ज ांच समिमि की रिपोर्ट

आई.ओ.सी.एल., उजै्जन एल पी जी प् ांर् िे घ िक घर्न

घर्न की मिमि: 14 अकू्टबि, 2021

INVESTIGATION COMMITTEE REPORT

On fatal incident at IOCL Ujjain LPG Bottling Plant

Date of incident: 14th October, 2021

तेल उद्योग सरुक्षा निदेशालय

OIL INDUSTRY SAFETY DIRECTORATE

पेर्र ोमलयि एवां प्र कृमिक गैस िांत्र लय, भ िि सिक ि

8 वीं मंजिल, ओआईडीबी भवन, प्लॉट संख्या 2, सेक्टर -73, नोएडा, उत्तर प्रदेश, 201301

वेबसाइट: www.oisd.gov.in / टेलीफोन: 0120-2593800

रिपोर्ट जि किने की मिमि: 13th December, 2021

Date of submission of report: 13th December, 2021

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OIL INDUSTRY SAFETY DIRECTORATE

EDS: OISD:ACCI/05 Dt: 13.12.2021

Sub: INVESTIGATION COMMITTEE REPORT ON FATAL INCIDENT AT ABOVE GROUND LPG BULLET OF IOCL UJJAIN LPG BOTTLING PLANT, ON 14th OCTOBER 2021

1.0 INTRODUCTION

1.1 On 14.10.2021 at about 15:30 hrs., fatal incident took place during the degassing process of 150 MT capacity, above ground LPG storage bullet no-3, at IOCL Ujjain LPG Bottling Plant. Information regarding the incident was received by OISD and PNGRB, from IOCL vide e-mail dt. 15.10.2021 (Annexure-1).

1.2 To investigate the incident, committee comprising of the below mentioned officers was constituted by ED, OISD, vide letter ref. OISD/EDS/ACCI/05 dt. 21.10.2021 (Annexure-2) for investigating the accident:

1. Shri Mahesh Kumar Goyal, Additional Director (MO), OISD

2. Shri Gagan Aggarwal, Dy. Director (Authorization), PNGRB

The terms of reference of the committee are as under:

Identify the lapses

To identify the root cause of the incident

Lessons learnt, and,

Remedial measures to avoid recurrence of such incidents.

2.0 BACKGROUND

Following are the salient features of IOCL Ujjain LPG Plant: -

1 Bulk Storage 2 x 700 MT Mounded Storage Vessel (Commissioned in 2001) and 3 x 150 MT Above Ground LPG Bullet (Commissioned in 2001). Total Bulk Storage – 1,850 MT

2 Bulk Receipt Through road primarily from Dahej and Dumad average receipt 16,225 MT per month

3 Tank Lorry Gantry

8 bays TLD for unloading of Bulk LPG out of which 1 bay has the loading facility too.

4 Carousel 3 nos 24 head electronic carousel commissioned in 2001, 2014 and 2018 respectively.

5 LPG Cylinder Bottling

Average bottling of 16,225 MT per month Actual bottling during 2020-21 was 194.7 TMT and during Apr’21 to Oct’21 was 107.0 TMT

6 Plant Commissioning

Plant was commissioned in 2001

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The incident took place on 150 MT capacity above ground bullet no. 3 during degassing process. Degassing of this bullet was being carried out for replacement of Magnetic Level gauge by Radar gauges.

Previous incident at this installation: One incident took place at this location on 23.08.2021 in green belt area where-in one packed cylinder truck was proceeding towards cylinder statutory testing shed in green belt area and one person on motorcycle was coming from statutory testing shed. Due to collision of the truck and the motorcycle, the two wheeler rider was injured and hospitalised. He was discharged from hospital on 21.09.2021 and subsequently expired on 15.10.2021. This incident was investigated by internal committee of IOCL (Annexure-3).

3.0 INCIDENT DESCRIPTION and CHRONOLOGY OF EVENTS

On 14.10.2021 at about 15:30 hrs, fatal incident took place during the degassing process of 150 MT capacity above ground LPG storage bullet no. 3 at IOCL Ujjain LPG Bottling Plant. Degassing of this bullet was being carried out for replacement of Magnetic Level gauge by Radar gauges.

IOCL Ujjain LPG Bottling Plant placed work order ref. LT05/20-21/26900461 dt. 23.03.2021 on M/s. Safess Quality Management Pvt. Ltd. (SQMPL), Mumbai for replacement of Magnetic Level gauge by Radar gauges on all the three above ground LPG bullets (Annexure-4).

M/s. SQMPL authorised their representative Mr. Mozammil Hussain vide letter dt. 09.10.2021 to execute this job and he reported at IOCL Ujjain LPG Bottling Plant on 11.10.2021 for execution of the job (Annexure-5).

Hot Work permit no. 3372H2100218/3372HT21000204 dt. 11.10.2021 was prepared for replacement of Magnetic Level gauge, by Radar gauge, on Bullet no. 1, 2 and 3. This permit was extended on 12th, 13th and 14th Oct’21. Permit was issued by Mr. S K Ramteke, DGM (Plant/ location incharge) and received by Mr. Abhishek Khare, Sr. Operation Officer (Annexure-6).

Plant has obtained PESO approval vide letter dt. 21.09.2021 and drawing no. IOCL/UJN/RG/2021/003 for replacement of gauge. Detailed procedure/ SOP is mentioned on PESO approved drawing (Annexure-7).

Work for replacement of gauge on bullet no. 1 commenced on 11.10.2021 and was completed on 12.10.2021 and bullet no. 1 was re-commissioned and put in use on 13.10.2021. For replacement of gauge, degassing of the bullet was not done and also before re-commissioning of bullet no. 1, hydro test was not done. (Annexure-8).

Emptying out of LPG from bullet no. 3 was started on 13.10.2021 for replacement of gauge and vapour recovery was also completed on 13.10.2021 evening. De-pressuring was done on 14.10.2021 from the isolation valve of the Safety Relief Valve (SRV), after removing the SRV. Magnetic Level gauge was removed at around 12:00 hrs. without degassing the bullet. As per statement given by officer, this job was carried out in presence of Mr. Mrigank Saini, Mr. Anshul Salvi, Mr. Abhishek Khare, Mr. Anoop Ingle (IOCL officers) and Mr. Md. Mozammil Hussein, Supervisor of the contractor M/s. SQMPL. After removal of Magnetic

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Level gauge, it was observed that both the floats and spring were detached from the rod and did not come out along with the rod. Prefabricated reducer (10”x4” size) along with isolation valve was fixed on nozzle on which earlier Magnetic Level gauge was fixed (Annexure-9).

At around 13:00 hrs. on 14.10.2021, this situation was discussed in the office of Plant In-charge Mr. S.K. Ramteke in the presence of IOCL officers Mr. Anshul Salvi, Mr. Mrigank Saini, Mr. Abhishek Khare, Mr. Anoop Ingle and Mr. Md. Mozammil Hussein, supervisor of M/s. SQMPL. In anticipation that the two floats may in future get stuck/ obstruct the LPG liquid bottom line, it was decided to remove the floats from inside the bullet no. 3 and for this degassing of the bullet was to be done after lunch hours on 14.10.2021 (Annexure-10).

For degassing of bullet no. 3, fire hose was connected from Double Hydrant no. 14 at water drain point of bullet no. 3, through a spool piece having male part for hose connection. To speed up the water filling for degassing of bullet no. 3, another fire hose was connected from Double Hydrant no. 15 up to the top of bullet no. 3 for water filling through manhole. For this purpose, top manhole was opened and both the deceased namely Mr. Lakhan Singh (petty contractor) and Mr. Rajendra Singh (labour), in presence of HSE officer Mr. Anshul Salvi, tried to hold/ fix the fire hose in manhole and in this process Mr. Rajendra Singh fell inside the bullet and second labour Mr. Lakhan Singh went inside the bullet to save Mr. Rajendra Singh.

IOCL plant personnel tried to rescue these two persons but due to lack of oxygen inside the bullet, small size of manhole (460 mm internal dia) and non-availability of appropriate equipments for rescue in such condition, no one could enter inside the bullet.

Emergency was declared by the plant and at around 16:30 hrs mutual aid members and local district administration were informed. Later State Disaster Response Force (SDRF) and National Disaster Response Force (NDRF) were also called. With the help of blower brought by Aditya Birla Grasim, Nagda, LPG vapour was pushed out from the bullet to increase the oxygen level and around 03:00 hrs. on 15.10.2021 both the dead bodies were taken out from the bullet by NDRF personnel. (Annexure-11).

Time of entry of Mutual Aid members and district administration is not entered in the gate register. As per gate register SDRF team reported at 22:00 hrs. and NDRF reported at 01:30 hrs. on 15.10.2021 (Annexure-12)

4.0 INVESTIGATION MODALITIES

4.1 The committee members visited the IOCL Plant on 22.10.2021. The incident site and facilities around the above ground bullets were visited to observe and understand the incident.

The methodologies followed for the investigation of the incident are as follows:

a. Site Visit.

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b. Interaction and recording written statements of plant in-charge, plant officers, contractor supervisor, LPG pump house operator, FWPH operator and security personnel (Annexure-10 & 13).

c. Interaction with Mutual Aid Members - M/s GAIL India (Annexure-11).

d. Scrutiny/ review of following records:

i) Work Permits, Job Safety Analysis (JSA), work order, etc.

ii) PESO approved drawing for replacement of Magnetic Level gauge rod with Radar gauge wherein SOP is also mentioned (Annexure-7).

iii) Log books of Fire Water Pump House from 10th to 14th Oct’21 (Annexure-14).

iv) Log books of LPG Pump House from 4th to 16th Oct’2021 (Annexure-15).

v) Record of online level and pressure reading of Bullet no-3 from 13th to 14th Oct’2021 (Annexure-16).

vi) GMS records of sensors provided on Bullet No-3 (Annexure-17).

vii) Review of post mortem reports of both the deceased (Annexure-18)

viii) CCTV footage, detail/location of CCTV cameras provided by plant is attached as Annexure-19

ix) IOCL internal investigation report of this incident (Annexure-20)

x) Training record of IOCL officers & IOCL’s training policy for officers (Annexure-21)

xi) Management of Change (MOC), administrative approval for replacement of magnetic gauges with radar gauges (Annexure-22)

xii) Gate Passes and Gate record (Annexure-23)

4.2 As per IOCL, no police FIR has been lodged till dt.18.11.2021 (Annexure-24)

4.3 As informed by plant, this incident has also been investigated by the following authorities: -

a. Internal investigation by three-member internal committee constituted by ED-HSE, IOCL.

b. A four-member committee constituted by District Magistrate, comprising of

i) SDM-Ghattiya (Ujjain)

ii) Joint Director, Industrial Safety & Health, Ujjain

iii) SDPO-Mahidpur

iv) Mr. D K Choubey, Safety officer of M/s Grasim Industries, Nagda.

c. One-member committee of Factory Dept. i.e. by Joint Director, Industrial Safety & Health, Ujjain.

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5.0 OBSERVATIONS/ LAPSES

5.1 Non Compliance of Standing Operating Procedures (SOP): -

a. Plant obtained the PESO approval on drawing no IOCL/UJN/RG/2021/003 for replacement of existing Magnetic Level gauge with Radar gauge on 21.09.2021. Procedure to be adopted for this work (without any hot work on bullet) was also mentioned in the drawing. This drawing, SOP/ procedure was prepared and submitted by IOCL plant and approved by PESO (Annexure-7).

b. Following major steps that were clearly mentioned in the SOP approved by PESO, were skipped during job execution:

i) #2 - Degas the bullet by filling water inside it from bottom liquid in/ out connection.

ii) #5 - Check LEL and Oxygen level (O2) inside bullet and if within limit make vessel entry with FLP lighting.

iii) #6 - Clean the bullet from inside, collect the sludge.

iv) #11 - Conduct hydro test of bullet with new spool piece at pressure 28.857 kg/cm2.

v) #13 - Purge the Bullet with LPG vapour drain water from bottom of bullet.

Above activity at S. No. i), ii) and iii) was to be carried out before removal of Magnetic Level gauge and installation of new Radar gauge. Activity iv) was to be carried out before re-commissioning of bullet as newly fabricated reducer/ spool piece was installed at first flange joint.

c. SOP/ procedure for the said work was neither jointly signed by IOCL and contractor nor SOP was handed over to the contractor by IOCL in writing, before commencement of work at site.

d. Committee is of the considered view that all above major steps i.e. b.i), ii), iii), iv) and v) were skipped during level gauge change job for bullet no. 1, with the mutual consent/ understanding between the contractor supervisor and the LPG plant in-charge and other IOCL officers. Similar planning for job execution was there for bullet no. 3 and so step no. b. i), ii) and iii) were skipped for bullet no. 3 job and subsequently the accident happened.

e. Prior approval for the modification job i.e. change of magnetic level gauge to

radar level gauge was obtained from PESO vide letter date 21.09.2021, however the LPG bullet B-1 was commissioned without obtaining amendment from PESO.

5.2 Lack of supervision by IOCL personnel and Contractor: -

a. Clear role and responsibilities of IOCL officers and staff as well as M/s. SQMPL personnel for critical activities of this job was not defined by location

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in-charge, due to which the supervision of jobs at field level was inadequate. Day wise activity time schedule was not prepared.

b. Permit receiving IOCL officer and contractor supervisor/ personnel were not present at site. M/s. SQMPL supervisor was out of plant at the time of incident.

c. Job which was supposed to take minimum 4-5 days for each bullet, if proper procedure had been followed, was completed in hurry in only 2 days for bullet no. 1 by bypassing critical steps of PESO approved SOP.

d. As per information provided by plant, fixing of spade in LPG liquid line was done on 13.10.2021 in presence of Maintenance Officer and fixing of spool piece in drain line of bullet no. 3 for water filling was done on 14.10.2021, without the knowledge of IOCL officers and staff, by the deceased workers. Based on interactions and nature of work, investigation team infers that this was done with the knowledge of Plant In-charge and IOCL officers who were involved in execution of this work. This was also in the knowledge of LPG Pump House operator, because this activity requires de-pressuring of LPG pipeline of Bullet-no-3 from first ROV to isolation valve no LL-79 which can only be done by using the LPG pump and then draining of residual liquid/ vapour LPG through drain line of bullet no. 3. However same is not logged in the LPG pump house log book. Also spool piece and gaskets for fixing in drain line for connecting fire hose from Double Hydrant-14 was provided by IOCL. Also in CCTV footage IOCL HSE officer and one of the deceased labour Mr. Lakhan Singh can be seen opening the Double Hydrant No. 14 and 15 for water filling in bullet no. 3 through water drain line and water filling through top manhole of the bullet respectively.

e. As per interaction with LPG Pump House operator, IOCL field staff/ workmen are not informed about the maintenance activities being carried out in their operation area.

5.3 Non-compliance of Work permit system: -

a. Hot Work permit no. 3372H2100218/3372HT21000204 dt. 11.10.2021 was prepared for replacement of Magnetic Level gauge by Radar gauge on bullet no. 1, 2 and 3. This permit was extended on 12th, 13th and 14th Oct’21. Permit was issued by Mr. S K Ramteke, DGM (Plant/ location incharge) and received by Mr. Abhishek Khare, Sr. Operation Officer. Work Permit was signed by permit issuer, receiver and contractor supervisor (Annexure-6).

b. Approved copy of Job Safety Analysis (JSA) for change of level gauges was not available in the LPG plant. Job Safety Analysis (JSA) attached with the Hot Work permit was for another job related to SRV testing/ GMS testing/ welding work.

c. Tool Box talk was carried out during execution of job from 11.10.2021 to 14.10.2021. However, there is no record of Tool Box Talk with the two deceased labours.

d. Work permit conditions were not filled correctly e.g. #7 - Equipment properly steamed/ purged - not required, #8 - Equipment Water flushed - not required, #11 - Gas test done have been shown and 20.9% of oxygen level and 0% of

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hydro carbon have been mentioned. Conditions of entry to confined space have not been correctly filled and no lack of oxygen and non-availability of combustible gases have been shown, whereas bullet no. 3 was having lack of oxygen and availability of combustible gases at the time of start of degassing process through water filling on 14.10.2021.

e. Hot Work Permit was received by Mr. Abhishek Khare, Sr. Operation officer, however he was not present at site during water filling process of bullet no. 3 for degassing. Also M/s. SQMPL supervisor Mr. Md. Mozammil Hussain was also not present at site, he was out of plant at the time of incident. Only safety officer Mr. Anshul Salvi was present at the site along with two deceased contract labours.

f. In the work permit extension, brief detail of work was mentioned for that particular day, however correct/ actual work details were not mentioned, e.g. purpose of permit extension on 14.10.2021 was mentioned as “Depressurisation of bullet no. 3”. Jobs being performed or to be performed in field on 14.10.2021 such as Degassing, removal of Magnetic Level gauge, installation of Radar gauge, opening of top manhole etc. were not mentioned in the permit extension detail.

g. In view of above, work Permit System was not properly followed as per OISD-STD-105 and proper planning and precautions for safe execution of job was not ensured by the location in-charge before issuing and extending the work permit and giving clearance for execution of the job.

5.4 Emergency handling response:

a. Rescue operation could not be done in time due to non-availability of proper equipments for safe entry in vessel (having LPG vapour or lack of oxygen) through manhole (460 mm internal dia). IOCL itself tried to rescue the deceased, but personnel were unable to enter the vessel through manhole carrying breathing apparatus, due to restriction faced by large size of BA to pass through the manhole.

b. Call to mutual aid members for emergency/ rescue was made after a delay of more than one hour. Incident occurred at 15:30 hrs. but first call to mutual aid member i.e. GAIL India was made at 16:40 Hrs (as per the statement given by GAIL India officer) and Director (DISH) was informed at 17:00 hrs.

5.5 Lack of exposure/proper training to IOCL Officers:

Mr. Anshul Salvi, HSE officer who was present at site at the time of incident joined IOCL on 10.07.2017 and he joined Ujjain LPG Bottling plant on 05.07.2021 i.e. three months back only from other function and this was his first posting in LPG. He has not undergone training on ‘Safety & Standard Operating Procedures (SSOP)’ as per IOCL policy.

5.6 Review of CCTV camera Recording:

a. Plant is having total 15 nos. CCTV cameras vis-à-vis total 22 cameras mentioned in PESO approved plant layout. As per Plant out of these 15 cameras, only one camera installed at LPG sheds is capturing the view of

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above ground LPG bullets. Recording of this camera dt. 14.10.2021 was obtained from Plant. This CCTV footage was shown and discussed with the plant officers during investigation on 22.10.2021. Based on interaction with plant officers, written statements and review of CCTV recording of this camera, following was observed: - i) Hose connections were made from Double Hydrant No. 14 and 15 for water

filling through drain point and top manhole cover respectively.

ii) Water filling process from both the hose connections was started in presence of IOCL officer Mr. Anshul Salvi and both the deceased workers. This was a planned activity with the knowledge of IOCL officer/ officers.

iii) While water filling process from top manhole, water splash is observed twice in CCTV footage which indicates that Mr. Anshul Salvi, HSE Officer and both the deceased workers were trying/ planning to hold/ fix the fire hose in the opened up manhole. The water pressure in the hose was high since fire engine of 410 kl/hr capacity and 88 m rated head was running and water draw was only through these two hose connections. For fixing of fire hose pipe with the ladder (inside the bullet) Mr. Rajendra Singh bent in the manhole and probably due to excessive pressure in fire hose he could not hold the hose and fell in the bullet. Immediately, Mr. Anshul Salvi rushed down to close the Hydrant Valve no. 15 to close the water supply. Meanwhile the other worker Mr. Lakhan Singh went inside the bullet to save/ help Mr. Rajendra Singh but due to lack of oxygen and presence of LPG vapour both got unconscious and died.

b. During interaction with Mr. Sandeep Yadav, IOCL workman who was posted at LPG Pump House in 1st shift on 14.10.2021, said that he is not aware of any maintenance work on bullet no. 3. However, in CCTV video Mr. Sandeep Yadav can been seen coming down from bullet top along with Mr. Md Mozammil Hussain, Supervisor of contractor M/s. SQMPL at around 12:45 hrs., this was confirmed by Mr. Sandeep Yadav and Mr. Md Mozammil Hussain after showing CCTV footage to them during interaction on 22.10.2021.

5.7 Analysis of Gas Monitoring System: -

GMS reading of dt. 13.10.2021 and 14.10.2021 for bullet no. 3 were reviewed and following are the observation (Annexure-17): -

a. Sensor no. 31 provided at drain point of bullet no. 3 reached up to 79% of LEL at around 10:30 hrs. on 13.10.2021

b. Sensor no. 25 on top of bullet no. 3 is showing increase in LEL upto 17% between around 11:00 hrs. to 14:30 hrs. on 14.10.2021. This may be the probable time when top manhole was opened. As per interaction with plant officers and contract supervisor, Magnetic Level gauge was removed around 12:00 hrs. and after observing booth the floats are inside the bullet, spool piece and isolation valve was fixed on this nozzle and isolation valve was closed.

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5.8 Recording and review of log books/ dip book:

a. Each bullet is having two level gauges i.e. Rochester gauge and Magnetic Level gauge, however reading of only Rochester gauge is being entered in the LPG Pump House dip book. Magnetic Level gauge of bullet no. 3 was not working and reading of the same was not being recorded in dip book. Plant is not aware since when this gauge was not working. Investigation team tried to fix the bottom nut of Magnetic Level gauge rod of bullet no. 1 on the Magnetic Level gauge rod of bullet no. 3 and found that threads were damaged and rusted, which implies that this gauge was already in defective condition (Annexure-15).

b. Factual and true record of events/ instrument readings in field log books, were not found maintained by the field staff. Review of the field logbooks was not being done by IOCL officials on daily basis.

c. On 12.10.2021 it was mentioned in the Fire Water Pump House logbook, that Fire Water Pump no. 2 was started from 09:45 hrs. to 12:15 hrs. to fill bullet no. 1 with water. But in reality, bullet no. 1 was not filled with water. This is evident from analysis of the record of Fire Water tank levels. The water required to fill the bullet was approx. 300 KL. However, the reduction in the level (10 cms) was not commensurate with the quantity required i.e. 300 KL (even if the hand corrected reading is considered). Overwriting (water tank levels) without any counter signatures, were observed in Fire Water Pump House logbook. (Annexure-14).

d. As per remarks made in the Fire Water Pump House logbook on 14.10.2021, Fire Water Pump no. 1 was started at 15:15 hrs. and stopped at 15:30 hrs. to fill water in bullet no. 3. On contrary, Mr. Anshul Salvi (the officer present at the incident site) has given statement that Fire Water Pump auto-started due to opening of fire water hydrant near LPG bullet area.

e. Name and signature of personnel on duty in Fire Water Pump House was not found recorded in the logbook. So, it is difficult to find out who has made entries in the logbook or who was on duty in FWPH in any particular shift/ day.

f. Status of various activities w.r.t. the job of level gauge change in LPG bullet no. 1 and 3 was not found mentioned in the LPG Pump House logbook.

5.9 Non-compliance of Access control/ gate pass systems for personnel: -

a. Personnel entry/ exit at plant gate is not being controlled and entered in gate registers. As per statement given by the supervisor of M/s. SQMPL, he left the bottling plant at 13:30 hrs. on 14.10.2021 without making any exit remarks in the register kept at the main gate. He again entered the bottling plant at 18:30 hrs. on 14.10.2021 without making any entry in the register. Incident took place during this period only.

b. On the day of incident i.e. 14.10.2021 there is no gate entry from 12:30 hrs. to 22:00 hrs. including arrival time of mutual aid members and district administration.

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c. As per record provided by plant, photo passes were issued to both the deceased labours (valid from 14/07/2021 to 13/01/2022). However, signature of issuing officer/ plant in-charge is not available on plant record/ register. Also copies of photo passes issued are not being retained by the plant (Annexure-23).

d. Purpose of labour/ contractor entering the plant on any particular day was not found recorded/ approved. IOCL officials were having no record as to why and for what job the two deceased personnel were allowed to enter the plant from 11.10.2021 to 14.10.2021

5.10 Management of Change (MOC): Administrative approval ref. 3372/LPG0/2020-2021/68443 dt. 16.01.2021 is available for replacement of Magnetic Level gauge by Radar gauge. However, MOC (Management of Change) was not obtained by the plant for same. As per OISD-GDN-178 and IOCL policy on MOC, same was required for this change (Annexure-22).

6.0 General Observations: -

a) While reviewing the CCTV footage, it has been observed that Packed Cylinder Trucks are parked on the road between LPG sheds and above ground bullet, which is not the designated place for truck parking/ waiting and drivers are sitting on road which is unsafe act. Also trucks can be seen moving on the road between above ground bullets and MSVs, which is not the route for movement of packed cylinders trucks.

b) Gaps were observed in the sequence of events as per initial information provided by IOCL personnel vis-à-vis observation made by the investigation team upon review of CCTV camera footage.

c) Contradicting statement by Mr. Md. Mozammil Hussain (Supervisor of M/s. SQMPL) and IOCL Plant officers including Plant In-charge for degassing of bullet no. 1. As per Mr. Md. Mozammil Hussain, before undertaking the removal of Magnetic Level gauge from bullet no. 1, bullet was fully filled with water i.e. degassing was done by IOCL and handed over to M/s. SQMPL. However, as per IOCL degassing was not done for bullet no. 1. Also as per LPG Pump House log book, water was not filled in bullet no. 1 for degassing purpose.

d) As per statement of Plant In-charge, degassing activity of bullets was in the scope of the contractor M/s. SQMPL and as per supervisor of M/s. SQMPL, same was in the scope of IOCL. However, no written clarity was made by both the parties before execution of the work.

e) Entry was recorded in Fire Water Pump House log book for water filling in bullet no. 1 on 12.10.2021. However, while seeing the condition of flange joints/ nut bolt of water drain of bullet no. 1 and also water level recorded in Fire Water Pump House log book, it was concluded by the investigation team that no such activity was carried out. (Annexure-14)

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f) CCTV recording is not having “date and time” on screen which made it difficult to review and analyse.

7.0 PROBABLE REASONS OF FAILURE/ ROOT CAUSE

Based on above observations, investigation team is of the opinion that non-compliance of Standing Operating Procedures (SOP) by IOCL personnel and contractor M/s. SQMPL, is the root cause of this incident.

8.0 CONCLUSION

The incident took place due to non-compliance of PESO approved SOP, lack of supervision and short cuts adopted to complete the work in hurry. Violation of SOP was with the prior knowledge of Mr. S.K. Ramteke, Plant In-charge, Mr. Abhishek Khare, Sr. Operation Officer, Mr. Anshul Salvi, HSE Officer and Mr. Md Mozammil Hussain, Supervisor of the contractor M/s. SQMPL.

9.0 RECOMMENDATIONS

The recommendations of the investigating team are as follows: -

9.1 Compliance of SOP: -

a) In view of this incident, existing procedure for degassing, hydro testing and commissioning of Bulk LPG storage vessels (Above ground bullets, spheres and MSVs) to be reviewed and revised detailed procedure to be circulated to all LPG Installations and compliance to be ensured. This procedure may be made part of tender for such jobs as “Typical Procedure”.

b) Adherence by officers, staff, contractor/ contract worker to the SOP for various plant operation/ maintenance/ periodic testing etc. to be ensured by the location In-charge with “Zero Tolerance”.

9.2 Effective Supervision of works: -

Effective supervision to be ensured while executing any critical maintenance/ periodic testing etc. Role and responsibility of IOCL officers, staff and contractor to be clearly defined. Job activity chart should be prepared and approved by location In-charge.

9.3 Work permit system:

Strict adherence to work permit system as per OISD-STD-105, which includes:

a) Conditions of work permit should be filled correctly in line with the SOP and nature of job to be carried out.

b) Appropriate JSA and SOP should be attached with work permit depending of actual nature of work. Tool Box talk to be carried out shift wise/ daily with persons involved in the job.

9.4 Training:

a) Transfer of officer from one function to other function is common HR practice in OMCs. Whenever any officer is transferred to new function, adequate training/ work knowledge should be imparted within specified time period and record to be maintained. IOCL’s policy on training (provided vide e-mail dt.

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03.12.2021) to be reviewed to include the time limit from date of joining the location for providing the essential trainings mentioned in the policy.

b) For new officer and officers joining on lateral transfers from other functions, structured induction training of minimum one week, at the new location, to be considered.

c) Revised policy to be circulated to all locations and implementation to be ensured.

9.5 Logbooks:

a) To ensure logging/ entry of daily activities and sequence of operation performed in the log book of respective area where maintenance work is being carried out.

b) Logbooks should be reviewed and countersigned by the role holder officer on daily basis.

c) Reading of both the level gauges provided on LPG storage vessels should be recorded in log book/ dip book irrespective of which gauge reading is used for stock accounting purpose.

9.6 CCTV Camera and GMS Sensors:

a) IOCL to review and ensure that, adequate number of CCTV cameras are installed at all LPG Installations to record critical maintenance activities. While issuing the work permit for such critical works, detail of CCTV cameras and GMS sensor number covering that work place and working condition of same to be entered in the work permit.

b) There may be some instance where CCTV cameras and GMS sensors may not be available to cover critical maintenance activities. To take care of such instance, IOCL to explore the feasibility of providing portable CCTV camera and GMS sensor.

c) CCTV should have provision of recording with “date and time” data on screen for ease of analysis/ review.

9.7 Contractor/TPIA Responsibility:

IOCL has awarded the job of replacement of gauge to M/s SQMPL, who is also the third party inspection agency (TPIA) for supervising this work as per the point no. #15 of procedure/SOP approved by PESO. Therefore, contractor for job execution i.e M/s SQMPL and TPIA (i.e. M/s SQMPL as inspector/supervisor) are same, which may lead to conflict of interest and this need to be reviewed & segregated.

IOCL should take up appropriately with the contractor M/s. SQMPL for SOP violations and also with PESO for violation of SOPs by PESO approved TPIA.

9.8 Equipments for Vessel Entry as well as Rescue

Rescue operation could not be done in time due to non-availability of equipments for safe vessel entry (having LPG vapour/ lack of oxygen) through manhole (460 mm internal dia). IOCL to provide suitable equipment such as hose mask with

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hand operated blower/ Supplied Airline Respirator system and full body safety harness with double lanyard, for safe vessel entry. Same to be used at the time of vessel entry even after degassing of vessels during periodic testing/ any other maintenance work.

9.9 System for ensuring proper and timely Emergency Response

a) In view of this incident, on site/ off site mock drills should be conducted for such emergency scenario involving mutual aid members and district administration as per ERDMP guidelines. Corrective action to be taken on observations made during the mock drill.

b) In case of any major incident, internal investigation team should evaluate emergency response done by the respective location w.r.t. ERDMP guidelines.

9.10 Access Control System-

Access Control System should be strictly ensured at main gate and entry gate to licenced area, to ensure entry/ exit time of each personnel is recorded. This observation has been made during OISD audits of many IOCL’s LPG Plants in previous years and compliance has been confirmed. Despite this, lapses have been observed at Ujjain LPG Bottling Plant. Considering the seriousness of this issue, IOCL to formulate the policy including formats of Gate Registers to be maintained and ensure the compliance of same.

9.11 Other Recommendations:-

a) Packed Cylinders trucks should be parked at designated place only for loading/ unloading of cylinders inside the hazardous area of the plant. Movement of trucks should be through designated route and drivers should not sit on road inside the plant.

b) Bullet no. 1, which was not hydro tested after fixing of Radar Gauge, should be

hydro tested immediately as per procedure/ SOP approved by PESO. Also IOCL to ensure that reducer spool pieces installed for fixing the radar gauges is fabricated by PESO approved fabricator, as per #8 of approved SOP. Also first fitting on bullet nozzle should be isolation valve, thereafter reducer & radar gauge to be installed.

c) Proper amendment from PESO, for modification i.e. change of magnetic level gauge to radar level gauge (for which prior approval was taken vide letter dated 21.09.2021) to be obtained before commissioning of LPG bullets.

(Gagan Aggarwal)

Deputy Director (Authorization) PNGRB, New Delhi

(Mahesh Kumar Goyal) Additional Director (MO),

OISD, Noida

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ANNEXURES

1. IOCL First Incident Report (FIR) dt. 15.10.2021

2. Order of ED, OISD w.r.t. constitution of investigation committee vide letter ref. OISD/EDS/ACCI/05 dt. 21/10/2021.

3. IOCL’s Internal Investigation report of previous incident dt. 23.08.2021

4. Work order issued by IOCL to M/s. SQMPL Ref. TL05/20-21/26900461 dt. 23.03.2021.

5. Authority letter for supervisor from M/s SQMPL

6. Hot Work Permit issued for the job for change of Magnetic Level gauge to Radar gauge and detail of JSA and toolbox talk.

7. PESO approval & approved drawing for change of Magnetic Level gauge to Radar gauge, including approved SOP.

8. Chronology of Radar gauge Installation on Bullet No-1

9. Chronology provided by IOCL Plant to Investigation team for the works done on Bullet No-3

10. Statements of IOCL Officers (Mr. S K Ramteke, Mr. Anshul Salvi, Mr. Abhishek Khare, Mr. Mrigank Khare & Mr. Anoop Ingle), and contractor supervisor (Mr. Md. Mozammil Hussain).

11. Detail of rescue operation, detail from Mr. Praveen of M/s. GAIL India, Mr. D.K. Chaubey-Aditya Birla Nagda and copy of e-mail sent to Factory Inspector

12. Copy of gate register dt. 08th to 14th Oct’2021 for visitor’s entry.

13. Statements of LPG Pump house operator (Mr. Satya Prakash Sahu, Mr. Sandeep Yadav & Mr. Guru Prasad), FWPH operator (Mr. Bihari Lal) & security staff (Mr. Sandeep Sharma & Mr. Ravi Singh Rathore)

14. Fire Water Pump House log book from 10th to 14th Oct’2021

15. LPG Pump house look book from 4th to 16th Oct’2021

16. Record of online level and pressure reading of Bullet no. 3 from 13th to 14th Oct’2021

17. GMS records of sensors provided on Bullet No. 3

18. Post mortem reports of both the deceased

19. Detail/ location of CCTV cameras provided by plant

20. IOCL internal investigation report for this incident

21. Training record of IOCL officers and Training policy if IOCL

22. Administrative approval for replacement of magnetic gauges with radar gauges

23. Gate Passes and Gate records

24. E-mail dt. 18.11.2021 from IOCL for FIR

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Site photos at the time of committee visit

FIXING OF RADAR GAUGE COMPLETED ON BULLET NO-1

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MANHOLE OF BULLET NO- 3 (460 MM INTERNAL DIA)

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LADDER OF BULLET NO- 3 REMOVED FOR TAKING OUT THE BODIES

SPADE WAS FITTED ON LIQUID LINE OF BULLET NO-3 FOR WATER FILLING THROUGH WATER DRAIN LINE

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HOSE CONNECTION AT DOUBLE HYDRANT NO-14 FOR WATER FILLING IN BULLET NO-3 THROUGH WATER DRAIN LINE

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LEFT (MAGNETIC LEVEL GAUGE OF BULLET NO-1)

RIGHT (DEFECTIVE MAGNETIC LEVEL GAUGE OF BULLET NO-3)

TOP OF BULLET NO-3

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ROV OF BULLET NO-3

(SPOOL PIECE WAS REMOVED AFTER INCIDENT DURING RESCUE OPERATION)