Major Safety Incident Analysis

Presented by: Charudatta Bhave

Plant/ Site Manager: Rajiv Batra

Location: CIL- ABO, Learning Center , Plant I, Kothrud, Pune

Date: 05 April 2010

2

Description of the Incident : Fire Incidence at CIL Plant I ,in Learning Center Classroom No.1

Describe the fire incidence & how it occurred:

On April 5 , 2010 at 2.30 PM a Training was arranged by one of Managers at Learning Center Classroom No. 1. The training commenced at @ 2.25 PM. An assistant from Learning Center was supporting him by putting “ON” the lights , Air conditioners (AC) , Desktop etc. as routine procedure.

Few participants arrived & occupied the chairs in the room. Suddenly crackling noise was heard & some smoke was observed from one of the split A.C. As fire was observed from the A.C., the manager immediately asked the participants to vacate the room & the assistant opened one of fire extinguishers available nearby. Another assistant from the Learning Center switched off electric supply. The fire alarm siren was actuated and classroom participants were also asked to leave the room. Security was informed about that & the security team attended the fire. Security informed to local fire tender . They also came and supported for extinguishing the fire. Within 15 minutes fire was brought under control.

Note : All people inside the building were moved to safe area & nobody was injured.

Describe equipment / plant involved and any related damage: Annexure 1

Describe the product / goods involved and any related damage: Annexure 1

1.Identify Problem

STEP 1 : Identify The Problem

WHERE - The physical location of the symptom. Where it occurs

At learning center, Classroom No. 1, Kothrud Plant, Pune

WHEN - The hour, time of day, day of week, month, time of year of the symptom

14:30 Hrs, Monday, 5th Apr 2010.

HOW MUCH - The extent, degree, dimension or duration of the occurance.

Items and area damaged has been detailed in Annexure 1. The fire lasted for 20 minutes. No physical injury to any person.

WHO - To whom, by whom, near whom, does this occur ?

8 Employees were at the location attending a training program

DESCRIBE THE SYMPTOMS

Where, When, to what extent does this symptom NOT occur,

though it might have ?Where, When, to what extent does this symptom occur

?

Step 1: Identify The ProblemView of Class room before Fire Incidence

The Split A/CNear which the

short circuit occurred

Class room with ProjectorAir Conditioners

Fire at Learning CentreClass Room-1

Combustible Material Present ( Hay )

Heat GenerationContinuous Oxygen

Available

Used for side wall Acoustic Treatment

1992 Construction.No design FMEA

done

Class room both the doors open

At the time of fire

Sparking from one Air Conditioner

Blower Motor Burnt ?

Cable InsulationDamaged

Old wiring (installed 18 yrs back)

No SOP to check Old Damaged wiring

Concealed wiring notVisible for inspection

AC circuit malfunction

Component failure

Voltage fluctuation

End of useful life approaching

Not possible as regulated Gen-set supply provided

Dry grass exposed To spark

Laminated acoustic Sheet puncturedFor passing drain pipeAnd cable

Cause Tree Analysis

No-Preventive Maint Records

ACCIDENTS INVESTIGATION : THE CAUSES TREE ANALYSIS METHOD

Major findings from the accident investigation

The root causes (latent failures) consisted of :

Room was having wooden partition made of sound skulpt ( Dry Grass ) within which thermo acoustic material had been packed. This is highly combustible material

18 years old Concealed wiring. Opening (doors, window) are not of self closing nor fire retardant.

Cause Tree Analysis

Step 2: Determine Possible Causes & Rank their importance

ISHIKAWA DIAGRAM Analysis

STEP 2 Determine Possible Causes & Rank their importance.

Step 3. Take short term action

Does problem still affect other employees' safety?

Yes.

Describe potential short term action :

Removal of all Partition mounted Air Conditioners from Learning Center.- Completed

Communication of incidence and the root cause to all employees.- Completed

Statement of Mr. Pramod Sadistap .The eyewitness Manager.

Attached. Statement of Mr. Charudatta Bhave ,DGM Learning Center.

Attached. Accident site photographs. Attached.

STEP 4 : Gather Data to Determine Cause

Statement of Mr. Pramod Sadistap The eyewitness Manager

Statement of Mr. Charudatta Bhave ,DGM Learning Center

Photographs of Training Class room

The Split A/CNear which the short

circuit occurred

Before Incidence After Incidence

Highly combustible material made of hay was used as for

acoustic partitioning

Photos of Class room after Fire incidence

Step6: Plan and implement permanent solution; Fail-safe where possible

Annexure 1 -Classroom No. 1 Burnt Material List.

Cont….

Sr No

Description Of Item Qty

1 Roof Sheets, Structures , Gutters , Downtake pipes , NLG Window 1

2 Wooden Panelling 66

3 Chairs 45

4Partition made from jindal make Aluminium anodised frame with 12 mm thk Pre laminated partical board from both sides.

50

5 Split uint AC with M.S stand 5

6 2x36 Wipro Light Fitting 35

7 Plastic Writing & Copying Board 1

8 Fire & Smoke Detection System 1

9 600x600 mm Mineral fiber Ceiling 100

10 Conference ModularTable 1

11 Doors 4

12 LCD Projector with screen 1

Annexure 1 – Contd.13 2mm thk Vinyl Carpet 90

14 Sound System with Hand Mic & Collar Mic 1

15 Broken Glass for Alu. Doors & Partition 9

16 Light Points 45

17 Desktop Comuter 1

18 Sliding Windows 2

19 Painting 100

20 Manager Table with ledge 1

21Copper Piping with suction lines insulated with Nitrile rubber Tubular Installation for 1.5 Tr Split AC

20

22 Vertical Blinds 12

23 Cupboard 1

24 DB 3

25 Training Stationary Material , files , books etc 200

26 MCB 36

27 VCR 1

28 Flip Chart Board , stand & Sheets 4

29 Pin-up Boards 2

30 Training Posters 10

End