
Category Contractor Fatality

Report lssue Date 29-Jan- Employee Type Contractor

Title contractor labor due to electric shock.

Contractor Name Friends Associates Unat / Area of Incident PH&S Urea

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.

Date Of Incident 2g-Jan-17 Time Of Incident 0430 Hrs.

Incident Score 110 Name Of Injured Fiaz Aheer

P/No 32'l Occupation / Trade Labor

Employee Dept PRODUCTION Employee Section PH&S (UREA)

Cause Of Injury Contact with Electricity Type Of Injury Other

Action Required Report-B with RCA required

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""]

l- R"prt c.d" --]t cAN R"*iltrs p"r" rJ""i, ---___-]


_ll- NM-t{tt44201?+H&s lE"prl A lf
|- l*d""t rvp" s"f"ty----l l--h''"h""t c"t"g*y lt r'r"", Mb" r""bil-__l
Incident Sub-
Category Near Miss

I R"p.1C"r" D"t"l I- E."pr"v*tp" -lt- c""dil---l


l-- rtrb ---l Earth Leakage observed in Stacker No. 6.

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.

I O"," a tctd"r,1|23Jar|-17| !-""tt"""n|0tt tl tn

l- r*id"rlt s"-- l------ 80 -----l l--N"r" of t"l-J-l


I prNo lt t o"""p"tr"" / T|."d"_-l
f E.pt")". D.p-
l cause Of tnrury l ---__l
I Action REuired I Repon-B with RCA required

f"*-"*.*;lt--;,;--_lF;'*f
I nCnteam MemOers ll Tayyab Rehman - Etectricat Engineer
Mahmood Paracha
Staff Engineer (NP)

I Approving Authonty ll Mtuhammad Aqeel - UM (tnstrument)

Itl Remarrs ll

-
A r,'rcr r 9

Flash Report
0p..--*lser*h

INJFA.2-2O.I 7.PH&S CAN Repon A Receiving Date 17-Jan-I7


Incrdent Type ll Safety Incident Category I nlury

lncident Sub-
Category
Contractor First Aid Case

Report lssue Date 18-Jan- Employee Iype Contractor

Title Helper got Electric Shock

Contractor Name Friends Associates Unit / Area of Incident

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.

Date Of lncident '16-Jan- 17 Time of Incident 1020 Hrs.

Incident Score 100 Name Of Injured Hafiz Nazar Muhammad

P/No 136 Occupation / Trade Helper

Employee Dept Employee Section

Cause Of Injury Contact with Electricity Type Of Injury Cut

Action Required Report-B with RCA required

Report Target Date 31-Jan-17 RCA Team Lead Hyder Ali - UM (CAN/CN)

RCA Team lvlembers M. Mohtashim Ali - Staff Engineer (lnstrument)

Approving Authority Abdul Nasir - Plant Head PFL

Rem arks
A Yrrrqt I 5

Stacking & De'stacking

Apptoved BY: AR

O@ Necessary PPE s must be used bY a$


personnel. Shin SuPelisor musl
ensurc lhis. In case of non{ompliance
inform to conlraclot b tePlace the
penion.
Ensure availability of drinking rvater
Ensure only PhYsical fit Person
perform the sbckirE6eslacling
actlvity
Ensure proper dress of labor. Loose
dress is not allowed
Contrador should provide ftesh labour
Problem relatsd to
unskilled for be nexl shift. However, in case o{
manpowet no. a ilability of enough manPowet,
ensure lhat labour for $e activity
$/orks not more than 16 hours wih

a maximum allotrable rest during $e


acftvity.
Start the shift with safety hlk to
dbcuss allthe potenlial hazards.
One person trom mntraclor labour
must be deputed as safety captain
vho will closety watch he aclivity and
intom to shift in charge in case of any
abnormality/hazard.

Housekeeping of the a.ea to be done


DismanUing/toading ol before starling the
stacking/de-
fertilizerc from stacks slacking activity. Slippery area shouH
be dried by using sand. SIoPPY

Scanned by CamScanner
in lie area can. d(ccl
lhe phys'rcal appearance ot ths bags.
1, Fallh.zard
Slacking ot lertilizef bags should be ot
20 bags {3.0 tletei maximum

2. Slippery harard Hwnver, a le't bags can be used in


he middle of the stack to taise leng0l
(3.5 M max.) lo Ptci'de sloTo lol
dain?le ol rcin vaiet in o?en arca'
Loading must be stopPed Yfiile
d'smantingfalling of bags ftom stack'
Never fall has he bag on stacker
direcuy wfiich may cuse iniury to
anyone /damaging ol shdr.
5. LIMO PANI Availabitity h be ensuted I

as per EquireFtent during hot & humid


3. Heat Strest I
weatherolsumrEt r

6, Retnoye he tarpaulin ttom sloct I


il. lll[mination caretufly and alter blding send it l0 |
0 sb'e wih fifi fuct.
?, Ensure pmpet lighting anat8etnenl I
5. Road accidents
before startiog the stacking/de- |
stacking edivity

6. Communication 8. Inspeot the truck bebre loading ' I

switch oft the engine, aPPIY hands I

bEak and place stopPers undsr lhe I


tyres. I
9. tturing loading/unloading aclivity all I
oher vehides musl be Pa*ed arvay i
lromliearea. I
10. While performing hammeting job on I
bags to refresh it, ensue thal no I
perlon is preseolnea6y. I

11, DO NOT rDv under the shcket , I


because any tine letflQer baS may
I
fallfomsbd(er I

12. Un.necessary peaons/Uucks rnust be I


kept avray from sbck atea. Stock bag I
nny hllwhile loading I
13. Follow be speed limit (20 KM/H) br a[ |
the vehicles in he arca., I
14, th not wak unnecssarily over stock I
due to uneven or slippery surface. I
,|5. Dudng sbcking/destacking activity I
efiective communkation betr,reen tre I

persons tio*ing in chain/sedes before


I
throwing lhe bag, must be eaban6d. I
e"rcurJ
tL),

lt I ltl rl|l!: lir|r r !


Scanned by CamScanner
1, While nnving lhe stackerc, E[CB's,
Porlable light and exlensjon board
ftom one area to olher , ensure thal il
is p'uggd out
2. Eleclical cables ot frcket ol
temporary lighling to be laid away trcn
lhe movemenl of l;ft Trucks/shovel
loaders/ trolleys
3. In case of portable lighls, ensure that
l[hb and ELCB,S are propetly
checked and bgged.
tf. Do not use any Elecbical Porlable
Equipment IDB I JA I Lighb wihout
cortificaton.
5. Ensure lhai insulaton of any eleclric

Oc Use of Stackers,
poriable ligbls, ELCB'S
and ortension board
Eleclric Shock
. appliances cable is not damaged and
tiere is no pinl in cable
6. Ensure be proper earhhg of he
electric apdhnces
7. Check the ONiOFF starter switch ot
be stacker b *orkhg proper
8. Do not buch he electrical appliance
wih rivel hand (use gloves)
9. Use Tdpod light only rvih the help of
ELCB
10, Do not use lripode I'ght it broken.
Anange to check thal light by electrical
technician
11. Do nol use lhe stacker it its starter got
broken.
12. ln case of bippirg ol any Eb*rlr:d
EquipfiEnl never restart/resel Inbrn
lo Electflzl slatf lor he sanre.

LEGEilDS: S = Sma/l Probability = Medwn Pob$ility H = HiSh P'obsbility

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Prepared By: Reviewed By: Reviewed By: Approved By:

Q,{ffiffi,. Vyt;,,,,,,
M. Munir Ahmad '

Staff Engr (PH&S) Sr. Production Manager


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ERS LIIIITO MULT II
S/NO 'oY42ff8"
ELECTRICAL WORK PERMIT
ISSUING uNtr Eleclrical DATE:

CHECKS
01 Hts lhe site beeniointv vbited by Oper. & Elect. Perlons?
02 13lhe work Io tle done on a dead circuit2

D D Apron-
tl LJ Safety Harness
D Live / Breathing Apparalus

a
Job handed over aflet domplete preParatioo
ted lock / tiagdn crtcuil whose
I have installed
Name ot OPtr
citcuit is de'nergized'
I 'rt"u" testd that th;
haw
i i*uri"o v"ihriv bii('' tag dn circuit whose number
!-"-----=-17:=-ii;:z
l*- ." "" "riiC
Petmit Hrs.

Extonded

UM/SrUEng.Elcc. Natre/si,n. coord. Eogr/N..nersEn.

or "i'mog'6/at{aaa x"

Job Taken ovr - H{xtsoteapino OK

Job compf.t6d Wt'

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