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Recommendations

1. Damaged ceiling part of warehouse to be repaired at the earliest.

2. Driver of fork lift to be strictly counseled and awareness to be increased for safe operation of forklift during
material handling by imparting trainings. Training on BBS to be imparted to all heavy vehicle drivers of PNC.
3. It shall be ensured by stores that forklift driver shall always be accompanied by helper during marching and
lifting of material.

4. It is to be ensured that wooden pallet size on which material are being kept are matching with forklifts jaws,
accordingly packing instruction to be incorporated in PRs/Purchase orders by user/purchase.

5. SOP is to be prepared and to be handed over to operator driving fork lift.

Case 9 Date: 04.05.2019 Time: 15:30 hrs.

Incident

NCU heater H-300 radiant and LMP coil replacement activity was in progress. Crane (Reg. no. NL-02-N-9636)
with capacity of 150 T provided by M/s- Radiant Hi-Tech was engaged for lowering/lifting of material under
W.O. 25751892 Dt.18.12.2018. On 04.05.2019, no lowering/lifting activity was carried out by crane, however
during idling period at around 15:30 HRS, Crane operator decided himself to do greasing in joints of crane
boom without informing IOCL at site itself. While repositioning of boom for greasing in last boom (out of 4
nos. boom), suddenly crane chassis got lifted above the ground and extended boom was fallen on structural
railing of flue gas analyzer shelter near heater area (south side corner). Immediately area was barricaded. No
personal injury and no process equipment damage were observed. Partial damage was observed in structural
railing of flue gas analyzer shade. Later on higher capacity cranes were called & crane was safely brought to its
normal position.

Root Cause

1. Negligence by crane operator and not following up the standard maintenance procedure for maintenance of
crane.

2. Standard maintenance procedure of crane maintenance not followed:

2.1 Required capacity of counter weights of crane were not kept on counter weight carrier before extension of
boom in fully horizontal condition for maintenance activities.

2.2 Safe load indicator (SLI) was bypassed by operator, while lowering down the crane boom below the angle of
hydraulic cut off (e.g. 30 degree for this case) with zero counter weight.

2.3 Crane hook along with wire ropes were not lowered down to ground level.

2.4 After completion of greasing in 4th, 3rd and 2nd boom, 4th and 3rd boom were fully closed and 2nd boom
was not fully closed by crane operator and he opened the 1st boom fully along with partially opened 2nd
boom. Then he lowered down the boom in same position to horizontal level. Due to excess weight of partially
opened 2nd boom and no counter weights in carrier, crane got toppled.

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