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Case 7 Date: 05.03.2019 Time: 12:00 hrs.

Incident

Chlorine shifting job was in progress inside chlorine dosing house of cooling tower (CT-1). The tonner was
shifted on manual chain hoist and placed at the designated position, when that chain block reposition job was
in progress,suddenly forwarding wheel of chain block fell down along with the chain very close to the two
casual workers who were doing the job in nearby.

Root Cause

1. Lock nut/ pin got broken during the repositioning activity due to wear and tear and prolong use.
(Failure of Equipment).

2. During checking of records of PM and load testing. It was found that the PM of the monorail was not
carried out which was due on 19.09.2018. However satisfactory load test of monorail with chain pulley
block was carried out on time i.e. on 04.10.2018 as per frequency of one year.

Recommendations

1. "Do Not Use” Tag to be provided in all lifting tools and tackles which are already due for PM job.
2. All the pending PM jobs of all lifting tools and tackles at PNCP complex are to be done on priority.

3. All tools and tackles PM and due date status to be published with in next 7 days with target for
rectification/completion by 30.04.2019.

Case 8 Date: 04.05.2019 Time: 16:19 hrs.

Incident

Material (Irgafos 168 antioxidant) unloading activity was being carried out by using fork lift. While storing/putting
away Irgafos-168 bags from forklift in chemical warehouse section 1; Jaws of fork lift touched/hit the nearby
placed EHA drums (2 numbers). EHA liquid started spilling on the ground. Immediately emergency help called
from store, F&S arrived at 16:20 hrs. With adequate protection AR-AFFF applied to cover the spillage at ground
level & leaked drums were identified and isolated. Ethyl Hexylamine (EHA) is corrosive & flammable liquid having
50 deg C flash point. Auto ignition temperature of EHA is high i.e. 265 deg C. Area barricaded & ensured no
person left inside the warehouse. Warehouse shutters kept open to ensure ventilation, power and HVAC switched off.

Root Cause

1. The Pallet used for keeping the Chemical drums is of small length then the jaw length of the forklift. The
width of pallet was 100 cms while the Jaw length of fork lift is 107 cms.

2. Negligence in following safety during forklift operation by fork lift operator.
3. The Chemical drums were kept in the warehouse are stored in a very limited space. There is a space
constrains for storage of the chemical drums in ware house.

4. The fork lift driver was not assisted by any helper for vehicle marching and flagging as there is limited space
constrain in the area.

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