Page 16 - Flip IOCL Book.cdr

Root Cause

(Unauthorized activity)
Incident happened due to faulty cable coupler. After detail investigation it was found that neutral screw found
loose & detached and caused to short circuit with the live phase inside the coupler joints.

Recommendations

1. As per existing practices any connection / disconnection is being done after de-energisation of power supply.
The existing practice is also required to be followed in case of connection/disconnection of adopters wherever
available in power cable of welding machine.

2. Check healthiness of adopter before taken into service and same is to be incorporated in existing temporary
power connection checklist.
3. Connection/Disconnection of any electrical equipment including adopter is required to be done by certified
electrician. Same is required to be ensured by respective EIC/Site In charge.

Case 14 Date: 21.12.2019 Time: 09:25 hrs.

Incident

A sampler was cleaning the bottles at bottle washing area of QC Lab. During cleaning, he put a bottle containing
chemical on funnel of closed drainage pipe to empty the bottle. After that he went to collect the empty bottles for
sampling of py gas. The empty bottles were kept in a rack which was at a distance of 10 feet from the incident area.
In the meanwhile some fumes came out from the drainage pipe due to some chemical reaction which led the bottle
to explode and splashed the chemical on the roof.

Root Cause
1. Sampler was trained to be clean only hydrocarbon sample bottles; however he was awarded the job to clean
process chemical sample bottles.

2. Supervisor did not segregated process chemical and hydrocarbon sample bottles due to missing tag. They
were removed at the time of receiving at QC lab.

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