Scribd
Upload
248 views

Case Study On Prevention of Fatal Accident

1) A fatal accident occurred at a thermal power plant during restarting activities of unit #2, where an operations engineer fell through an unbarricaded floor opening and suffered a head injury, later dying at the hospital. 2) An investigation found that the C&I helper left his post at the opening without notifying anyone, and the operations engineer was rushing out of the control room and failed to notice the opening. There were no visual warnings or barricades around the opening. 3) In response, the plant modified their permit-to-work system to require clearance and physical verification of safety measures like barricades by three departments before any work with floor openings. This led to some delays but improved

Uploaded by

Sachin Agarwal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
248 views

Case Study On Prevention of Fatal Accident

1) A fatal accident occurred at a thermal power plant during restarting activities of unit #2, where an operations engineer fell through an unbarricaded floor opening and suffered a head injury, later dying at the hospital. 2) An investigation found that the C&I helper left his post at the opening without notifying anyone, and the operations engineer was rushing out of the control room and failed to notice the opening. There were no visual warnings or barricades around the opening. 3) In response, the plant modified their permit-to-work system to require clearance and physical verification of safety measures like barricades by three departments before any work with floor openings. This led to some delays but improved

Uploaded by

Sachin Agarwal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
You are on page 1/ 12

Case study on prevention of fatal

Accident ?
1.

Safety concerns:
While workers are expected to carry out their work in a safe and healthy
environment, we know, with the number of workplace accidents, this isnt
always the case.
And

2. When you are confronted with safety and health issue at work, you dont have
to deal with it alone.
Thus

Safety is every bodies responsibility as for as accident


prevention is concerned.

I , K Venkateshwar Rao, on behalf of Group1,


Welcome you to the presentation on case study
on prevention of Fatal Accidents.
My other team members are
Sh. Abhimanyu Suttar
Sh. Om Prakash Saini
Sh Devashis Nayak
Sh. Gurucharan Singh Virdi

FACTS:

IN CASE STUDY

FATAL INJURY- AT THERMAL POWER


COMPANY Thermal Power Companys is a 2000 MW Thermal
power plant .
The plant is fully operation, on the day of the
incident unit #1 was under overhauling and unit
#2 had a Boiler tube leakage .every body in the
turbine floor was busy trying to get the units
operational
The accident took place during restarting activity
of unit #2

Chronological Order of
Events
HP bypass valve replacement activity was
planned in untit #2. C & I had applied for
and had taken Permit to work ( PTW)
For shifting of material from 8.5 mts to 17.0
mts. Floor Grill near UCB entrance was
opened and put aside so as to be able to
access the equipment
One non-technician helper was asked to
stand near opening so as to warn people
regarding the opening
C&I Engineer had gone to bring EOT crane
near to floor opening for lifting the valve
from 8.5 mtr to 17.0 mtr

Chronological Order of
Events
At that time, Operation Engineer came out
of UCB and fell through that opening and
got horrible head injury.
C & I Engineer came near to the opening
and saw someone fall into the opening and
raised the alarm.
Operation Engineer was taken to hospital in
ambulance immediately.
Doctors on duty declared patient brought
dead

TPC: AIC
An Accident Investigation
Committee was formed to :
Establish the circumstances and reasons
leading to the accident.
Fixation of responsibility to the extent
possible.
Suggest remedial measures for prevention
of recurrence of similar or related nature of
accident.
Any other aspect.

TPC : Investigation by the AIC :

AIC went through


Site visit:
Documents Checked
1. Accident FIR report
2. Photograph of accident place.
Interviewing: Persons :.
1.Shift charge Engineer :
2.C&I Engineer
3 Helper kept at site to warn people
Enquiry finding:

Enquiry findings
1. C&I helper told that he was at the washroom at that time for
nature call. He was not told about the importance to staying near
the floor opening by the engineer.
2. The Operation engineer had rushed out of the Unit Control Room
(UCB) due to some urgent work and had failed to notice the
opening .
3. No Visual Indication or barricading was in place to warn anybody
as to removal of floor plate at that location

ACTION TAKEN BASED ON ENQUIRY FINDINGS

PTW system modified .For issuing PTW for


opening of floor safety, CISF-fire ,
operation Shift In charge has to give
clearance only after Physical verification
the barricading near opening and all other
safety measures taken.
Then only actual PTW issued with cross
PTW with barricading PTW and signature of
all 3 concerned departments
representatives.

Effect of the Safety Procedure Adopted

Maintenance personnel had a


complaint that they were facing
delay in completion of work as
getting signature from all concerned
is time taking.

Learnigs
1. All locations where work is in progress and unsafe condition
persist are to be guarded and visual warning signal provided
.
2. Only after all the safety measures are in place the required
required permit to work is to be issued
3. Proper guidance and training is to be given to the Engineers
and workers for working at unsafe areas.
4. Continuous, close supervision should be available and risk
assessment of work to been ensured while working at such
locations.

Any question
please ?

You might also like