CASE STUDIES

We do not wish any accident, but when any accidents take place, it teaches
the real lesson. Our knowledge and safety measures are tested and we are
compelled to acquire the knowledge of the causes of that accident and of
preventive measures to stop its recurrence. This requires thorough investigation
and correct conclusion. That shows us the path of safety. Thus any accident has
two effects; bad and good.

The loss or injury is the bad effect and the knowledge acquired to prevent
similar occurrence is the good effect. Thus we have to utilize the accident causes
to raise our knowledge for the purpose of safety and this becomes possible by
the case studies. A case study sharpens and tests our knowledge and arrangement
and asks us why did they fail ? we rethink our arrangement (which failed) and
turn to redesign it on the bases of that real case study. That is the utility of any
safety case study whether it may be an accident case or non-accident
experiment. However an accident case study gives much experience. Some
typical cases are given below ;

1
S. Types Accident/ Incident Cause of Remedial Measures
No of Accident
Accide
nt

1 Fire in In one of the medium scale Fire 1. Management should train

Pharma pharmaceutical industry in Panoli, cause due their employees in safe process
ceutica the process of charging Toluene to static handling, General safety & Fire-
l Plant and then methanol from storage charge or fighting and first Aid.
Tank to CP-1 vessel of Plant-1 for due to
layer separation process was going some 2. Housekeeping was very poor.
on and at that time fire took place spark It should be properly maintained.
in open drainage in plant. from
3. Considering the area of the
electrical
company fire hydrant system
system of
should be installed with Diesel
the plant.
operated pump.

2
2 Road One Road tanker containing 18 Over 1.Tanker containing hazardous
Accide Tones of Propane was overturned turned chemical must be maintained
nt due to some mechanical failure. due to testing & certifications as per the
(Loade Cleaner of tanker was dead on the some norms.
d with spot and Driver was seriously mechanic
Propan injured. Factory Inspectorate of al failure. 2. Periodically preventive
e) Panchmahal called DPMC, maintenance should be carried
Ankleshwar for the help. Luckily out to avoid breakdowns.
there was no leakage of Propane.
3.Drivers transporting hazardous
Under the guidance of the DPMC
material should be well qualified
staff the tanker was lifted safely
and must be trained under 3 days
with help 2 cranes of 45 tones
training of Safe Transportation
capacity. Lifting operation was
of Hazardous Goods.
completed within 3 hrs. Factory
Inspector, Panchmahal &
Mamlatdar, Halol, highly
appreciated to DPMC & Fire staff
for positive & quick response to
attend the road emergency. They
were very much impressed for our
good performance at the incident
site.

3
Sr. Types Accident/ Incident Cause Remedial Measures
N of of
o Accid Acciden
ent t

3 Fire in In one of the small scale chemical Transfer

1 1.Company management
entire industry in Ankleshwar, fire was took ring should aware of thechemical
chemi place and within a second it was Pump properties.
cal spread in whole plant, which includes gland
plant. several chemical drums, Process became 2.Material transferring should
vessels, boiler house, HDPE storage over be done under proper
tanks, etc. Within about 1 hour fire heated supervision.
was controlled under the guidance to &
3.Maintenance of the plant and
DPMC. Total 8 Fire Tenders caught
equipments should be proper.
including 3 fire tenders of DPMC and the Fire.
other 5 tenders from surrounding area 4 .S 4.Fire extinguishers should be
who are in mutual aid with DPMC provided in the plant and it must
put in operation to combat the be regularly maintained and
operation. There was no injury but tested.
whole plant was damaged, as it was
major fire.

4
4 Fire in There was fire with explosion in one Heavy
multip of the large-scale pharmaceutical rainbefall.
urpose industry manufacturing bulk drugs in
Bulk Panoli industrial estate. Cause was
Drug suspected due to some electric short
Plant circuit spark was generated and
explosion took place due to lot of
solvent like Methanol, Toluene etc.
was using in this plant. Four persons
got minor burn injury.
All the injured persons were transfer
to Smt. Jayben Mody Hospital before
DPMC reached at incident point.
1.All the equipments should
flame be proof.
2. 2.All the equipments should be
properly earthed and earthing
should be tested periodically.
3.On-line monitoring of
Explosive vapour detectors
should be installed.
4.Good Housekeeping should
be maintained.
5. Employees should be
trained for fire fighting.
5
5 Dange One Swaraj Mazda Tempo got Actuall Tempo driver should cross the
rous entangled on the railway track and hit y tempo railway track after checking both
Accid by train during crossing between driver side about Train.
ent Sanjali & Panoli railway station trying to
where no road crossing was there. cross
Luckily driver successes to escape the
from tempo and train passed hitting railway
tempo on side without any effect to track
train. Dy. Collector, Ankleshwar where
informed about accident. Immediately there
DPMC arranged 2 Ambulances from was no
industries rushed to the site. Also crossing
informed other companies who are but
maintaining rescue team to send them tempo
on the site at the earliest. Also crane was got
was arranged and tempo was lifted entangle
out. d in
track.
Before
Driver
could
remove
tempo
from the
track
one
super
fast
train hit
the
tempo.

6
S Types of Accident/ Incident
r. Acciden
N t
o
6 Explosi In one of the small scale
ve on in chemical industry in Panoli
Dryer industrial estate explosion in
hot Oil circulated dryer took
place. In this explosion 2
persons died on the spot and 3
persons got serious injuries.
Dryer was charged with
Dichlofin (Intermediate
product) for drying in drier.
The heating medium of drier
is Hot Oil circulation in coil.
As soon as heating was
started explosion took place.
If material contained solvent
then it should be air-dried
first and slowly steam heating
should be increased. But in
this case directly high temp
heating is applied to dry
solvent contained material.
Cause of Accident Remedial Measures
It was suspected that 1.Solvent contained
solvent traces from the material should be dry
material under drying in steam heating dryer
might have become only.
vapours and due to
contact with some spark 2.Drier must be fitted
or high temperature it with temp indicator and
might have exploded in auto cut off system.
dryer room & the hot
3.Before starting
vapours of fire ball
heating it should be
spread to neighbouring
verified that whether
rooms breaking the
its vents are open and
glass panes etc. These
clear from any
hot vapours caused fire
obstacles.
in the materials kept
outside the dryer room 4.Initially only air
also. drying should be
started and after some
time slowly increase
the temp.
7
7 Explosi In one of the large scale It was suspected that 1.Before starting any
on in chemical industry in when hot work has hot work on any
A/c Ankleshwar industrial estate, started without releasing machinery it should be
compres explosion in A/c compressor the Nitrogen filled checked for any
sor took place during the yesterday for pressure explosive or flammable
maintenance work. 3 persons testing, explosion might material with explosive
got injuries out of that 1 have occurred due to Meter before issuing
person died in hospital one over pressurization. hot work permit.
person was serious and one
was got minor injuries while 2.Any hot work on
rescuing injured persons.It pressurized machinery
was an A/C cooling unit fitted or equipments should
on a platform at the height of not be carried out until
about 8 9 meters outside the & unless the equipment
laboratory building where is completely emptied.
explosion had occurred and
whole machine was blasted
and flew away. In
investigation information
come that some brazing work
of A/C machine has been
done by outside servicing
party and two persons have
worked. Yesterday after some
repairing work, Nitrogen was
charged in receiver for
pressure testing and left
whole night for checking the
leakages. On next day, the
pressure was found slightly
reduced and they have start
emp. Shift.

8
S. Types of Accident/ Incident Cause of Remedial Measures
No Accident Accident

8 Oleum In one of the large It was suspected 1.Dangerous substances should be

Leakage scale chemical that during handled and stored under the
industry of unloading supervision of competent person
Ankleshwar operation, the who is familiar with the risks and
industrial estate company fitter the precautions to be taken.
Oleum (23% was making
strength) was arrangement for 2.They should maintain proper tools
leaked while unloading oleum set and spare like gaskets, Packing,
unloading from from tanker to bolts etc required for such operation.
road tanker to storage tank. He
3.They should train their persons in
storage tank. The has opened blind
emergencies and safe material
quantity of Oleum flange of that
handling to avoid incidents.
in road tanker was valve. At that
14 tons. The fitter time, it was found 4.Transporter should maintain
was opening Blind that valve was 30 vehicle and their equipments in
flange of the valve % passing and good working condition.
and at that time, oleum was
valve of oleum flowing due to 5.While working with hazardous
tanker was found some defect of chemical appropriate safety
passing 30 % of valve. It was not appliances must be used.
valve discharge. working on-off
During this Position. It was6. Management should train their
operation, fitter and defective valve employees in General safety & fire-
Tanker Cleaner got fitted to Road fighting
acid burns by Tanker.
Oleum. These two
injured were sent to
Hospital

9
9 Dangero In one of the the top of the Investigation could not be done
us pesticides vessel containing thoroughly. As per preliminary
Occurren intermediate material P2S5. investigation, it was known that
ce manufacturing large while removing the dip pipe of the
scale industry in vessel containing about 400 liters
Panoli industrial (800 kgs.) of P2S5 at a temp. of
estate fire took about 3200 c, there was a leak of hot
place on the top of P2S5 from the flange of dip pipe and
the vessel the moment the leaky material came
containing material in contact with atmospheric air, it
P2S5. It was a ignited automatically due to auto
dangerous ignition (Auto ignition Temp. of
occurrence and P2S5 is 1420 C. So long the leak
heavy fumes continued there was fire. The cause
for overflow leakage could not be
ascertained. During this leakage,
some P2S5 has gone into insulation
of the vessel and it was continuously
burning. Even after leakage checked
the insulation was burning till the
insulation was completely removed.
This has continued for 10 hrs.

10
10 Fire in In one of the It is suspected that during 1.Periodically earthing
Chemi large scale charging of Toluene in should be checked for its
cal chemical Reactor No. R-102, static effectiveness.
Plant industry in charge might have developed
Panoli industrial causing minor explosion 2.House Keeping was very
estate fire took with fire. Due splashing of poor it must be improved.
place in process material fire was spread on
3. There was not any facility
plant No. 2 and the drums and surrounding
to provide the water for fire
chemical, area of the plant.2
fighting. So, either Overhead
solvents drums,
water storage tank or Diesel
carboys stored
pump should be provided to
around the plant
fulfill the requirement of
and one of their
water during fire fighting.
chemist was got
minor burn 4.Sufficient number of
injury. When Hydrant Points must be
DPMC staff on installed.
the way they
show heavy 5.Sufficient number of
smoke. From the portable fire extinguishers
way immediately should be installed and all
informed to the employees must be
control room to trained for its use.
send other fire
vehicles and also 6 .Separate storage yard
called fire should be provided for
vehicles from solvent & Chemicals drums.
other fire station.
Also asked to
control room to
inform all
concern persons
about the major
fire.
11
11 Explos In one of the The cause of disaster was
ion in Fertilizer found that one road tanker
Nitro company there came for loading
Phosph was a devastating Ammonium Nitrate. It is the
ate explosion in mandatory that every vehicle
plant Nitro Phosphate must be checked for initial
Plant, heard content whether previously it
about 10-15 km. is used for same material or
away, 7 persons not. If it is not used for same
were killed and material then it must be
over 45 injured. cleaned and washed by a
The totally plant competent person and same
structure was must be certified by them. It
destructed and is suspected that whether
varying degrees responsible person did not
of damage of check cleaning certificates or
surrounding it is transporters malpractice
homes, shops, to show false certificate.
and factories also Whatever there may be but
resulted. tanker was not cleaned
properly and some other
contain may be present.
During loading of
Ammonium Nitrate about
half of the tanker was loaded
and suddenly explosion took
place and also caught fire in
plant.
1.Company management
should make a practice to
check strictly the cleanliness
of the tankers before loading
any hazardous material. This
should be done in presence
of well-qualified supervisor.
2.Transporters should not
make any malpractice while
transporting hazardous
chemicals. They must be
followed all the safety
precautions.
3.Driver must be undergone
for 3 days Safe Transporting
of Hazardous Goods training,
which must be endorsed by
RTO.
4.Driver must be explained
about hazards and safety
precautions about the hazards
of the chemical, which he
carries.
12
12 Fire in A truck-tanker of Toluene, a tanker discharge 1.Dyke wall around the
Toluene highly flammable solvent pipe was broken storage tank to be
Storage unloading was going on in one and started provided.
Tank of the Pharmaceutical company leaking of
of Ankleshwar. After unloading Toluene. Also 2. Motor and pump to
about half of the tanker due to backside of be maintained explosion
some reason it was required to tanker was (flame) proof.
reverse the tanker. So, without struck with
3.Proper electric wiring
disconnecting the discharge pipe supporting metal
and flame-proof electric
and closing discharge valve rope of the
fittings to be provided.
while reversing tanker discharge boiler chimney.
pipe was broken and started It was suspected 4.Hydrant system,
leaking of Toluene. Also that either due to storage of fire water and
backside of tanker was struck friction of metal Sprinkler system for the
with supporting metal rope of rope with tanker tanks to be provided.
the boiler chimney. It was body spark &
suspected that either due to caught 5. Required fire-
friction of metal rope with uncontrollable fighting equipments and
tanker body spark might have fire. material to be maintained
generated or may be spark from by the company.
the tanker exhaust pipe fall on
the leaked toluene and caught
uncontrollable fire. The whole
truck burnt out and also fire was
spread in storage tank and near
by other chemical drums.

13
13 Fire in In one of the medium scale Company was 1.Periodical checking
Chemica chemical manufacturing visited several of earthing of each and
l Plant company in Ankleshwar times after the every equipments of
industrial estate caught fire. The incident but still plant should be done.
vessel was a non metallic the exact cause
(PPFRP) and given earthing of fire could not 2.They should train their
connections with special wire of be found. In persons in safe working
Tantalum for resistance free discussed with practices and safe
earthing from four different the companys material handling to
positions which are metallic DGM, avoid incidents.
valves / portions one of the Production
3.Wherever necessary
earthing appeared to have been Manager and
non-sparking tools
disconnected or loosened due to Technical
should be provided and
which static charge developed Adviser and
used in explosive
could cause fire in side the they told
atmosphere.
vessel which could not be following
known from outside. When the suspicion of 5.Dangerous substances
temperature of inside vessel cause of fire should be handled and
crossed 70 / 800C, the vessel stored under the
collapsed and fell down causing supervision of competent
spillage of the liquid, which is person who is familiar
highly flammable caught fire with the risk and the
and spread all over the floor precautions to be taken.
area and it spread to whole plant
within 5 to 10 mts of area.

14
14 Fatal One operator The vessel was idle since two 1.The company should
Accident entered in idle days and this was cleaned on introduce vessel Entry
vessel for cleaning previous day of the incident Permit System.
and he was with water. For washing of
unconscious and the cake, water steam and 2.Air contaminants /
fell down. Two Hydrochloric Acid are used. Oxygen level should be
another employees The cake contains Sulphor, checked before vessel entry.
try to pull out the Sulphamic Acid and Urea,
3.Fix S. S. Pipe or other
unconscious which remains as residue in
alternative so that it would
operator but they last stage of the operation. On
not get damaged.
also inhaled the gas the day of incident, the steam
and became pipe was found damaged and 4.Airline with sufficient
unconscious and it was required to change with length of pipe should be
immediately fell new PVC pipe. For changing installed and training should
down outside the job, one operator went inside be given to all employees.
vessel. Then one of the vessel. He inhaled the
supervisor of the gas and he became 5.Rope line or safety belt
another plant came unconscious and fell down with rope should be used
and he rescued the immediately. So, other 2 during vessel entry.
operator by operators tried to rescue him
entering in vessel but, they were also affected
but he was also with the gas slightly. Then,
unconscious and one supervisor came from
fell down due to another plant and went inside
inhalation of gas. the vessel without using any
respirator. He rescued the
victim but he himself became
unconscious and fell down in
the vessel.

15
15 Overturn One road tanker The vessel was idle since two 1.Tanker containing
ing of containing Ethyl days and this was cleaned on hazardous chemical must be
Road Mercaptan previous day of the incident maintained as per the
Tanker overturned on with water. For washing of norms.
carrying National Highway the cake, water steam and
Ethyl No. 8 Near Panoli Hydrochloric Acid are used. 2.Periodically preventive
Mercapt GIDC. The whole The cake contains Sulphor, maintenance should be
an. tanker was Sulphamic Acid and Urea, carried out to avoid
overturned by 180 which remains as residue in breakdowns.
Deg. No damage last stage of the operation. On
3.Drivers transporting
was found on tank the day of incident, the steam
hazardous material should
in that position as pipe was found damaged and
be well qualified and must
the tank was fitted it was required to change with
be trained of Hazardous
in sturdy new PVC pipe. For changing
Goods.
rectangular frame. job, one operator went inside
The earth was also of the vessel. He inhaled the 4.TREMCARD must be
soft due to water gas and he became provided to drivers.
logging and lot of unconscious and fell down
bushes. The immediately. So, other 2
drivers cabin and operators tried to rescue him
chasis were badly but, they were also affected
damaged and with the gas slightly. Then,
practically they are one supervisor came from
separated. Luckily another plant and went inside
the driver and the vessel without using any
cleaner escaped respirator. He rescued the
with only first-aid victim but he himself became
minor injuries. unconscious and fell down in
the vessel.

16
16 Natural As we know very well that the above Due to 1.Training should be
Calamity worst incident of killer earthquake took earthquake given to all person for
place at Kutch and we were sent there Out of them facing this type of
earthqua to help in various types of jobs by 35000 people Natural Calamity.
ke took Ankleshwar Industries Association. feared dead.
place at
Bhuj On 28th January, 2001 at about 9:00 pm,
Kutch on we started to go from AIA office and
Dated reached at Bhachau District on next day
26th at about 4:00 pm. We have four trucks
January loaded with water carboys, wheat
2001 at floors, rice, chana dal, bamboos,
8:46 am. plastics, cloths, steel plates, stoves,
food packets, Gen. set and acetylene
cylinders etc.

17
17 Fire in In one of the chemical company one The road 1.Transfer the
Chemical road tanker containing 20,000 lits. tanker loaded material. The earthing
Plant Diesel came for unloading. As soon as with about wire was not
during Diesel unloading was started after 20,000 ltrs. of connected between
unloadin connecting discharge line with storage Diesel which pump and tanker,
g Diesel tank caught fire in tanker and storage was used to which must be
tank and within few second it spread manufacture connect before
into whole plant. Textile oil. starting unloading of
During the chemicals.
As soon as call was received at DPMC connection of
Control room, DPMC staff along with tanker with 2.The tanker should
fire crew reached the site. Seeing the the storage not be placed so much
intensity of the fire called another fire tank, the spark nearer to the plant and
vehicles from other fire services of generated the line should be
Bharuch district. from some made permanent from
unknown suitable location away
origin or from plant.
proper static
3.Sufficient nos. of
charge might
Fire fighting
have not
extinguishers should
discharged
be kept in the
before starting
company.
unloading and
the fire broke 4.Unloading
out. chemicals should be
done under
supervision of well
qualified and trained
supervisor.

5.Driver must be
undergone 3 days
training.

18
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