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Investigation Report - Paradeep

An accident occurred at an engineering construction site where a module structure collapsed, injuring two workers. An investigation found the structure was lifted while only tack welded. Proper safety procedures were not followed and supervision was inadequate. To prevent recurrence, training was conducted on hazard identification, risk assessment, and competency development for riggers. Toolbox talks and inspections also increased to ensure safety compliance.

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ajeet kumar singh
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217 views

Investigation Report - Paradeep

An accident occurred at an engineering construction site where a module structure collapsed, injuring two workers. An investigation found the structure was lifted while only tack welded. Proper safety procedures were not followed and supervision was inadequate. To prevent recurrence, training was conducted on hazard identification, risk assessment, and competency development for riggers. Toolbox talks and inspections also increased to ensure safety compliance.

Uploaded by

ajeet kumar singh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 26

PETRON ENGINEERING CONSTRUCTION LTD.

C- 908, IOCL,PARADIP REFINERY PROJECT.

ACCIDENT INVESTIGATION REPORT BY


HSE CORPORATE

17th April 2012


INCIDENT INVESTIGATION REPORT

Date of Incident: 5th Apr, 2012 Location: AVU-Heater Site. Contract Code: C-908

Sr. no. Name of the injured person Age Designation


1 Mr. Arjun Kumar Jha 43 years Charge Hand
2 Mr. Bishnudev Tanti 38 years Khalasi
Name of Supervisors:-
Description of Incident:Mr.Brijesh Kumar Executive Engineer
Name of Erection foreman:- Mr. Kamaljit Singh

Description of Incident :
On 04.04.2012 at 4:20 evening , Module structure DSS ( L-9 x H-5 ) meters was assembled with two portals and 4
Nos of connecting beams ( top and bottom). All the beams connected with the portals were tack welded. Next day
during fixing of the bottom bracings, base was found fouling at bed beam, therefore decided to lift one side of
structure for putting packing under Module. After applying wire rope sling connected with Hydra(OR-21C-9931)
for base alignment (whole module weighing approximately 8MT) as soon as lifting force applied at base, top
connecting beams started falling one by one . Mr. Arjun Kr. Jha (Supervisor) & Mr. Bishnudev Tanti ( rigger) working
near by ran away, during such time falling beam struck both of them, resulted in head injury.Immidiatly they were
transferred to Govt.Hospital at Paradip. After rendering first aid on Doctor advised , they were shifted to Cuttack
Hospital for further check-up e.g. CT Scan etc. & better care.
Please refer slide No.4-6 for better understanding

17th April 2012


INCIDENT INVESTIGATION REPORT

Probable Cause:
 Not following safe work procedure. (e.g. Tried to shift structure under tack welded condition )
 Inadequate supervision ,since job sequencing steps were not followed.
 Job was erected over soft ground, that was the reason by next morning module base was found fouling.
 Module weight approximately 8 MT under tack welded condition was tried to be lifted for aligning purpose.
 Lack of coordination among different team e.g. Execution team ,QAQC & HSE.
 Critical lift check list was not followed, since by it’s job nature it would have been treated as as critical lift.
Suggestions to present reoccurrence:
 Follow safe work procedure.
 Immediate Tool Box Talks conducted to create awareness.
 Prior to begin with such type of activity joint tool box talk to be delivered by respective Engineers /
Supervisors and HSE persons for more effectiveness.
 Activity to be carried out under close supervision of concern erection Engineer.
 Prior to beginning of such activity HIRA to be designed by respective erection engineer to ensure necessary
control measures are in place.
 Better coordination /consultation among different team e.g. execution, QAQC, Erection & HSE expected.

17th April 2012


INCIDENT INVESTIGATION REPORT

Mr.Bishnudev Tanti was


putting the packing

Collapsed DSS-2 Structure


17th April 2012
INCIDENT INVESTIGATION REPORT

Mr. Arjun Kumar Jha hit on the beam.

17th April 2012


First fall Second fall
Third fall
9 meter

Hydra connected
with wire rope sling
5 meter

RIGGER

SUPERVISOR
INCIDENT INVESTIGATION REPORT

PECL Action Plan

Sl. No Action Taken By Whom By When


All site staff to be trained to conduct HIRA prior to all
1 HOD HSE Immediately
activities.
Rigger, Scaffolder, Electrician & Crane/Hydra/Winch
th
2 operator competency training to be conducted to certify Site HSE 15 May 2012
workmen possess adequate competency.
All critical jobs to be closely supervised by concerned Concerned Job
3 engineer & supervisor after designing necessary HIRA for Engineer / Immediately
ensuring control measures. Supervisor
Overall Project
All near miss incidents are to be investigated and discussed
4 In charge Immediately
for taking adequate corrective & preventive action.
Mr. Noor Md.
All site
Critical lift checklist to be implemented strictly for better Engineers /
5 Immediately
co-ordination among team e.g. Operator, Signal man etc. Supervisor
Lead site HSE

17th April 2012


INCIDENT INVESTIGATION REPORT

Corrective Action Taken

17th April 2012


INCIDENT INVESTIGATION REPORT

Contract Code : 905 (VGO)

Toolbox Talk / HIRA Training / Rigger, Scaffolder & Electrical


Competency Development

17th April 2012


INCIDENT INVESTIGATION REPORT

Date : 10th April, 2012

Tool Box talk conducted at site in presence of Corporate HSE C-905 VGO

17th April 2012


INCIDENT INVESTIGATION REPORT

Date : 10th April, 2012

Corporate HSE imparted training on “Hazard Identification & Risk Assessment” (HIRA) to site staff
(1st Batch)

17th April 2012


INCIDENT INVESTIGATION REPORT

Date : 10th April, 2012

Site HSE imparted competency development & assessment training to Rigger workmen (1st Batch)

17th April 2012


INCIDENT INVESTIGATION REPORT

Contract Code : 908 (AVU)

Toolbox Talk / HIRA Training / Rigger, Scaffolder & Electrical


Competency Development

17th April 2012


INCIDENT INVESTIGATION REPORT

Date : 11th April, 2012

Tool Box talk by Corporate HSE at site C-908 AVU

17th April 2012


INCIDENT INVESTIGATION REPORT

Date : 11th April, 2012

Corporate HSE conducted training on topic “Hazard Identification & Risk Assessment” (HIRA)to site
staff (2nd Batch)

17th April 2012


INCIDENT INVESTIGATION REPORT

Date : 11th April, 2012

Site HSE imparted competency development & assessment training to workmen (2nd Batch)

17th April 2012


INCIDENT INVESTIGATION REPORT

Contract Code : 909 (NHT CCR)

Toolbox Talk / HIRA Training

17th April 2012


INCIDENT INVESTIGATION REPORT

Date : 12th April, 2012

Tool Box talk conducted at site C-909 NHT CCR

17th April 2012


INCIDENT INVESTIGATION REPORT

Date : 12th April, 2012

Corporate HSE imparted training on topic “Hazard Identification & Risk Assessment” to site staff
(3rd Batch)

17th April 2012


INCIDENT INVESTIGATION REPORT

Date : 12th April, 2012

Site management meeting at site in presence of


Corporate HSE & Project Coordinator Mr. Gautam Das (Sr. Vice President ) with all RCMs
17th April 2012
INCIDENT INVESTIGATION REPORT

Contract Code : 921 (Electrical)

Toolbox Talk / HIRA Training

17th April 2012


INCIDENT INVESTIGATION REPORT

Date : 13th April, 2012

Tool Box talk conducted at site C-921

17th April 2012


INCIDENT INVESTIGATION REPORT

Date : 14th April, 2012

Corporate HSE imparted training on topic “Hazard Identification & Risk Assessment” to site staff
(4th Batch)

17th April 2012


INCIDENT INVESTIGATION REPORT

Date : 13th April, 2012

Joint walk through compliance by site management, client & site HSE staff

17th April 2012


INCIDENT INVESTIGATION REPORT

Summary of HSE training conducted at sites & number of person covered

Topic : Hazard Identification & Risk Topic : Competency Assessment &


Assessment Development
Date Faculty : Mr. A.M. Rasal (Corporate – HSE ) Faculty : Site HSE Staff
Number of Staff covered Number of Person covered
10.04.2012 24 19 (Riggers)
11.04.2012 21 21 (Riggers)
12.04.2012 19 5 (Electricians)
13.04.2012 21 ------
Total 85 45

17th April 2012


THANK YOU

www.petronengineering.com
www.kazstroyservice.com

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