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A fire broke out in a classroom at a learning center during a training session. An assistant had turned on the lights, air conditioners, and desktop as usual for the training. Smoke was noticed coming from one of the split air conditioners, and a crackling noise was heard. The manager evacuated the participants and an assistant used a fire extinguisher while another switched off the power. Security was notified and helped extinguish the fire within 15 minutes, with no injuries reported. An investigation found the room contained combustible acoustic material and 18-year-old concealed wiring as potential causes.
A fire broke out in a classroom at a learning center during a training session. An assistant had turned on the lights, air conditioners, and desktop as usual for the training. Smoke was noticed coming from one of the split air conditioners, and a crackling noise was heard. The manager evacuated the participants and an assistant used a fire extinguisher while another switched off the power. Security was notified and helped extinguish the fire within 15 minutes, with no injuries reported. An investigation found the room contained combustible acoustic material and 18-year-old concealed wiring as potential causes.
A fire broke out in a classroom at a learning center during a training session. An assistant had turned on the lights, air conditioners, and desktop as usual for the training. Smoke was noticed coming from one of the split air conditioners, and a crackling noise was heard. The manager evacuated the participants and an assistant used a fire extinguisher while another switched off the power. Security was notified and helped extinguish the fire within 15 minutes, with no injuries reported. An investigation found the room contained combustible acoustic material and 18-year-old concealed wiring as potential causes.
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 Problem View of Class room before Fire Incidence The Split A/C Near which the short circuit occurred Class room with Projector Air Conditioners
Fire at Learning Centre Class Room-1 Combustible Material Present ( Hay ) Heat Generation Continuous 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 Insulation Damaged Old wiring (installed 18 yrs back)
No SOP to check Old Damaged wiring Concealed wiring not Visible 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 punctured For passing drain pipe And 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/C Near 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 4 Partition 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 21 Copper 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