Annexu

ACCIDENT (INCIDENT) ANALYSIS

(INVESTIGATION REPORT)

Report No.: DGM (TPI-E)/A./2010/ Dt. 28-09-2010

Sub: Accident of Shri Hemrai, Sr.Tech. MRDType of Accident: Reportable

Details of the Injured:

Name : Shri Hemrai Date : 28-09-2010

Age : 56 Shift : AP.No. : 140869 Time : 01:30 PM

T.No. : 32347 Department: MRDDesignation: Sr. Tech. Location : Slag Processing Shop

Section : Electrical DSO : Shri B.S. Vashistha

Brief of the case (Accident/Incident):

Portable welding M/c connection job at Crane no.-3 at Slag Processing Shop was assigned to Shri Hemrai. Circuit Breaker with 125A rating is mounted at incoming side of the power pack panel, while Shri Hemrai was connecting portable welding machine at the incoming side of the incoming CB of the power pack with the help of screw driver, flashover occurred and the individual got super facial burn injury in hands, neck & face. He was admitted at Main Hospital in the burnt unit.

During the investigation it was found that:

1. Heavy flash point found in incoming side of the CB in left & middle phase terminals.

2. Both the lugs found in melted condition.

3. Screw driver found in melted condition.As per the above findings, while connecting the leads of single phase portable welding machine on the both incoming live terminals of CB with the help of screw driver is the cause of flashover resulting in burn injury.

Immediate cause of Accident/Incident

Unsafe condition:

Unsafe Act:

1. Single phase load connected across 440V.

2. Supply taken from incoming of the CB.

Basic Causes of Accident/Incident:

Personal factors:

1. Lack of awareness

2. Carelessness

3. Lack of training

Job/System Factors:

Lack of Control:

1. Inadequate Systems & Procedures (SOPs/SMPs)

2. Lack of supervision / monitoring.

Recommendations:

1. Supply is never taken from incoming of the CB.2. Awareness should be there for voltage level and their system before connecting the leads.3. Single phase to be taken from CB at outgoing side on OFF condition.

4. Proper supervision to be done.

5. Safety training should be given to individual.

(H.C. Chandniha)

Dy. Mgr.(TPI-E)

DGM(TPI-E)

AGM -Elect. (MRD)

CC:

1. DGM-I/C (EHT)

2. GM (E)