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Report on Fatal Accident that occurred on 04/11/2012 at

Bokaro Steel Plant


1.

General Information:

Plant

Bokaro Steel Plant

Department

Hot Strip Mill

Location

(-) 11 mtr. level, Motor Room # 5,


Feeder 45 L

Nature of Accident

Reportable (Fatal)

Date, Shift & Time of Accident

04/11/2012, 3.30 PM, G Shift

Date & Time of Death


2.

04/11/2012, 3.30 PM

Employee Information:

Name

Late S.K. Irfan

Category

Contractors Employee

Name of the Contractor

M/s Deepak Enterprises, Chas, Jharkhand

Designation

Electrician

Age

29 years

3.

Background Information:

As per Purchase Order No. P35/024/4510016704, Dated 19/01/2012, M/s Deepak


Enterprises, Chas, Jharkhand was awarded the work of supply and complete
retrofitting of General Electric (GE) make 2000 Amp Circuit Breakers (04 nos.) in
03T 11, 415 Volts Sub-Station at () 11 mtr. level, in Motor Room # 5 of Hot
Strip Mill. This Electrical Sub-station, though installed in Hot Strip Mill but supplies
power to some areas of Slabbing Mill which is situated by the side of Hot Strip Mill.
4.

Circumstances prior and up to the fatality:

a) Capital Repair of Hot Strip Mill was planned from 30th Oct. 12 to 9th Nov. 12.
Accordingly the Mill was under shutdown since 30th Oct. 12 from 3.00 PM
onwards.
b) During capital repair many jobs were undertaken in the Mill.
c) Replacement (Retrofitting) of circuit breakers was also planned in 03T 11,
415 Volts Sub-Station at () 11 mtr. level, in Motor Room # 5 of Hot Strip Mill.
d) As per Purchase Order No. P35/024/4510016704, Dated 19th Jan. 12, M/s
Deepak Enterprises, Chas, Jharkhand was awarded the work of supply and
complete retrofitting of General Electric (GE) make circuit breakers. M/s
Deepak Enterprises had deputed a group of six (06) persons to execute the
job.

e) On 29th Oct. 12, visitors gate pass was made and the crew members were
allowed to visit the site to take measurement. After taking the measurement of
the panels, the crew members returned back.
f) On 3rd Nov. 12, the crew members again entered the plant on visitors gate
pass and started the job. On that day, 1 no. circuit breaker was successfully
replaced by the crew. (Fig. 1)
g) On 4th Nov. 12 (Sunday), it was decided to replace another circuit breaker at () 11 mtr. in 45-L panel of Hot Strip Mill also and the job was started at 12 pm.
Before start of the job, job briefing was given to the crew members by the area
in charge wherein it was explained that Section-I was without power and
Section-II (i.e. adjacent panel) was live. Because from live panel (Section II)
was feeding power to EOT Cranes of Slabbing Mill. Accordingly front and
backside doors of live panel were kept in closed and locked condition.
h) It was reported that, at 3.30 PM, a flashover had occurred in the backside of
live (Section-II) panel during the job and Late Irfan got electrocuted. Other
crew members informed the concerned officials about the incidence. Late Irfan
was unconscious and his body was lying half inside the live panel. (Fig. 2 & 3)
i) Immediately electrical shut-down was given for Section-II and the victim was
removed from the panel. The victim succumbed to his injury at site.
5.

Observations:

Based on interactions at site and discussions held with concerned officials, the
following circumstantial facts were gathered:
a) Proper Safety Protocol was not prepared keeping the sequence of activities and
job wise responsibility in view.
b) On 25th Oct. 12, a letter was given by the representative of agency to the
executing deptt. for seeking permission for retrofitting of circuit breakers. He
had given a list of six expert/ trained persons who were deputed to execute the
job.
c) Accordingly, visitors gate pass was issued and all six persons were allowed to
work in the site.
d) Process for issue of gate pass for six persons was not routed through Safety
Engineering Department.
e) There is no system to impart Safety Induction training to the persons engaged
for the job on turnkey basis (material supply and installation), before issue of
gate pass.
f) It was informed that the same persons had already executed similar type of jobs
in other departments.
g) Required Safety information was not shared with the crew members during job
briefing before start of job.

h) Locking arrangement of the live panel was not foolproof, because the crew
members opened the lock of live panel to execute the job conveniently.
i) It was informed that it was not possible to give shut down to live panel, because
it was feeding power to Slabbing Mill and there was no alternate power supply
arrangement to Slabbing Mill EOT Cranes.
j) Proper insulation barriers were not provided between live and dead panels.
k) Proper supervision was not provided by the contractor as well as executing
department.
6.

Causal tree analysis:

The victim working by


the side of live panel.

No physical barriers
between live and
dead panels.

Inadequate supervision
completion of job.

7.

Victim
was
electrocuted.

till

Cause of Incidence:

i) Immediate Cause of incidence: Electrocution due to contact with live bus-bar


in substation section-II.
ii) Root Cause of incidence:
a) Section-II was live while job was being carried out in Section-I.
b) Physical barriers were not provided to isolate the live bus-bar.
c) Job supervision was inadequate.
8.

Safety aspects involved / violation of safety norms:

(a) Protocol for the capital repair jobs during the shutdown period was available
but job wise responsibility was not mentioned in the protocol.

Injury

(b) Process for issue of gate pass for six persons was not routed through Safety
Engineering Department.
(c) There is no system to impart Safety Induction training to the persons engaged
for the job on turnkey basis (material supply and installation), before issue of
gate pass.
(d) Victim was not wearing insulated hand gloves while carrying out electrical job
though he had carried out similar jobs in other departments.
(e) Job briefing was given to the crew members by the concerned officials before
start of job.
(f) Locking arrangement of the live panel was not foolproof, because the crew
members opened the lock of live panel to execute the job conveniently.
(g) Proper insulated barriers were not provided between live and dead panels.
(h) Proper supervision was not provided by the contractor as well as executing
department.
9.

Recommendations to prevent recurrences:


Accident factors established
Possible preventive measures
a) Protocol for the capital repair Proper Safety Protocol should be prepared
jobs during the shutdown
for the capital repair jobs during shut down
period was available but job
period and job wise responsibility should
wise responsibility was not
be mentioned.
mentioned in the protocol.
b) Process for issue of gate
pass for six persons was not
routed
through
Safety
Engineering Department.

c) Locking arrangement of the


live panel was not foolproof.
d) Proper insulated barriers
were not provided between
live and dead panels.
e) No supervision till completion
of job.

Process for issue of gate pass for the jobs


by turnkey basis (material supply and
installation) should be routed through
Safety Engineering Department and proper
Safety Induction training should be
imparted to the persons before issue of
gate pass.
On-the-job training w.r.t. existing hazards
and preventive measures to be imparted to
the persons before putting them on the job.
If it was not possible to isolate the live
panel, proper insulated physical barriers
should have been provided.

Strict Supervision should be ensured till


completion of such type of jobs where jobs
are undertaken on turnkey basis (material
supply & installation).
Proper inspection of work site by the
concerned officials to be done and hazards
prevailing at the sites to be highlighted and
people should be cautioned accordingly.

Use of proper PPEs by the contractor


workers should be ensured.

10.

Details of enquiry committee:

(a) An internal committee was constituted to enquire the fatal accident. The
members of the committee are as under:-

11.

M Ravi Varma, General Manager, CRM

N Mohapatra, AGM (safety), SED

C R K Sudhanshu, Manager, Pers-Works

Details of next of kin:


Name

: Smt. Shakila Khatoon


Wife

Relationship with deceased

Islam Nagar
Jugsalai
P.O. Jugsalai
East Singhbhum
Jharkhand

Permanent Address

Islam Nagar
Jugsalai
P.O. Jugsalai
East Singhbhum
Jharkhand

Enclosed: Fig - 1, 2, 3 showing view of the accident site.

(Suresh Kumar)
AGM (Safety)
SAIL Safety Organisation, Ranchi

This Circuit Breaker was


replaced successfully on
03-11-2012

Section I
(Under Shutdown)

Job was going on in


this cubicle on
04-11-2012

Section II
(Live)

Fig. 1 Showing view of 3T 11 Substation, Front Side

Section-I
(Under shutdown)
Circuit breaker
replacement was
being done here

Section-II (Live panel)


Victim was standing
here for circuit
breaker replacement
job & got
electrocuted.

Fig. 2 Showing view of 3T 11 Sub station, Back Side

Section II
(Live)

Flashover
marks

Section I
(Under
Shutdown)

Fig. 3 Showing view of Bus-bars in 3T 11 Sub station, back


Side