Final Near Miss Booklet

LEARNINGS
NEAR MISS REPORTING

It gives me immense pleasure to present the manual on “Learning’s derived out of
near misses reported by LPG plants”.
This manual is intended to achieve uniformity in approach across our all LPG plants.
The purpose of this manual is to understand, appreciate and make sure that the
safety is monitored in all applications. In order to implement safety culture in
operation this manual will be handy for consultation by the plants staff.
I am sure that learning will inculcate safety and will further improve safety in
operation in days to come.
We are in the process of expanding our LPG plant operation by introduction of

modern equipments and machineries for which SOPs are in position which will
facilitate the new incumbent to learn LPG operation.
This manual will encourage the people to report near misses and also learn from near
misses to avoid accidents at the plant locations.
This manual has been designed and compiled by experienced officers in plant
operation under the guidance of Regional OPS & HSSE team NR. This step taken by
Northern region officers will go a long way to build safety culture in the region.
Pradeep Saxena
2
About the Report,
Near miss reporting and investigations identify and control safety or health hazards before
they cause a more serious incidents. One of the best ways to avoid further incidents is to
understand how an incident occurs and steps taken to avoid that type of incident in the
future. The incident investigation is a tool. The goal is not to lay blame but to find out
what happened and determine immediate and underlying root causes. Many of the
reported accidents injuries and fatalities would have likely previous unreported near miss
incidents relating to the process. Injuries and illness can be prevented and lives can be saved
by reporting near miss incidents.
NEAR MISS — A near miss is an unplanned event that did not result in injury, illness, or
damage – but had the potential to do so. Only a fortunate break in the chain of events
prevented an injury, fatality or damage, in other words, a miss that was nonetheless very
near. Near miss describes incidents where given a slight shift in time or distance, injury, ill-
health or damage easily could have occurred, which did not happen this time. Although the
label of 'human error' is commonly applied to an initiating event, a faulty process or system
invariably permits or compounds the harm and should be the focus of improvement in near
miss situations.
In terms of human lives and property damage, near misses are cheaper, zero-cost
learning tools for safety compared to actual injury or property loss. You will agree that
near miss incident can result from many circumstances, Conditions, behavior, machinery
failure and so on. No matter what the condition the events that caused the near miss are
subjected to a root cause. An analysis to identify the defect in the system that resulted in
the error and factors that may either amplify or ameliorate the result must be conducted.
Predominant causes of no-injury accidents are identical with the predominant causes of
accidents resulting in major injuries is not supported by convincing evidence .If we
concentrate our efforts on the types of accidents that occur frequently, the potential for
severe injury will be addressed. Investigation of numerous accidents resulting in fatality or
serious injury by leads to the conclusion that their causal factors are not linked to accidents
that occur frequently and result in minor injury.
Near misses are smaller in scale, relatively simpler to analyze and easier to resolve.
Thus, capturing near misses not only provides an inexpensive means of learning but also has
some equally beneficial spin offs. The process provides immense opportunity for "employee
participation," a basic requirement for a successful workplace safety program. This embodies
principles for behavior shift, responsibility sharing, awareness, and incentives. One of the
primary workplace problems near miss incident reporting attempts to solve directly or
indirectly is to try and create an open culture whereby everyone shares and contributes in a
responsible manner. Near miss reporting has been shown to increase employee
relationships and encourage teamwork in creating a safer work environment.
An ideal near miss event reporting system includes both mandatory (for incidents with
high loss potential) and voluntary, non-punitive reporting by witnesses. A key to any near
miss report is the "lesson learned." Near miss reports can describe what they observed
throughout the event and the factors that prevented loss from occurring. This information
can be used to identify and eradicate the root cause of the near miss incident. The
investigation of near misses should be carried out with full sincerity .The goals in a near miss
3
incident investigation shall include: (1) What happened and determine the immediate and
underlying root cause of the incident (2) Rethink the safety hazards (3) Introduce ways to
prevent a reoccurrence and (4) Establish training needs. All incidents or near miss incidents
should be investigated properly. Incident investigations are a tool for uncovering hazards
that either were missed earlier or require new controls (policies, procedures or personal
protective equipment). Near miss reporting and investigation identify and control safety or
health hazards before they cause a more serious incident. All investigations should focus on
prevention of future incidents, not placing blame. We should conduct an investigation as
soon as possible following the event to gather all the necessary facts, determine the true
causes of the event and develop recommendations to prevent a recurrence. Near miss
investigation tips include investigating as quickly as possible, ensuring the area is safe to
enter, looking for witnesses and asking for input, and recording the scene with photos
(ideally date and time printed) or sketches for future training or communications to other
employees.
Employees should also be encouraged and not be punished for reporting a near miss
incident. This is part of a proactive safety culture for the organization. Unless we make
a visible commitment to institutionalizing workplace-safety practices, the safety program
will remain at status quo. Our support means modeling the desired behavior so other
employees understand that workplace safety is essential. People at all levels of the
organization need to understand why safety is a crucial issue and how to actively &
effectively participate in a workplace safety program. It can be difficult to convey that
knowledge and appreciation to an entire group. Training is one way of beginning the process.
Another way is to identify the amount of time and money that accidents/injuries are costing
the organization -Money that could be used to purchase needed resources. Lack of clarity
about the issues surrounding safety and the consequences of accidents and injuries to the
organization’s overall well-being are often barriers to workplace safety. We need to clearly
and consistently communicate performance expectations about safety. We should spell out
the goals and objectives in terms of reducing the cost and frequency of accidents and
injuries. This will promote open communication and the culture to encourage employees
to report near miss incidents.
Investigation process should be in place for senior management at locations to make

immediate decisions relating to corrective actions. The safety committee is a very good
resource for near miss follow-up and solution to problems, as well as for corrective
actions. During the meeting we should clearly define what the expected results are from a
particular recommendation and set priorities for each action, identifying which ones should
be completed before operations resume. Any recommendations or improvement suggestions
that are not associated with the incident facts or situation should not be included. The
lessons learned and recommended /solutions will go a long way toward preventing incidents
from happening again. When it comes to incident investigation, there are two levels of
formal communication. First, there is an official incident investigation report with a limited
distribution. Second, there is a widely-distributed flyer to communicate contributing factors
of the incident and chief lessons learned from the incident. It should be promptly reported
as the corporate guidelines to all concerned in system and thru mail. The final step of
incident investigation is to follow up on your recommendations for corrective or
preventive actions to be sure they were implemented and are effective. The goal of
follow-up is to prevent a re-occurrence of the incident. Ensure recommendations receive
4
prompt attention by creating an action plan. Keep in mind that some recommendations
may look good on paper but are not that realistic to put into place. Be sure to follow the
progress of recommendations prior to final closure to determine and verify that the
action is completed and fully addressed.
It is necessary to conduct root cause analysis and the basic elements of root cause are:
Materials - Defective raw material, wrong type for job, lack of raw material; Man Power -
Inadequate capability, lack of knowledge, lack of skill, stress, improper motivation; Machine
/ Equipment - Incorrect tool selection, poor maintenance or design, poor equipment or tool
placement, defective equipment or tool; Environment - Orderly workplace, job design or
layout of work, surfaces poorly maintained, physical demands of the task, forces of nature;
Management - Poor management involvement or none at all, inattention to task, task
hazards not guarded properly, stress demands, lack of process, lack of communication;
Methods - Poor procedures or none at all, practices are not the same as written procedures,
poor communication; Management system - Training or education lacking, poor employee
involvement, poor recognition of hazard, previously identified hazards were not eliminated.
Root cause analysis (RCA) is not a single, sharply defined methodology. There are many
different tools, processes, and philosophies for performing RCA analysis. However, several
very broadly defined approaches or "schools" can be identified by their basic approach or
field of origin: safety-based, production-based, process-based, failure-based and systems-
based are all various root cause analysis procedures. You must determine which process best
suits the needs in your case.
One of the most important parts of the near miss process is identifying corrections and
implementing change to ensure the root cause of the near miss is eliminated. Identify
corrective action(s) that will certainty prevent reoccurrence of the problem or event.
Identify solutions that are effective, prevent reoccurrence with reasonable certainty with
consensus agreement of the group, are within your control, meet your goals and objectives
and do not introduce other new, unforeseen problems. Implement the recommended root
cause correction(s). Ensure effectiveness by observing the implemented recommendation
solutions.
Near miss investigation conclusions must be provided to all employees with related job
functions to identify the fundamental reasons why the incident occurred and the
associated root cause(s). This makes all employees aware of the issues relating to the near
miss and helps to find opportunities for eliminating potential risks for the future.
In developing a safety culture, employees and volunteers are able to observe report and
correct hazards & near miss incidents. Once a near miss incident or hazard is identified,
the correction must be made and reported. It is to be developed as safety culture. The
process of infusing a safety culture needs to address an array of motivations. Management
will want to see that the safety culture reduce the cost of insurance / damages etc and
employees will want to feel safer and less prone to injuries. Employees will want to feel
valued for their contributions in terms of identifying and correcting near miss incidents and
hazards.
Successful implementation of an Near Miss Management System (NMMS) requires: (a) Strong
management ownership with team members knowledgeable of the business process and in a
5
position to implement process changes if needed (b) Participation and reporting of as many
incidents as possible and (c) Use of quantitative tools to identify weaknesses and improve
the system.
Near-miss management systems (NMMS) are designed to enable people and institutions to
learn from high-frequency, low-impact incidents (near misses) to prevent low-frequency,
high-impact events (accidents). A comprehensive NMMS includes several important
implementation steps, such as identification of near misses, disclosure and reporting,
prioritization and classification, distribution of the information, analysis of causes,
solution identification, dissemination of actions and knowledge, resolution and closure
of the case.
Auditing a near miss systems performance is a very important step in the near miss
management process. This provides a view of what is working well and what needs to be
improved. An important point in the near miss audit process is inclusion of all levels of
employees in the information/data collection and analysis. This is the only way to find out if
management’s expectations match the employee’s expectations, which is critical for an
effective near miss program. Accordingly all the near miss of 2014-15 have been scrutinized
at regional level by team of expert and now being presented to location for corrective
actions involving all team members.
Workplace safety is about preventing injury and illness to employees in the workplace.
Therefore, it is about protecting the company’s most valuable asset,its workers. Near
miss reporting helps to formulate strategies, reduce workplace injuries and fatalities
and enhance the safety culture of the workforce. A near miss system operated in the
proper format is designed not only to identify near miss incidents but to also help break
down communication barriers among co-workers as well as between management staff and
the employees on the front-line. Effective and lasting change generally comes about when
we all commit to adopting safety as a top priority.
We thanks to team members namely Mr Sunil Brar, Mr Praveen Yadav, Mr Abhishek

Yadav and Ms Sukirti Gupta who have finalized and brought all near misses of Northern
Region of 2014-15 together and thereafter learning was consolidated on near miss.
We are presenting herewith the ready reckoner on “Learning’s thru Near Misses
reporting” during 2014-15 for better understanding, initiating actions to avoid reoccurrence
and taking corrective measures. The teams of experts have commented on each and every
near miss so that learning’s are well disseminated amongst all.
Pradeep Saxena
6
WHAT IS NEAR MISS?
The term “Near Miss” in the context of HSSE Incident reporting
initiative, is an incident at workplace that does not result in fire
and /or accident but has potential to cause one or a
combination of any of the following:
• Fire,
• Injury,
• Fatality,
• Loss of Product or containment &
• Property damage”
SAFETY PYRAMID- HEINRICH THEORY
7
CATEGORIZATION OF NEAR MISSES OF FY 2014-15
Poor supervision.
6%
Design Failure Equipment failure
Poor Safety Poor supervision 8%
3%
Awareness 3%
1%
Lack of training
5%
Poor Maintenance
28%
Negligence
28%
Others
Non follow up of
4%
SOP
11%
Poor Housekeeping
3%
8
INDEX
S. NAME OF ROOT
NO. PLANT DATE CAUSE DESCRIPTION REPORTED BY
Sharp dent at Cylinder due to
mishandling of the cylinder in the Bhagwat Singh
1 BIKANER 21.04.2014 Negligence market Sankhla
Non follow up
Segregation of DPT Cylinder
2 LALRU 29.04.2014 of SOP Sohan Singh
Poor Failure of 10 kg DCP Fire Ex during Bhagwat Singh
3 BIKANER 29.04.2014 Maintenance hydrotesting. Sankhla
Non follow up
Work Permit system not followed
4 ROORKEE 19.05.2014 of SOP Kamlesh Kumar
PCVO Crew underwent the lorry
5 ROORKEE 21.05.2014 Negligence with bypass handbrakes. Rinky Rana
Improper design of drain handle
6 Jhansi LPG 21.05.2014 Design Failure mounting Pankaj Verma
7 HISSAR 26.05.2014 Negligence Pit below Test Bath not covered Archana Mahaur
One of the rear tyres of TT got
burst due to presence of huge pit
8 Jhansi LPG 27.05.2014 Others hole in front of main gate of plant Rajeev Bansal
Non follow up SC Valve not tightened fully to
9 PIYALA 28.05.2014 of SOP Cylinder. Vinod Kumar
Poor Falling of Wash basin due to rusting
10 Jhansi LPG 29.05.2014 supervision. of its MS support angles. Rameshwar P. Kori
The gate of HT Pole structure
enclosure was found closed but not
11 LUCKNOW 30.05.2014 Negligence locked. Deepmalya Dutta
LPG leakage from the joint of
Lack of coupling screwed onto the tank
12 LUCKNOW 31.05.2014 training lorry valve Ved Prakash
Lack of Unsafe driving by PCVO Crew inside
13 HISSAR 02.06.2014 training plant premises. Archana Mahaur
Non follow up Mishandling of Cylinder in the
14 Bareilly 04.06.2014 of SOP market. Sarita Firmal
Poor Spillage of soap solution from soap
15 Jaipur LPG 05.06.2014 supervision. trays. Sankalp
LPG Leakage from welding joint of
Equipment Liquid LPG pipe with the vessel
16 Loni LPG 10.06.2014 failure during first filling of TT. Anushi Gupta
Fire in dry vegetation just outside
17 Hissar LPG 16.06.2014 Negligence the plant boundary. Archana Mahaur
Poor Falling of telephone & light pole Mahesh Chand
18 Piyala LPG 20.06.2014 Maintenance just outside plant gate. Kumawat
Poor
Non checking of fire siren
19 Jaipur LPG 21.06.2014 supervision Sankalp
9
Poor One tyre behind driver seat of TT
20 Jaipur LPG 28.06.2014 supervision was in poor condition Sankalp
Poor 10 kg DCP Fire Ex hose found
21 Jaipur LPG 30.06.2014 Maintenance cracked after operation Sankalp
Fire Ex operated in upwind Bhagwat Singh
22 Bikaner LPG 30.06.2014 Design Failure direction. Sankhla
discharge pressure tripping of LPG
Equipment Compressor is occurring at 13 Bhagwat Singh
23 Bikaner LPG 30.06.2014 failure kg/cm2 instead of 11 kg/cm2 Sankhla
Falling of Empty cylinder from
24 Hissar LPG 05.07.2014 Negligence Lorry. Archana Mahaur
Poor Overheating of cable at loading
25 Ajmer LPG 09.07.2014 Maintenance point Ashish Kudopa
Poor Overheating of stabilizer coil at
26 Ajmer LPG 09.07.2014 Maintenance admin block. Ashish Kudopa
Shooting of HAS machine
Bhatinda Equipment temperature to 260 degrees due to Arun Kumar
27 LPG 09.07.2014 failure malfunctioning of Thermostat. Sonvani
Bhatinda Poor LPG leakage at loading arm swivel Arun Kumar
28 LPG 10.07.2014 Maintenance joint in vapor line at TLD Gantry Sonvani
Equipment leakage from Centre weld of
29 Lalru LPG 24.07.2014 failure Cylinder C.V. Ravikumar
Equipment leakage from Centre weld of
30 Lalru LPG 24.07.2014 failure Cylinder C.V. Ravikumar
Poor Non Functioning of EFCV of Tank
31 Lalru LPG 25.07.2014 Maintenance Wagon Gantry C.V. Ravikumar
Poor
Less Thickness of LPG Pipeline
32 Lalru LPG 25.07.2014 Maintenance C.V. Ravikumar
Poor LPG Vapour leakage from the
33 Lalru LPG 26.07.2014 Maintenance pressure gauge of Tank Lorry C.V. Ravikumar
Job Safety Analysis not done
properly before carrying out the
34 Jhansi LPG 10.08.2014 Negligence job Omvir Singh
Non follow up Non Usage of Conveyor Crossover
35 Piyala LPG 12.08.2014 of SOP by Staff. Praveen Yadav
36 Hissar LPG 13.08.2014 Negligence PCVO Crew resting below Lorry. Archana Mahaur
Roorkee Lack of GMS was turned off by security
37 LPG 16.08.2014 training personnel during night shift. Rinky Rana
Lucknow
LPG Leakage from VCM face seal
38 LPG 19.08.2014 Design Failure Deepmalya Dutta
Crack observed at base of lighting
Others
39 Piyala LPG 24.08.2014 pole Tejeshwar Raj
Falling of Empty cylinders from
40 Hissar LPG 26.08.2014 Negligence Lorry. Archana Mahaur
leakage from unloading arm
Non follow up adaptor while unloading bulk from
41 Bareilly LPG 03.09.2014 of SOP tank lorry Sarita Firmal
10
LPG Leakage from bent pipe
Lucknow Poor section welding of TLD while
42 LPG 06.09.2014 Maintenance unloading operation. Deepmalya Dutta
Presence of live match sticks, live
Sultanpur Poor beedis at PCVO Crew room at
43 LPG 09.09.2014 supervision parking area. Madan Lal
Poor LPG Leakage from gland area of
44 Bareilly LPG 11.09.2014 Maintenance valve of ROV Sarita Firmal
Sultanpur Poor
Hand Siren found non operational
45 LPG 12.09.2014 Maintenance Satram
The cleaner of TT walked under
Allahabad Poor bottom of the moving TT and
46 LPG 13.09.2014 supervision. crossed it. Jayant Kumar
Saleempur SC Valve not tightened fully to
47 LPG 22.09.2014 Negligence Cylinder. Tirthankar Maiti
Bhatinda Poor Site not cleared after completion of Arun Kumar
48 LPG 30.09.2014 Supervision job Sonvani
Cable laid improperly causing Bhagwat Singh
49 Bikaner LPG 30.09.2014 Design Failure obstruction at workplace. Sankhla
Poor Deterioration of chequered plate at Bhagwat Singh
50 Bikaner LPG 30.09.2014 Maintenance Cylinder loading point. Sankhla
Bhagwat Singh
Bypassing of Handbrakes of Lorry.
51 Bikaner LPG 30.09.2014 Negligence Sankhla
Poor Blockage of adapters connected to Bhagwat Singh
52 Bikaner LPG 30.09.2014 Maintenance vacuum line at Purging unit. Sankhla
Driver left the vehicle without
Saleempur applying handbrakes & without
53 LPG 05.10.2014 Negligence shutting off the engine. Rajnish Kumar
Sultanpur Safety belt not hooked properly by
54 LPG 08.10.2014 Negligence operator while working at height Himanshu Jain
Equipment Cap of 10 Kg DCP Fire Ex broke out
55 Udaipur LPG 08.10.2014 failure during operation. Sri Chand
Lack of Over speeding by PCVO Crew at
56 Loni LPG 08.10.2014 training Lorry parking area of plant. Abhishek Yadav
Allahabad The bonding wire of LPG hose of
57 LPG 10.10.2014 Negligence Filling Machine found broken Jayant Kumar
Roorkee Spillage of Soap solution from tray
58 LPG 11.10.2014 Negligence of a chain conveyor Rinky Rana
Poor Snake found in the admin block
59 Jaipur LPG 03.11.2014 Housekeeping gallery Sankalp
Lucknow Improper back to back parking of
60 LPG 05.11.2014 Negligence Tank Lorry inside plant. Deepmalya Dutta
Lucknow Poor
Improper sealing of TSV
61 LPG 05.11.2014 Maintenance Deepmalya Dutta
Poor One of the metal rope of HMT
62 Ajmer LPG 05.11.2014 Maintenance found broken Ashish Kudopa
Lucknow Poor Drain chamber cover made of CI Ramesh Chand
63 LPG 05.11.2014 Maintenance material on pathway found broken Dinesh
11
Lucknow Poor
Settling of soil below pathway.
65 Hissar LPG 13.11.2014 Negligence Broken neutral wire of 11 kVA line Archana Mahaur
Allahabad Fire in dry vegetation just outside
66 LPG 18.11.2014 Others the plant boundary. Ramprit
Malfunctioning of Security Gate no.
67 Hissar LPG 26.11.2014 Negligence 2 Archana Mahaur
Lucknow Equipment LPG Leakage from EFCV of tank
68 LPG 12.12.2014 failure lorry Deepmalya Dutta
Poor Deterioration of Iron Grating stand
69 Piyala LPG 19.12.2014 Maintenance due to rusting Tejeshwar Raj
LPG Leakage from swivel joint of
Lucknow Poor the liquid unloading arm at TLD
70 LPG 24.12.2014 Maintenance Gantry Deepmalya Dutta
Poor SC Valve not tightened fully to
71 Piyala LPG 29.12.2014 supervision. Cylinder. Tejeshwar Raj
Poor Internal MS support of Fire water
72 Loni LPG 29.12.2014 Maintenance tank found damaged. Abhishek Yadav
Falling of empty cylinders inside
Bhatinda lorry due to improper arrangement Arun Kumar
73 LPG 30.12.2014 Negligence of cylinder stacking in the truck. Sonvani
Poor
Slippery tank floor.
74 Bareilly LPG 30.12.2014 housekeeping Sarita Firmal
Broken Mastic flooring near
75 Hissar LPG 02.01.2015 Negligence Carousal Archana Mahaur
Sultanpur
Security left gate no. 2 opened.
76 LPG 02.01.2015 Negligence Himanshu Jain
77 Hissar LPG 10.01.2015 Negligence Site not cleaned after repair work. Archana Mahaur
Poor Diesel leakage from hose pipe of
78 Jaipur LPG 13.01.2015 supervision. box lorry Sankalp
Lack of LPG Leakage from filling hose while
79 Ajmer LPG 19.01.2015 training carrying out maintenance work. Ankur Maloo
Poor one fire-ex of packed Lorry failed to
80 Jaipur LPG 21.01.2015 Maintenance operate Sankalp
Leakage of LPG from without O
Roorkee Poor Ring cylinder while filling
81 LPG 22.01.2015 Maintenance operation. Rinky Rana
Leakage of LPG from without O
Roorkee Ring cylinder while filling
82 LPG 24.01.2015 Negligence operation. Rinky Rana
Roorkee Poor
MCP Switch found damaged
83 LPG 30.01.2015 Maintenance Rinky Rana
Sultanpur Work permit not followed
84 LPG 10.02.2015 Negligence religiously Himanshu Jain
Non follow up
Improper Step size of stairs.
85 Bareilly LPG 12.02.2015 of SOP Sarita Firmal
Lack of Work Permit not followed
86 Bareilly LPG 12.02.2015 training religiously. Sarita Firmal
12
Cylinder with badly damaged
Equipment bottom segregated just before
87 Loni LPG 13.02.2015 failure filling. Abhishek Yadav
Footstep of staircase of watch
88 Loni LPG 14.02.2015 Negligence tower found damaged Anushi Gupta
Non follow up Without cap & seal filled cylinders
89 Loni LPG 14.02.2015 of SOP lying on floor at loading point. Abhishek Yadav
Over speeding of Packed Truck in
90 Loni LPG 14.02.2015 Negligence plant license area. Abhishek Yadav
Poor Lack of training to Contract
91 Bareilly LPG 15.02.2015 supervision. personnel Sarita Firmal
Poor
Slippery floor.
92 Bareilly LPG 16.02.2015 Maintenance Sarita Firmal
Cylinder hanged on only one
93 Loni LPG 18.02.2015 Negligence hanger of the overhead conveyor Sachin Kumar
During Night shift, Uncapped valve
Non follow up leak cylinder found on valve change
94 Loni LPG 18.02.2015 of SOP machine. Abhishek Yadav
Roorkee Bundle of Electrical cable left on
95 LPG 20.02.2015 Negligence pathway. Rinky Rana
Supply of Temperature Gauge
Poor Calibration machine left in ON Ravinder Kumar
96 Lalru LPG 23.02.2015 Maintenance condition. Raghav
Sultanpur Poor Diesel leakage from pipeline of DG
97 LPG 23.02.2015 Maintenance set Himanshu Jain
Poor
Earthing strip laid over the pathway
98 Bareilly LPG 28.02.2015 Maintenance Sarita Firmal
Poor Slippery floor due to oil leakage
99 Bareilly LPG 28.02.2015 Maintenance from Driving Unit Gear box. Sarita Firmal
Poor Soap water spillage near the
100 Bareilly LPG 28.02.2015 housekeeping conveyor railings Sarita Firmal
101 Bareilly LPG 28.02.2015 Negligence Work Permit system not followed. Sarita Firmal
Saleempur Non follow up Defective Master Switch of Tank
102 LPG 02.03.2015 of SOP Lorry. Rajnish Kumar
Saleempur Equipment
Radar gauge of MSV got hanged.
103 LPG 07.03.2015 failure Nasrul Kumar
Bhatinda Filled Cylinders with cap threads Arun Kumar
104 LPG 07.03.2015 Negligence open found at loading point. Sonvani
Poor lizard popped out from hose box
105 Jaipur LPG 07.03.2015 Maintenance and fall on the legs of operator Sankalp
Non follow up Bonding wire at Vapour Line valve
106 Udaipur LPG 09.03.2015 of SOP of Tank Lorry found broken. Sri Chand
Maintenance work at conveyor was
Bhatinda carried out without de-energization Arun Kumar
107 LPG 09.03.2015 Negligence of driving unit Sonvani
Roorkee Poor Safety Parking of personnel vehicle on
108 LPG 10.03.2015 Awareness slope in neutral gear. Rinky Rana
13
Poor Broken earthing wire of Filling
109 Bareilly LPG 12.03.2015 Maintenance Machine. Kartar Singh
Allahabad Work permit system for working at
110 LPG 20.03.2015 Others height not followed religiously Jayant Kumar
LPG Leakage from unloading arm at
Lucknow Non follow up TLD Gantry due to non follow up of
111 LPG 21.03.2015 of SOP SOP by operator Deepmalya Dutta
Lucknow Poor Earthing strip causing obstruction
112 LPG 23.03.2015 supervision. at pathway. Deepmalya Dutta
Saleempur Poor Just before unloading the TT, its
113 LPG 23.03.2015 Maintenance Body Valve found loose at Thread. Nasrul Kumar
Equipment RCCB of MCC Room DB found non
114 Udaipur LPG 23.03.2015 failure operational. Sri Chand
Operating of 10 kg DCP Fire Ex Bhagwat Singh
115 Bikaner LPG 23.03.2015 Negligence accidently by PCVO Crew. Sankhla
Usage of Mobile phone by Officer's
116 Piyala LPG 26.03.2015 Others Pick up driver while driving. Rajesh Manocha
Non follow up Work permit system for excavation
117 Gonda LPG 26.03.2015 of SOP work not followed religiously Arvind Kumar
Lucknow Poor
Deterioration of Iron Grating stand.
Negligence by Technician while
119 Bareilly LPG 30.03.2015 Negligence doing maintenance work. Sarita Firmal
Poor Site not cleaned after maintenance
120 Bareilly LPG 30.03.2015 Maintenance work. Sarita Firmal
14
NEAR MISS NO. 1
Detail Incident Report
BHAGAWAT
Application Name Incident Reporting System (HSSE) Report Submitted By
SINGH SANKHLA
Incident Date 18.04.2014 Incident Time 16:00 SBU/Entity LPG
FIR No F04140022 FIR Date 21.04.2014 Region/Refinery NR
DIR No D04140038 DIR Date 17.06.2014 Location Code 3106
Location BIKANER LPG
PLANT
Incident Type NEAR MISS
Incident Occurred At LOCATION Root Cause Negligence
Question List
10 Brief Description (Max. 5000 Char.)
Feedback A heavily dented cylinder received from one of the distributorship. The dent was due to
mishandling of the cylinder in the market. The cylinder had hit on some sharp objects
which caused such a heavy dent. This could have been lead to a big accident if the
cylinder leaks/bursts. The cylinder was manufactured in the year 2011.
20 Investigation Team
Feedback Staff no (Numeric) Name
5205 Rajeev VR
10666 Dhrubajyoti Das
30 Details of investigation (max. 5000 char.)
Feedback On investigation it was found that the cylinder had hit on some sharp objects which
caused such a heavy dent, it may happen during mishandling in the market. The said
cylinder was loaded from M/s. Ashish Gas Agency Padampur. The distributor has been
call at plant to provide explanation for such mishandling at his premises or market.
Attachments Sr. File Name File Type File Size(In Attached By
MB)
1 image003.png image/x-png 0.13 LPG_TeamMember
2 Doc1.docx application/ vnd. open xml formats- 0.47 LPG_TeamMember
office document. word
40 Fatality Injury Details
Feedback Person type No. of injured Man hours Lost (in days) Lives Lost
0
50 Details of Fire
Feedback Duration in min. (put "0" in case of no fire) Source of fire
15
0
60 Basic cause of Accident (Max. 100 Char)
Feedback MISHANDLING OF THE CYLINDER IN THE MARKET
70 Product Loss
Feedback Product Quantity Comments (For Other Products
0
80 Loss Details
Feedback Type of Loss Amount (in Lacs)
0
99 Compliance Details
Feedback Learning Action to be Taken Target Date
Distributor to be sensitized for mishandling at Distributor to be call at 17-Jun-2014
his end. plant.
Training to be provided to deliverymen and go Training to be provided to 17-Jun-2014
down staff for safe handling of the cylinder. distributors’ staff.
100 Submit compliance
Feedback Action Taken Action Date
Distributor has been call at plant and instructed to improve the cylinder 30-Jul-2014
handling.
SO has been advised to provide field training during distributor go down 30-Jul-2014
visit.
EXPERT COMMENTS:
As per the description mentioned above, following inferences were made:
1. Supervision to be done at distributor’s end.

2. Proper loading/unloading process to be followed as per standard practice.
16
NEAR MISS NO. 2
Application Name Incident Reporting System (HSSE) Report Submitted By SINGH SOHAN
Incident 07:30 SBU/Entity LPG
Incident Date 29.04.2014
Time
Location LALRU LPG PLANT
Incident Occurred LOCATION Root Cause Non follow up of
At SOP
Question List
Feedback Plant operation was going on in First shift and Mr. Bheem Kumar contract
labour of M/s. Kalanidhi Builders & Suppliers, Ambala was assigned the duty of
segregating cylinders due for pressure testing near unloading point of Kosan – II
shed. He was sitting on a stool and resting his right feet on the Plumber block of
Drive Unit K-32. Suddenly he noticed that his shoe’s laces has got loosened
which could have entangled in running 14 teeth gear. He immediately drew his
feet out and escaped from any injury. Mr. Karnail Singh, unloading operator was
moving near the contract labour, he instructed him to sit away from the running
equipments positions like Drive units etc. to avoid any incident.
4207 Mr. C.V. Ravi Kumar
5170 Mr. Sohan Singh
Feedback There is no fix position of segregating the due for pressure testing cylinders and
contract labours are carrying out the job of segregation of DPT cylinders at
different positions and Mr, Bheem Kumar sat near the running Drive unit
position. Fix position of segregation of DPT cylinders to be provided with
proper gate arrangement etc. for taking out the DPT cylinders from main
conveyor chain.
NIL
50 Details of Fire
17
0
Feedback Wrong sitting position of contract labour while working
70 Product Loss
NIL
80 Loss Details
0
Fix position for segregating DPT Fix positions to be 15-May-2014
cylinders to be provided in all three provided in all three
sheds with proper gate arr sheds.
Training to be strengthened to Trainings & Safety 10-May-2014
contract labour staff to follow the talks to be conducted
SOPs and safety talks to be co on safe working.
EXPERT COMMENTS:
1. Fix position for segregating DPT cylinders to be provided in all three sheds with
proper sheet arrangement.
2. Training to be strengthened to contract labour staff to follow the SOPs and
safety talks to be conducted as per norms.
3. Monitoring to be strengthened to check whether SOPs are being followed or not.
DETAILED INCIDENT REPORT NO. 2
18
NEAR MISS NO. 3
First Hand Incident Report
Report Submitted BHAGAWAT SINGH
Application Name Incident Reporting System (HSSE)
By SANKHLA
Time
Location Code 3106
PLANT
Incident Type NEAR
MISS
Incident Occurred LOCATION
At
Question List
1 Brief Description (Max. 5000 char.)
Feedback One 10 Kg DCP fire extinguisher failed during hydrotesting, Leakage from bottom
welding observed during pressurizing at20 Kg/cm2. The fire extinguisher was
procured in year 1999 and was due for three year hydrotesting.
2 Description of facility involved (max 100 char.)
Feedback DCP fire extinguisher
3 Duration of fire in minutes(Enter "0" (zero) in case of no fire)
Feedback 0
Comment
4 Estimated property loss in INR (lacs) (Enter "0" in case of no property loss or if it is
yet to be estimated).
5 Fatality/Injury details (Staff):
Feedback Name Staff no. (Numeric) Status Treatment Given
0
6 Fatality/Injury Details (other than staff):
Feedback Name Type of Staff Age Status Treatment Given
0
7 Product Loss
Feedback Product Quantity Comments (For Other Products)
0
19
EXPERT COMMENTS:
1. All locations should ensure timely hydro testing of fire-extinguishers.

2. In case of non-functioning of fire-ex, immediately pressure to be vented out
from vent holes before opening of the cap.
20
NEAR MISS NO. 4
Application Report Submitted
Incident Reporting System (HSSE) KUMAR KAMLESH
Name By
Incident Incident 11:00 SBU/Entity LPG
19.05.2014
Date Time
Location Roorkee LPG Plant
Incident NEAR
Type MISS
Incident LOCATION Root Cause Non follow up of SOP
Occurred
At
Question List
Feedback On 19.05.2015 at 11.00 hrs one of acting technician (Elect.) was working on
control panel of Gas Detection (GD) unit at filling shed, as electric supply to the
GD unit was disturbed. He had hung the Work Under Progress board on the panel
in the MCC room. As it was taking time and filling operations were stopped, filling
shed officer sought the help from other technician (who had also undergone
training for up-skilling technician (electrical)) to look into the matter and expedite
the work. The second technician without consulting the technician working in shed
removed the board from panel in MCC room and switched on the electric supply.
Switching on electric supply caused the spark in the control panel of GD unit at
Filling shed. Immediately technician working at filling shed asked to technician at
MCC over VHF set to switch off the supply and supply was switched off.
7795 Kamlesh Kumar
Feedback Maintenance of GD unit by acting electrician was in progress after isolation of
electric supply from MCC and display of WORK IN PROGRESS Board. Since
filling was stopped, one staff who was told to help the acting electrician, removed
the Board and switched on the power supply from MCC Room and suddenly there
was a spark at GD panel. IMMEDIATE CAUSE: Local Power supply was not
isolated & GO was switched ON without Consulting Acting electrician / shed
officer.
Engineering officer. WHY DID THEY ESCAPE ATTENTION: 1.Lack of
Knowledge. 2. Short cut to procedures. Systematic approach: Fuse to be taken out
& to be in the custody of who is doing the job.
21
Others 0 0 0
50 Details of Fire
0 nil
Feedback Local Power supply was not isolated & GO was switched ON without Consulting
Acting Electrician.
70 Product Loss
LPG (in MT) 0 NIL
80 Loss Details
Indirect Loss 0
Training Training to be strengthened 10-Aug-2014
Safety Talk Safety talk to be organized. 02-Aug-2014
EXPERT COMMENTS:
1. Electrical work permit system to be followed strictly.

2. Electrical isolation to be done before maintenance.
3. Proper training to be provided to the staff.
4. Only authorized well trained person should be allowed to handle electrical
equipment maintenance.
22
NEAR MISS NO. 5
Report Submitted
Application Name Incident Reporting System (HSSE) RINKY RANA
By
Time
Incident Type NEAR
MISS
Incident Occurred LOCATION Root Cause Negligence
At
Question List
Feedback On Date 20.May.2014 at 3:45P.M. Normal operation of filling was under process. Four
box lorries were standing in queue inside plant for unloading. Meanwhile the discussion
about bypassing of Air brake started between some company staff & drivers. During
discussion, staff came to know that Air brake bypass condition could be known by seeing
the position of plunger under the truck. In order to make it more clearly by showing it
practically, a driver of truck number UP07C8910 named- Mehfoos, went under the
nearby truck - UK08CA2208. The truck was standing in Neutral position & its air brake
was bypassed, shown by driver who was under the truck. Meanwhile our Plant in charge
noticed that the driver went under such a truck whose Air brakes were bypassed as well
as no wooden block was placed under the tires in order to oppose any unwanted motion
of truck.
7795 Kamlesh Kumar
10627 Rinky Rana
Feedback This near miss happened due to negligence & casual attempt of people. This was
behavioural error, the near miss was discussed with drivers also and they were sensitized
for its repercussions.
Others 0 0 0
50 Details of Fire
23
0 0
Feedback Negligence of staff & drivers standing on spot.
70 Product Loss
0 0
80 Loss Details
0
All labours & staff were sensitized Placing of wooden block was 12-Jul-2014
for such incidents & its made first action followed by
repercussions. session on same.
Wooden blocks are being used for all waiting box lorries. 19-Aug-2014
EXPERT COMMENTS:
1. SOP for box lorry checking at security gate no. 2 to be followed strictly.
2. Driver and company staff training effectiveness to be ensured.
24
NEAR MISS NO. 6
Incident Reporting System (HSSE) PANKAJ VERMA
Name By
Time
Location Jhansi LPG Plant
Incident Type NEAR
MISS
Incident LOCATION Root Cause Design Failure
Occurred At
Question List
Feedback During DSA, the officer checked the connectivity of earthing wire at TLD (tank lorry
decantation). While turning around his leg, he was stuck in fixed handle of drain cover
& he was about to fall down.
8593 Ajay Kumar Patel
8672 Pankaj Verma
Feedback During investigation, it was found that the design of drain handle mounting was not
proper. The fixed type handle instead of moving type was provided for
moving/shifting of the same while cleaning work in the drain.
Employee 0 0 0
50 Details of Fire
0
Feedback Improper mounting of drain cover handle.
70 Product Loss
25
LPG (in MT) 0
80 Loss Details
Direct Loss 0
Work place should to be free of Unwanted projection/handle 25-Jul-2014
unwanted projection/ obstacles. removed.
EXPERT COMMENTS:
1. Walk around management to be strengthened.

2. Design of drain cover to be checked and corrected
26
NEAR MISS NO. 7
Incident Reporting System Report
Application Name ARCHANA MAHAUR
(HSSE) Submitted By
Time
Location HISSAR
LPG
PLANT
Incident Type NEAR
MISS
Question List
Feedback In our location the test bath and the leveled floor have a gap between them.
This gap is to ensure cleaning of area under the test bath. But on 26.05.2014 at
12:15 hrs one of our GO deployed at test bath was trying to observe a cylinder
for body leak. For this he stood up from his seat and went close to the test bath
and his foot slipped. He was just about to fall, however managed to balance
himself avoiding any injuries to his body.
4059 Surinder Dogra
Feedback In the investigation done by Mr. Surinder Dogra, TC Hisar LPG plant it was
found that the area between test bath and the leveled floor was uncovered. He
recommended proper covering of that area on immediate basis. Also to ensure
cleaning of the area it was suggested to use a removable cover.
0 0 0
50 Details of Fire
0 0
27
Feedback NA
70 Product Loss
0 0
80 Loss Details
0
Feedback Learning Action to be Target
Taken Date
Proper awareness of staff and shed officers, staff Covering of the 28-May-
to be careful while working. area 2014
The area was covered with a mesh over it 28-Aug-2014
in order to avoid falling in the void space.
EXPERT COMMENTS:

2. Root cause is poor supervision.
28
NEAR MISS NO. 8
Incident Reporting System (HSSE) BANSAL SANJEEV
Name By
26.05.2014
Date Time
Incident LPG PKD LORRY IN TRANSIT Root Cause Others
Occurred At Poor Road Condition
Question List
Feedback The security Guard deployed at Gate No.1 started taking filled lorries (which were
waiting outside) for safe parking inside the plant. Because of huge pit hole in front
of Main gate of the plant, the rear tyres of the TT went in the pit hole & due to hot
weather or excessive jerking , one of the rear tyres of TT got burst (which was
about to enter into the plant). The lorry tilted to one side & about to fall down.
5165 Sanjeev bansal
8593 Ajay Kumar Patel
8672 Pankaj Verma
Feedback During investigation, it has been observed that the condition of road is very poor.
No action has been initiated neither by local administration nor by NHAI as the
matter is subjudice under court.
PCVO Crew 0 0 0
50 Details of Fire
0 0
Feedback Poor condition of road.
70 Product Loss
29
LPG (in MT) 0 NIL
80 Loss Details
Direct Loss 0
Front area of the plant should be pit Timely action on road 31-Jul-2014
hole free. repairing.
Driver must be made aware of this Refresher trainings to be 04-Aug-2014
type of situations imparted time to time.
EXPERT COMMENTS:
1. Unsafe conditions should be identified and arrested immediately so that no

such near miss takes place.
30
NEAR MISS NO. 9
Report Submitted VINOD
By KUMAR
Time
Location Piyala
LPG Plant
Incident Type NEAR
MISS
Incident Occurred At LOCATION Root Cause Non
follow up
of SOP
Question List
Feedback One cylinder sr. no. 7449976, DPT due on B 19, came for filling from repair shed but the
SC valve was not tightened properly (only two or three threads were tightened). The
contract labour at O ring replacement identified that the valve is not tightened properly.
The cylinder was segregated by PT machine due to O ring defect. After identification, the
contract labour on duty informed shed officer about cylinder. Shed officer instructed the
cylinder to be shifted to Valve Change Machine (VCM) carefully with the help of two
CL and the valve of cylinder was properly tightened to correct torque.
3360 sunil brar
55975 vinod kumar
Feedback 1. The person deployed for valve tightening did not check tightness of valve on cylinder.
2. The staff deployed at repair shed did not properly supervise the cylinders before
releasing them for filling.
3. The staff deployed for checking of cylinders while feeding on to chain did not
supervise the cylinders properly before filling.
Others 0 0 0
50 Details of Fire
31
00 00
Feedback The person deployed for valve tightening did not check tightness of valve on cylinder.
70 Product Loss
LPG (in MT) 00 nil
80 Loss Details
Indirect Loss 00
Feedback Learning Action to be Target Date
Taken
Strictly follow up of SOP, the staff should be more Immediate 16-Jun-2014
vigilant during the inspection.
EXPERT COMMENTS:
1) PMS of online VCM and manual VCM at PT shed to be followed strictly.

2) Some interlocking arrangement should be provided in online VCM such that
sealing bell will lift only when required SC valve threads are tightened.
32
NEAR MISS NO. 10
Incident Reporting System (HSSE) RAMESHWAR P KORI
Name By
29.05.2014
Date Time
Incident NEAR
Type MISS
Incident LOCATION Root Cause Poor supervision.
Occurred
At
Question List
Feedback The wash basin in facility room of security and contract labour near gate no.2 are hung
by improper supports. During the investigation by the officer, it was found that he
channel mount are rusted and grouting support have become weak due to poor
maintenance work. Hence, while security guard was using the wash basin, it was fall
down and was immediately caught by security guard.
5165 S BANSAL
Feedback The wash basin in facility room of security and contract labour near gate no.2 are hung
by improper supports. During the investigation by the officer, it was found that he
channel mount are rusted and grouting support have become weak due to poor
maintenance work. Hence, while security guard was using the wash basin, it was fall
down and was immediately caught by security guard.
Others NIL 0 0
50 Details of Fire
NIL NIL
33
Feedback Poor maintenance and unattended area.
70 Product Loss
Other Products (in MT) 0 Nil product loss due to near miss
80 Loss Details
Indirect Loss 0
POOR MAINTENANCE The wash basin maintenance properly by 31-Jul-2014
the replace support.
LACK OF SUPERVISION Proper monitoring by the all before use. 31-Jul-2014
EXPERT COMMENTS:

2. Schedule for health check of sanitary items to be prepared and implemented.
34
NEAR MISS NO. 11
DEEPMALYA
DATTA
Location Lucknow LPG
Plant
Question List
Feedback During daily safety round, the gate of HT Pole structure enclosure was found closed but
not locked. Electrician had gone inside by unlocking and opening the gate in the morning
at around 8: 30AM for a routine check to ensure no presence of
dry vegetation. While coming out, the lock did not work and he had closed the gate
without locking it. He had asked contract labor to bring a lock from the store to him for
replacing the faulty lock. Then he went to substation for his routine jobs after closing the
gate. He forgot to inform officer present / security about the unlocked gate. Follow up was
also not done to ensure that the gate gets locked. The gate was immediately locked on
making the observation.
4060 PUNEESH KUMAR SOTI
9107 DEEPMALYA DATTA
Feedback 1. Gate to HT Pole enclosure was closed but unlocked for approximately 3 hours.
2. Follow up was not done by electrician for getting another lock from the store and
replace the faulty one. He relied upon contract labour to bring the lock to him. Contract
labour got engaged in other jobs.
3. No information was given to Officer present / Security about the unlocked condition of
the gate.
4. Gate was immediately locked on making the observation.
0 0 0
50 Details of Fire
35
0 NA
Feedback Faulty lock of enclosure gate.
70 Product Loss
NA
80 Loss Details
0
Gate for HT Pole Enclosure/ Other One time check for all 30-May-2014
hazardous areas to be kept closed at all such area to be done and
times. ensured.
Any such unsafe condition to be To be ensured by 30-May-2014
brought in the knowledge of officer sensitizing.
present/ security immediately
EXPERT COMMENTS:
36
NEAR MISS NO. 12
Application Report
Incident Reporting System (HSSE) VED PRAKASH
Name Submitted By
Time
Location Lucknow LPG Plant
Incident Type NEAR
MISS
Incident LOCATION Root Cause Lack of training
Occurred At
Question List
Feedback Tank lorry number UP-83-AT-1392 of M/s Garga International Pvt. Ltd. , reported
to Lucknow LPG Plant for unloading with 2 drivers. However, while going inside
plant for unloading, only the new and untrained driver went inside and parked for
unloading in bay number 1. While connecting the unloading arms to the tank lorry,
our operator had advised the drivers not to operate any valve without his presence,
as he would make the connections and check for leakage turn by turn for different
bays. While our operator was in bay number 2, the driver of the lorry at bay no. 1
opened the liquid valve of the bulk lorry. Since the connection was not yet checked
by the operator, minor leakage started from the joint of coupling screwed onto the
tank lorry valve. Our TL operator on observing the unsafe condition immediately
rushed to bay number 1 and closed the valve. The co-driver when questioned told
that he was not fully trained to drive heavy LPG carrying vehicles, though he had a
driving license to drive heavy vehicles, and was on the lorry for past few days only.
At the loading location, however the original driver was present.
56126 Amit Kumar
9107 Deepmalya Datta
Feedback 1. The tank lorry was taken to the facility by the co-driver, who was not fully aware
of the decantation process. 2. The security ensured presence of the regular driver at
the time of attendance in parking area at 05:50 a.m. but repeat check was not done
while taking the lorry inside the plant premises at 06:05 a.m. The time gap between
the two events was only fifteen minutes. 3.The driver parked in the bay no. 1 for
decantation of the TL. 4. Operator made the connections of the arms to the
respective lorries from Bay 1 to Bay 6. Then the operator started checking the
37
connections from Bay 6 towards Bay 1. 5. While the operator was still at Bay 2, the
driver of the lorry at bay no. 1 opened the liquid valve of the bulk lorry thinking the
decantation had already started. 6.Driver's details Name: Kasim Father's Name:
Noor Md. License No. UP6219970003131 valid till 10.02.2017, issued by RTO
Jaunpur.
0 0 0
50 Details of Fire
0 Nil
Feedback The co-driver's inexperience and lack of training.
70 Product Loss
0 Nil
80 Loss Details
0
Security to recheck driver's identity be Security to be sensitized. 05-Jun-2014
force taking TL inside.
EXPERT COMMENTS:

1) Security at Gate no. 2 to check PCVO crew training certificate before
allowing TL to enter licensed area apart from following SOP.
2) Root cause: Lack of training and supervision.
38
NEAR MISS NO. 13
Report Submitted ARCHANA
By MAHAUR
Time
Location HISSAR LPG
PLANT
Incident Type NEAR
MISS
Incident Occurred LOCATION Root Cause Lack of training
At
Question List
Feedback One of the Packed truck drivers after unloading the Pressure tested cylinders
from the truck removed his vehicle from the unloading finger. While removing,
the driver could not negotiate the turn and hit one of the sand drums in front of
the shed. This resulted in tilting of the drum, which is used as a barricade for fire
water line. It was just a miss; otherwise it could have damaged the fire water line.
4059 Surinder Dogra
Feedback The incident was investigated by Mr. Surinder Dogra, TC Hisar LPG plant. He
found the drum tilted. Also the fire water line was found in safe condition. He
recommended to train the drivers about the safety precautions to be taken while
driving, unloading and loading.
0 0 0
50 Details of Fire
0 0
Feedback Improper handling of the packed truck by the driver
39
70 Product Loss
0 0
80 Loss Details
0
Safety precautions to be taken while Training to be 07-Jun-2014
driving and at unloading and loading imparted to drivers
points.
EXPERT COMMENTS:
Note: Driver training details to be mentioned while reporting incident related to

PCVO crew for proper analysis.

1. Driver’s training to be conducted effectively.
2. Data base for health check up of driver including eyesight checking report to
be maintained and analyzed.
40
NEAR MISS NO. 14
Incident Reporting System (HSSE) SARITA FIRMAL
Name By
Time
Location Bareilly LPG Plant
Incident Type NEAR
MISS
Occurred At
Question List
Feedback On 02.06.2014 around 11:30 am routine operation activities were going on. While unloading
truck no. UP80AM9225 (transporter: M.R.C); unloading operator detected a punctured
cylinder having 6mm diameter hole on the bottom of the cylinder .Operator immediately
segregated the cylinder and informed the officer.
0 NIL
Feedback Punctured cylinder having sr.no.034820 was received from truck no. UP80AM9225
(transporter: M.R.C) which was unloaded around 11:30 am at plant. Hole on cylinder bottom
was found which seems to be a typical case of cylinder mishandling at the distributor end.
0 0 0
50 Details of Fire
0 NIL
Feedback cylinder mishandling at the distributor end.
70 Product Loss
41
0 NIL
80 Loss Details
0
Needs to sensitize distributor staff to Proper training to distributor staff on 10-Jun-2014
avoid any kind of cylinder mishandling. safe cylinder handling.
EXPERT COMMENTS:
Note: Complete details of cylinder in near miss reporting is missing for carrying out
proper analysis like test date, HR cylinder, new cylinder, etc.

1) Lack of supervision at distributor end.
2) Loading/unloading process was not proper as per standard practice.
3) Inspection of cylinder not carried out at plant properly.
4) Inspection of bottom of the cylinder is to be further strengthened.
42
NEAR MISS NO. 15
Incident Reporting System (HSSE) SANKALP
Name By
Time
Location JAIPUR LPG PLANT
Incident Type NEAR
MISS
Occurred At
Question List
Feedback During visit to Filling Shed area, when I was moving near test bath, I was slightly slipped.
On checking it was found that there was soap solution overflow from the tray which
caused the nearby floor slippery.
8663 Sankalp
Feedback During investigation following has been observed: 1) Soap solution overflow was caused
as the labour did not closed the ball valve of the water for soap tray completely due to
which water got accumulated and overflowed from the tray.
0 0 0
50 Details of Fire
0 0
Feedback Partial Closing of Ball valve of water pipeline for soap tray filling arrangement
70 Product Loss
0 0
43
80 Loss Details
0
All Contract staff to be properly trained More focused job specific 30-Jun-2014
for their job specific duties. training to be given to Contract
staff.
EXPERT COMMENTS:

1. Training to be provided to contract labour regarding procedure for putting
soap solution in trays so that there is no spillage.
2. Safety awareness to be improved amongst all.
44
NEAR MISS NO. 16
Report Submitted
Application Name Incident Reporting System (HSSE) ANUSHI GUPTA
By
Time
Location LONI LPG PLANT
Incident Type NEAR
MISS
Incident Occurred LOCATION Root Cause Equipment failure
At
Question List
Feedback On 30.05.2014 at around 14:45, tank Lorry No. DL 1GC1855 with capacity 12.23
MT of LPG of M/s Shakti Transport Corporation having Vessel No. PE-76 (M/s
Paruthi Engineers) explosives license no. S/NC/DL/04/6914 (S61025) valid upto
31.03.2015was taken into the Plant for first filling at Bay No. 1. Lorry was under
loading operation and, at around 8 % of Ro to-gauge, operator at TLD observed
oozing vapours of LPG near welding joint of Liquid LPG pipe with the vessel.
When closely observed it is found that the vapours were oozing from the internal
EFCV welding joint of LPG Liquid line. LPG loading operation was immediately
stopped and the Tank Lorry decantation was carried out immediately in
consultation with Planning Officer and Territory Coordinator. The degassing of the
lorry was done as per norms. Vendor has already deposited charges for Degassing
vide SAP doc nos. 0534380300001 and 0534380300002 dated 07/06/2014.
Attachments Sr. File Name File Type File Size(In MB) Attached By
1 Lorry 1.png image/x-png 1.75 LPG_TeamMember
4140 Narendra Kumar
8233 Yadvendra Chandel
Feedback On 30.05.2014 at around 14:45, tank Lorry No. DL 1GC1855 with capacity 12.23
MT of LPG of M/s Shakti Transport Corporation having Vessel No. PE-76 (M/s
Paruthi Engineers) explosives license no. S/NC/DL/04/6914 (S61025) valid upto
45
31.03.2015 was taken into the Plant for first filling at Bay No. 1. Lorry was under
loading operation and, at around 8 % of Roto-gauge, operator at TLD observed
oozing vapours of LPG near welding joint of Liquid LPG pipe with the vessel.
When closely observed it is found that the vapours were oozing from the internal
EFCV welding joint of LPG Liquid line. LPG loading operation was immediately
stopped and the Tank Lorry decantation was carried out immediately in
consultation with Planning Officer and Territory Coordinator. The degassing of the
lorry was done as per norms. Vendor has already deposited charges for Degassing
vide SAP doc nos. 0534380300001 and 0534380300002 dated 07/06/2014.
Others 0 0 0
50 Details of Fire
0 0
Feedback It is found that the vapours were oozing from the internal EFCV welding joint of
LPG Liquid line.
70 Product Loss
LPG (in MT)
80 Loss Details
Indirect Loss na
Feedback Learning Action to be Taken Target
Date
Physical inspection and test certificates to be Physical inspection 29-Dec-
thoroughly checked before bulk lorry loading. and test certificate 2014
s thoroughly checked
before bulk lorry
loading.
EXPERT COMMENTS:
1. Manufacturer and testing party reports to be cross verified for quality/ standards
46
of EFCV.
NEAR MISS NO. 17
Report ARCHANA
Submitted By MAHAUR
Location HISSAR
LPG
PLANT
Question List
Feedback At around 13:30 hrs security guard at gate no. 1 noticed black smoke around
400mts away from the plant in the nearby forest. The fire was close and was
spreading fast due to strong winds. Immediately high alert was sounded in plant
and our
emergency handling teams were positioned on the sides of the plant with water
hoses and monitors. Fire brigade was called immediately and within 5 Minutes the
tenders reached near the plant and took positions. SHO Sadar Thana was informed;
police parties lead by SI reached the site and suspended the vehicular traffic. DC
Hissar, SSP Hissar, Dy. Director IH&S were also informed. Mutual aid members
were asked to remain in ready positions to take care of any eventuality. Fire tenders
from Jindal Industries & Rajiv Gandhi Thermal Plant were kept in ready condition
on the instructions of Asst. Director Factories, Hissar. 5 tenders were put on job, 2
teams from plant were also fighting the fire with monitors and hoses. Tankers in the
tank lorry parking area were also being cooled continuously using one double
hydrant and two monitors. Bore well was operated to replenish water in the
underground water tanks. Fire tenders which got emptied were filled with the use of
double hydrant and hose at the plant. After fighting the fire for 4.5 Hrs, the plant
team with the help
of district administration could manage to extinguish the fire.
3334 Yogesh Chandra Pande
4059 Surinder Dogra
Feedback Yogesh Chandra Pandey (TM, Hisar) and Surinder Dogra (TC, Hisar) investigated
the near miss site outside plant premises.
The forest nearby was covered with dry vegetation. As a result of human error a
47
part of it caught fire which aggravated due to strong winds. Experiencing extreme
weather Team Hisar managed to extinguish the fire , ultimately, Rain God also
helped in reducing the risk of fire to zero.
0 0 0
50 Details of Fire
0 0
Feedback Nil
70 Product Loss
0 0
80 Loss Details
0
Date
Dry vegetation outside and inside plant Dry vegetation to be 30-Jun-
premises should remain clear cleared immediately 2014
Individuals within the plant should be Each plant personnel to 30-Jun-
cautious and attentive remain cautious 2014
EXPERT COMMENTS:
1. Safety clinics to be conducted for persons residing in nearby places.

2. Walk around management to be conducted around boundary wall of plant.
3. Letters to be written to district authorities for removing dry vegetation from
around plant boundary.
48
NEAR MISS NO. 18
MAHESH CHAND
KUMAWAT

Location Piyala LPG
Plant
Incident Occurred At LOCATION Root Cause Poor
Maintenance
Question List
Feedback On 20.06.2014 morning at 3 AM, a truck loaded with bhoosa (wheat plant after
thrashing used for eatable material for animals) 3 feet height beyond the top body,
was going towards railway gate barrier. While passing on road in front of gate, the
truck passed under overhead telephone cable & carried away the telephone cable
along with it. The telephone cable was tied on the roof of house on one side and on
the telephone pole fixed on other side of the road. Due to pulling of telephone cable
along with the truck, the telephone pole on side of the road also fell down in front of
our plant gate. Due to falling of telephone pole, light pole along with aluminum
power cables which was meant for village power supply and fixed on the same side of
the road where telephone pole was fixed also fell on the ground. Hence, the gate got
obstructed and power got tripped instantly due to short circuit and breakage of power
cables. The power cable in front of plant gate buried underground also pulled out due
to sudden jerk and got broken at one place. The power cables could be rectified only
after two days and power could be restored. Till then, plant was operated on DG set.
3360 Sunil Brar
55736 Mahesh Chand Kumawat
Feedback 1. The telephone cable laid overhead across the road was loose and falling
downwards due to which it got stuck in the truck and pulled telephone pole along
with it.
2. Power cable pole was placed adjacent to telephone pole due to which telephone
pole pulled down light pole along with it.
3. Power cable were laid loose and there was no overhead protection provided
underneath power cables even though the same were not passing thru’ gate.
49
0
50 Details of Fire
0
Feedback Overloaded truck passing thru’ underneath of loose cable breaking the same during
movement.
70 Product Loss
0
80 Loss Details
0
Telephone dept. & HSEB for Whenever such cables are laid 25-Jun-2014
laying the cables underground nearer to plant, laisoning will be
in the area in front. done with concerned officials.
EXPERT COMMENTS:
Note: It is not the case of near miss.
50
NEAR MISS NO. 19
Application Name Incident Reporting System (HSSE) Report Submitted By SANKALP
Location JAIPUR
LPG
PLANT
Incident Occurred At LOCATION Root Cause Poor
supervision.
Question List
Feedback As per OISD fire siren needs to be checked regularly basis, however while inspecting the
records it has been found that fire siren at gate 2 was not tested for last 15 days. This is
near miss as same is also not recorded in the daily safety audits.
8663 Sankalp
4145 Rajkumar SIngh
Feedback During investigation it was found that it has happened due to human error and poor
monitoring and supervision.
0 0 0
50 Details of Fire
0 0
Feedback Human lapse of not testing the siren
70 Product Loss
0 0
51
80 Loss Details
0
Preparation of Log registers for operation of Log Register for daily 28-Jun-2014
Siren on daily basis. siren operation
EXPERT COMMENTS:

1. PMS to be followed strictly.
2. Daily monitoring of safety equipments to be ensured.
52
NEAR MISS NO. 20
Application Report
Name Submitted By
Time
Incident Type NEAR
MISS
Occurred At
Question List
Feedback During Daily Safety Audit it was observed that Packed Lorry RJ142g2700 was inside
plant and during physical checking of that lorry it was found that one tyre behind
driver seat is in poor condition. This poor condition of tyre is near miss as it may
cause potential hazard. The poor condition of lorry was also not inspected by the
Security at Gate no. 2.
8663 Sankalp
4145 Rajkumar Singh
Feedback During Investigation following has been found: 1) Lorry tyre condition was not
checked by Security at Gate no. 2.
0 0 0
50 Details of Fire
0 0
Feedback Basic cause of near miss is improper inspection by Security at Gate no.2.
70 Product Loss
53
0 0
80 Loss Details
0
Strengthening of Inspection by Security a Security 30-Jun-2014
t Gate 2
Inspection of tyre conditions by Tallyman on Tallyman/Officer 07-Jul-2014
random /surprise basis
EXPERT COMMENTS:

1. Box lorry checklist to be followed religiously.
2. Security staff to be trained regarding physical checking and check points of the
box lorry checklist.
3. Quarterly box lorry checking to be strengthened.
4. Effective training to be provided to the drivers.
54
NEAR MISS NO. 21
Name By
Time
Location JAIPUR LPG
PLANT
Incident LOCATION Root Cause Poor
Occurred At Maintenance
Question List
Feedback On Sunday 29th June 2014 at 1155 hrs, Off Shift Security Fire Drill was
conducted at plant. During the drill Security Guard operated the Fire-ex No 55 and
during fire-ex operation it was found that after fire-ex operation, there was minor
crack in the fire-ex hose (nozzle end) towards the end of the fire-ex operation. Due
to minor hose cracking powder spray was not even towards the desired direction.
4145 Rajkumar Singh
8663 Sankalp
Feedback During investigation it was found that 1) Minor crack in the hose may be due to
the high temp. In summers 2) Crack may be developed due to improper
positioning of hose. 3) Crack could be due to ageing of hose.
0 0 0
50 Details of Fire
0 0
Feedback Improper inspection method
70 Product Loss
55
0 0
80 Loss Details
0
Inspection of All hoses Strengthening of inspection 09-Jul-2014
of fire-ex. methods of Fire Hoses.
Proper recording of Proper recording of dates of 03-Jul-2014
Hoses replacement dates hose replacement in the history
in the history sheets. sheets.
EXPERT COMMENTS:

1. PMS of fire-ex to be followed strictly including hose checking.
2. Good quality of fire-ex hoses to be procured and used.
3. Records of fire-ex hose replacement to be maintained properly.
56
NEAR MISS NO. 22
Application Report BHAGAWAT SINGH
Incident Reporting System (HSSE)
Name Submitted By SANKHLA
Time
Location BIKANER LPG PLANT
Incident Type NEAR
MISS
Occurred At
Question List
Feedback During the mock drill at Cold repair shed it was observed that the wind sock was
not visible from the fire fighting site near valve change unit. The fire extinguisher
team has operated the fire extinguisher against the wind direction and by timely
intervention of the filling shed officer they manage to escape from the dense spray.
m55627 B.S.SANKHLA
M5205 RAJEEV VR
Feedback During the mock drill at Cold repair shed it was observed that the wind sock was
not visible from the fire fighting site near valve change unit. The 10 kg DCP
operation team has operated the DCP without considering the wind direction which
resulted in dense fog around the operator. Fire combat team leader immediately
asked operator to reverse position for effective use of fire ex. as well as personal
safety. in review of fire drill, reason for the above was discussed and decision was
taken to provide another wind sock on DV house near filling shed.
0
50 Details of Fire
0
57
Feedback 1. Non-visibility of wind sock from CR shed, to ascertain wind direction.
70 Product Loss
0
80 Loss Details
0
Date
Wind sock to be visible from all Wind sock to be fixed on DV house 29-Dec-
parts of plant. near filling shed. 2014
Wind sock provided on DV house 10 near filling shed. 29-Dec-2014
EXPERT COMMENTS:
1. All operating points to be checked for clear visibility of wind socks.

2. All operators to be trained for fire-ex operation.
3. Basic norms of operating fire-ex from upwind direction to be followed.
4. Direction of wind to be checked by using sand in case wind sock is not
visible.
58
NEAR MISS NO. 23
Time
PLANT
Incident Type NEAR
MISS
Incident LOCATION Root Cause Equipment failure
Occurred At
Question List
Feedback During quarterly inspection of the tripping of the LPG compressor No. 1 it was
observed that the hi discharge pressure tripping is occurring at 13 kg/cm2.The
desired tripping should occur at 11 kg/cm2. This is undesirable as it could have
resulted in development of high pressure in bullet as well as in TT. Considering the
high ambient temperature in Bikaner, high vapour pressure may endanger the
vessels. Also, a slight increase in pressure could have led to popping of SRV- an
unsafe condition.
5205 rajeev vr
55627 B.S.Sankhla
Feedback During quarterly inspection of the tripping of the LPG compressor No. 1 it was
observed that the hi discharge pressure tripping is occurring at 13 kg/cm2. The
continuous vibration may loosen the sensor point which resulted in the change in
the tripping setting. The sensor has been tightened and the alarms and tripping of
the compressor has been rechecked.
0
50 Details of Fire
59
0
Feedback The vibration in the line or loose fitting of pressure sensor
70 Product Loss
0
80 Loss Details
0
The electrical connections and along with tripping the health 24-Jul-2014
fittings to be checked. of equipment also to be
checked.
Health of equipment checked and technician has been advised to 24-Jul-2014
check it regularly during monthly checking.
EXPERT COMMENTS:
1. Monthly and quarterly tripping of equipment to be ensured.

2. Vibration studies of major equipments to be carried out annually.
3. Sensors to be tightened as per standard engineering practices.
4. PO and tank lorry operator should monitor all the critical parameters and log
the same.
5. Role holder to initiate action immediately based on logging of readings.
60
NEAR MISS NO. 24
Application Report Submitted ARCHANA
Name By MAHAUR
Time
Location HISSAR LPG
PLANT
At
Question List
Feedback At around 13:00 hrs one of the packed truck driver after getting the counting of
cylinders done by the security guard at gate no. 2, while taking his truck inside the
plant dropped one of the empty cylinder on ground. This was the result of
improper stacking of cylinders inside the packed truck and un-awareness of the
driver.
4059 Surinder Dogra
11340 Archana Mahaur
Feedback The security guard at Gate no. 2 reported the incident to safety officer and TC,
Hisar. The incident was then investigated by the above mentioned officers.
During investigation they found that the stacking of cylinders inside the packed
truck was not proper, also the driver was not aware of the cylinder being dropped
on ground.
0 0 0
50 Details of Fire
0 0
61
Feedback Nil
70 Product Loss
0 0
80 Loss Details
0
Stacking of cylinders to Drivers to be informed 31-Jul-2014
be proper inside the about taking proper care
packed trucks of cylinders inside the
truck while driving
Drivers of packed trucks Drivers to be trained of 31-Jul-2014
to be careful and cautious safe driving conditions
while driving inside as
wellas outside the plan
EXPERT COMMENTS:
1. During induction of box lorry and during quarterly box lorry checking,
wooden planks and their health need to be ensured at all the three tiers of
cylinder stack.
2. All vehicles to be checked for proper placement of cylinders with stoppers to
avoid falling of cylinder in route.
3. Repositioning of cylinders in trucks from top should be avoided.
4. In parking area, designated place to be defined along with placing of rubber
mat on the ground for such vehicles.
62
NEAR MISS NO. 25
Report Submitted
Application Name Incident Reporting System (HSSE) ASHISH KUDOPA
By
Time
Location Code 3115
Location Ajmer LPG Plant
Incident Type NEAR
MISS
Incident Occurred At LOCATION
Question List
Feedback During the normal shed operation it was observed that the chain conveyor of loading
shed was tripping again and again. The process operator along with electrician went
to the chain conveyor and they found heating of control cable. He mimetically
operates the ESD of loading shed and passed information about the incident on VHF.
Feedback 00
Feedback 00
Comment
4 Estimated property loss in INR (lacs) (Enter "0" in case of no property loss or if it is
yet to be estimated)
00 00 00
00 00 00
7 Product Loss
LPG (in MT) 00
Comment
FIR DelayReason
63
Due to investigation of incident.
EXPERT COMMENTS:
1. Insulation testing of all the cables to be done annually.
64
NEAR MISS NO. 26
Application Incident Reporting System Report
ASHISH KUDOPA
Name (HSSE) Submitted By
Time
Location Code 3115
Incident Type NEAR
MISS
Incident LOCATION
Occurred At
Question List
Feedback In the admin office all the equipment was running. A stabilizer was provided to Air
conditioner for constant voltage supply. During running of equipment there was
sound in the stabilizer and smoke was coming out from it. Immediately the MCB
was off but smoke was still coming out from the stabilizer. We opened all the
windows in the room. The coil of the stabilizer was heat up, and the CO2 fire
extinguisher was operated on the stabilizer.
Feedback Stabilizer of AC
Feedback 00
Comment
4 Estimated property loss in INR (lacs) (Enter "0" in case of no property loss or if it
is yet to be estimated)
00 00 00
00 00 00
7 Product Loss
LPG (in MT) 00 00
65
Comment The new stabilizer has to be replaced with new one.
FIR Delay Reason

due to investigation
DIR is not available.
Expert
1) Schedule for health check up of electrical equipments in admin block to
Comments
be prepared and followed.
EXPERT COMMENTS:
Note: DIR is not available.

1. Schedule for health check up of electrical equipments in admin block to be
prepared and followed.
66
NEAR MISS NO. 27
Application Report
Incident Reporting System (HSSE) SONVANI ARUN KUMAR
Name Submitted By
Time
Location Bhatinda LPG Plant
Incident Type NEAR
MISS
Occurred At
Question List
Feedback At hot air sealing machine in filling shed temperature shot up to 260 deg. centigrade more
than operating pressure of 210 -220 deg. Cen. And heating system was not tripped. This
was noticed by the staff at loading point and informed as sealing quality was not good. We
have analyzed the reason that thermostat of heater was not properly working which has
been immediately corrected. During checking it has been also observed that test button of
the control panel is stuck and not coming back on spring loaded system was also
corrected.
4523 SUBHASH CHANDER
Feedback At hot air sealing machine in filling shed temperature increased upto 260 degree
centigrade more than operating temperature of 210 -220 degree centigrade and heating
system of hot air sealing was not tripped even after reaching the high temperature .Since
the sealing quality was not as per the standard required and seal are found in melting
condition as noticed by the staff at loading point. Staff at loading point immediately
rushed to the hot air sealing machines and switched off the machines and called the
technician and electrician. After checking the details by technician and electrician we have
found that electrical contractor operating the heater stuck up and thermal safety tripping is
not working. Electrician immediately checked and cleaned the electrical system contactor
and checked the thermal safety system and made it operational both electrical contactors
and thermal tripping system. Hot Air sealing made operational and started under the
supervision and found proper working condition. We have analyzed the reason that
thermostat of heater was not properly working and electrical contact stuck which has been
corrected. During checking it has been also observed that test button of the control panel is
not properly operating and not coming back on spring loaded system was also corrected.
67
This is also the reason of the malfunctioning of the hot air sealing system and all problem
rectified Heater temp was high and the same can create problem in case of any leakage
cylinder on line. Consider the near miss reported regular monitoring of the hot air sealing
by technician and operator at loading point is being ensured along with regular
maintenance for non occurrence of possible incident.
Others 0 0 0
50 Details of Fire
0 0
Feedback Reason for High Rise in Temp of Hot Air Sealing Machine due to failure of Triiping
system
70 Product Loss
LPG (in MT) 0 Nil
80 Loss Details
Indirect Loss 0
INCREA MONITORING REGUALR MAITENENCE 04-Oct-2014
EXPERT COMMENTS:

1. Routine checks to be carried out by plant technician before start of the shift.
2. PMS to be followed for HAS machine.
3. HAS should be operated by company own workmen.
4. Thermostat functioning should be checked regularly for tripping.
5. Probability to be explored for providing tripping at high temperature.
68
NEAR MISS NO. 28
Application Report
Incident Reporting System (HSSE) SONVANI ARUN KUMAR
Name Submitted By
Time
Incident Type NEAR
MISS
Incident LOCATION Root Cause Poor Maintenance
Occurred At
Question List
Feedback During normal Plant visit of the Tank Lorry Gantry it has been found minor leakage at
loading arm swivel joint in vapour line at Bay No. 2 while decantation operation is going
on. Operation of the bay no. 2 immediately stopped and checked the details with
Technician and found that O ring inside the swivel joint is slightly damaged which was
the reason of the leakage in vapour line.
55676 SANJAY KUMAR
Feedback While Plant visit of the Tank Lorry Gantry it has been found minor leakage at loading
arm swivel joint in vapor line at bay No. 2 while decantation operation is going on.
Operation of the bay no. 2 immediately stopped and checked the details with Technician
and found that O ring inside the swivel joint is slightly damaged which was the reason of
the leakage in vapour line. Related O Ring has been changed and leakage was stopped
and thereafter we have checked the sufficient stock of related O Rings. We have found
that sufficient stock of O Ring stock was not available hence immediately contacted
OEM for supply of O Rings and also requested them for precautions need to make in
maintenance to avoid such incident. As per document we have checked from our end and
found that a detail of process of preventive maintenance was not available and we have
approached the OEM of the loading arm fitted at T/L Gantry. After regular discussion
with the OEM we have found details of the working of the equipment. We have also got
the information of process of the preventive maintenance along with Do’s and dont’s of
the loading arm. We have started the preventive maintenance of the loading arm as per
the details mentioned by OEM and not facing the issue and mentioned in incident and
also procuring parts form OEM in case of any such observation.
69
Others 0 0 0
50 Details of Fire
0 0
Feedback Minor damage of O Ring related to Swivel Joint of loading arm at Tank Lorry Gantry
70 Product Loss
LPG (in MT) 0 0
80 Loss Details
Indirect Loss 0
Regular Maintenance as per OEM PMS need to be followed as per 06-Oct-2014
process. process.
EXPERT COMMENTS:
1. Other locations should also develop PMS after laisioning with OEM for
loading arms.
2. Regular checks are to be carried out as per PMS once developed.
3. O-ring quality and life span is to be checked as per OEM recommendation.
4. Quarterly alignment of loading arms to be checked.
70
NEAR MISS NO. 29
Application Report Submitted RAVIKUMAR C
Name By V
Time
Location LALRU LPG
PLANT
Occurred At
Question List
Feedback Normal filling was in Progress in and suddenly minor leakage was detected in
three cylinders from the centre weld. Details of the cylinders being as below 1)
Sr no. 308510 of Intel Make, date of Mfd- Jan 14 2) Sr no. 295564 of Intel
Make, Date of Mfd- Dec 13 3) Sr no. 166689 of PGC make, Date of Mfd- Aug
12 It is observed that the Life of the Cylinders is just between 7 months to and
haly years Notification has been raised in System for Further necessary action by
CLEM All three cylinders were removed from the carousal and evacuated.
4207
2064
Feedback All the three cylinders were leaking from Centre weld due to poor quality of
weld. Notification created in system to inform the CLEM & Manufacturers.
NIL
50 Details of Fire
0
Feedback Poor quality of centre weld of cylinders
71
70 Product Loss
NIL
80 Loss Details
NIL
QAP to be strengthened Ensured 100% QAP by 31-Dec-2014
while receiving new visual inspection
cylinders immediately.
EXPERT COMMENTS:
1. To be check with LERC whether such cylinders technical spurious or not.

2. 100% checks to be carried out for new cylinder receipt from these
manufacturers.
72
NEAR MISS NO. 30
Application Report
Incident Reporting System (HSSE) RAVIKUMAR C V
Name Submitted By
Time
Incident Type NEAR
MISS
Occurred At
Question List
Feedback Normal filling operations were in progress when one cylinder was found leaking on
Carousal from Centre Weld. The details of the Cylinders are as below 1) Sr no. 408884 of
HCL make, Date of Mfd- March 13 The cylinder is hardly one year old and started leaking
from Centre weld.
4207
2064
Feedback Two cylinders found leaking from centre weld due to poor welding quality. Informed the
CLEM by creating notification in system & manufacturer too.
NIL
50 Details of Fire
0
Feedback Poor quality of weld leads to LPG Leakage
70 Product Loss
73
NIL
80 Loss Details
NIL
QAP to be strengthened while receiving 100% Visual inspection ensured 31-Dec-2014
new cylinders immediately.
EXPERT COMMENTS:
3. To be check with LERC whether such cylinders technical spurious or not.

4. 100% checks to be carried out for new cylinder receipt from these manufacturers.
74
NEAR MISS NO. 31
RAVIKUMAR C V
Time
Incident Type NEAR
MISS
Occurred At
Question List
Feedback During Routine checkup of EFCV of Tank Wagon Gantry as per the SOP it was
observed that the EFCV was operating by giving a sound as desired, however it was not
stopping the Flow. For further investigation EFCV was opened and checked and it was
detected that the Spring was totally damaged, disc as not holding properly. But due to
pressure the Sound as desired was being observed.
4207
10034
Feedback The excess flow check valves are all old and have operated their safe operating life.
Necessary maintenance of these EFCVs to done to put them in order.
NIL
50 Details of Fire
0
Feedback Dirt accumulation/corrosion
70 Product Loss
75
NIL
80 Loss Details
NIL
The operating life of EFCVs to be The old EFCVs need to be 31-Dec-2014
studied by testing procedure. repaired or replaced.
EXPERT COMMENTS:

1. Yearly checking of EFCV from third party to be strengthened by location.
76
NEAR MISS NO. 32
Application Report
Incident Reporting System (HSSE) RAVIKUMAR C V
Name Submitted By
Time
Incident Type NEAR
MISS
Occurred At
Question List
Feedback During Ultrasonic Testing of LPG Pipeline at Tank Wagon Gantry on 14/05/2014 it was
observed that thickness of pipeline of some of the pipelined branching out of the header to
the Hose was failing at bends. Immediately appropriate action for Replacement was
started and already more than 10 no were replaced. However, the job was still in progress.
Today while carrying out decantation of tank wagon, one of the identified low thickness
pipe section started leaking forming a pinhole. Immediately this portion was replaced.
There are other four points where thickness is less.
4207
10034
Feedback The pipe lines are corroded over the period of time of 27 years put in operation.
NIL
50 Details of Fire
0
Feedback Corrosion to pipe lines
70 Product Loss
77
NIL
80 Loss Details
NIL
Date
Regular pipelines testing as per Regular pipelines testing as per 31-Dec-
standards & necessary repair to be standards & necessary repair being 2014
ensured. ensured.
EXPERT COMMENTS:

1. Yearly checking of ultrasonic thickness of all LPG line is to be ensured and
covering all portion of line.
78
NEAR MISS NO. 33
Incident
Application Reporting
Report Submitted By RAVIKUMAR C V
Name System
(HSSE)
25.07.2014
Date Time
FIR Region/Refinery NR
FIR No F07140264 26.07.2014
Date
Location Code 3101
Incident NEAR
Type MISS
Incident LOCATION
Occurred
At
Question List
Feedback Bulk TT PB10 CG 8197 of M./s new CARRIER loaded vide document no 9905441620
dated 25.07.2014 at 11.41.23 for Jammu IOC LPG PLANT. Before loading of the bulk TT
safety check list prepared by our Field operator Sh Karnail Singh & found bulk TT fit for
loading. After loading and At the time of leaving main gate of our Plant our security guard
noticed minor vapour leakage from the pressure gauge. The security guard informed
Planning officer. Accordingly Planning officer & Sh Sohan Singh - HSSE officer inspected
the bulk tt & asked the driver to bring The bulk TT at our parking. Sh. C V Ravikumar TC
Lalru & Sh Sohan Singh Safety Officer thoroughly checked the gauge & decided to unload
the bulk TT. The said bulk TT was taken inside the plant for decantation. After the
Decantation Bulk TT was advised to get the problem rectified.
Feedback Bulk LPG tanker no PB10 CG 8197
Feedback 0
Comment
4 Estimated property loss in INR (lacs) (Enter "0" in case of no property loss or if it is yet to
be estimated)
nil
79
nil
7 Product Loss
LPG (in MT) nil
Comment
FIRDelayReason Due to busy schedule the matter is being

reported today
EXPERT COMMENTS:
Note: DIR is not available.

1. Locations to ensure proper checking of tank lorry fitting before loading &
training to provide to staff on duty and cross verify his job.
80
NEAR MISS NO. 34
Incident Reporting System (HSSE) OMVIR SINGH
Name By
10.08.2014
Date Time
Incident NEAR
Type MISS
Incident LOCATION Root Cause Negligence
Occurred
At
Question List
Feedback Kosan Crisplant engineer was on his scheduled (AMC) visit at Jhansi plant for
carousal maintenance. he was checking the carousal wheel by using screw type
jack with a skilled manpower. The carousal is covered with the sheet guard
surrounding it. These guards are fitted on the fixed poles. The gap between the
machine & pole is 1'' inch. one by one both were checking the wheel very
deeply by rotating carousal manually. Suddenly the labor's hand got stuck
between the machine & guard pole, he cries loudly stop......stop. Then, I rushed
near the carousal & pull the pole outside forcibly, than the hand of the person
could be free from the machine.
55809 OMVIR SINGH
Feedback As per detail investigation it has observed that both people were focused on their
job, they want to finished this job very soon, to removing the pole from the base
they avoided. But they were not aware about the forthcoming incident. One
additional manpower should be deployed there to help in any unsafe condition.
1 DIR COPY.jpg image/pjpeg 0.35 User
81
contractor Staff 0 0
50 Details of Fire
0
Feedback 1-Lack of sufficient manpower. 2- ignorance of safe working method.
70 Product Loss
LPG (in MT) 0
80 Loss Details
0
Date
Provide sufficient manpower & Organized tool box training for 26-Nov-
work in safe manners. contractor workmen. 2014
Training organized for contractor staff. 21-Jun-2015
EXPERT COMMENTS:
1. Job safety analysis to be done properly while preparing work permit.

2. Supervision of critical activities to be supervised by Officer/trained staff.
3. Toolbox talks to be conducted properly.
4.
82
NEAR MISS NO. 35
PRAVEEN YADAV
12.08.2014
Date Time
FIR No F08140037 12.08.2014
Date
DIR Location Code 3102
DIR No D08140010 12.08.2014
Date
Location Piyala LPG Plant
Incident NEAR
Type MISS
Occurred At
Question List
Feedback Normal cylinder filling operation was going in first shift in Shed B & the shed
technician was sitting at other side of test bath. Suddenly he noticed that a cylinder
fell at introduction unit, as a result of which one of the filling machines got stuck &
toppled down. Seeing the criticality of situation the shed technician immediately
tried to rush to the carousal but instead of using the nearby crossover he tried to jump
over the test bath. While doing so, his foot got slipped & he was just going to fell on
the test bath but somehow he got hold of mirror stand and prevented himself from
falling on test bath.
9076 Praveen Yadav
9103 Mukesh Rojra
Feedback Normal cylinder filling operation was going in first shift in Shed B & the shed
technician was sitting at other side of test bath and was busy in talking to one of his
colleague. At the same time one of the 14.2 kg cylinders with damaged foot ring got
stuck at introduction plate & fell on filling machine no. 14 & as a result the filling
machine got toppled down. The contract labour at carousal immediately cut the
supply of carousal, the technician has also noticed the whole situation & he also
immediately tried to rush to stop the carousal but instead of using the nearby
crossover he tried to jump over the test bath. While doing so, he put his right foot on
83
test bath & tried to jump over it but due to wet conditions of test bath his foot got
slipped & he was just going to fell on the test bath but somehow he got hold of
mirror stand (installed on other side of test bath to improve visibility of cylinders in
test bath) and prevent himself from falling on test bath. He sustained minor scratches
on his right knee.
Employee 0 0 0
50 Details of Fire
0 nil
Feedback N.A.
70 Product Loss
0
80 Loss Details
0
All workmen to focus on their Safety talks to be conducted for 13-Aug-2014
work only, gossiping at work all workmen about the criticality
place to be prohibited. of operation/safe operations.
Damaged foot ring cylinder to be Monitoring to be strengthened 13-Aug-2014
100 % segregated before for 100 % segregation of cold
reaching carousal repair cylinders
While crossing the conveyor, Safety talk conducted on use of 13-Aug-2014
only crossovers to be used. crossovers
EXPERT COMMENTS: ARCHANA

MAHAUR
As per Date
the description Incidentabove,
mentioned 10:00following
SBU/Entity
inferences LPG
were made:
Incident 13.08.2014
Time
1. Safety talks need to be conducted on use of crossovers &about the
criticality of operation/safe operations.
2. Monitoring to be strengthened for 100 % segregation of cold repair cylinder
84
NEAR MISS NO. 36
Incident Reporting System Report ARCHANA
Application Name
(HSSE) Submitted By MAHAUR
Time
Location HISSAR LPG
PLANT
Incident Type NEAR
MISS
Question List
Feedback At 10 a.m a truck loaded with new cylinders was being emptied on ground. The
cylinder lot was placed up till the truck height. At the same time the truck driver
was lying on the ground just besides the truck. In the event of emptying the truck
any cylinder could have fallen from the truck and could have hit the driver.
Feedback The incident was reported by the security guard who could view it from gate no. 2.
It was investigated immediately and found that the driver was lying there due to the
shade present. He was immediately removed and told about the consequences of his
act and precautions to be taken while unloading of cylinders. The labour emptying
the truck was also involved in the sharing.
0 0 0
50 Details of Fire
0 0
Feedback Lack of knowledge of the driver and unloading labour
70 Product Loss
85
0 0
80 Loss Details
0
The drivers to be careful Drivers of truck carrying new cylinders 31-Aug-2014
and aware of the effects will be informed prior about precautions
of such acts. to be taken (cont.) while unloading the
cylinders.
Drivers of trucks carrying new cylinders are informed about 01-Sep-2014
safety precautions to be taken while unloading.
Unloading labour is also told the safe unloading practices on 01-Sep-2014
regular basis.
EXPERT COMMENTS:

1. Safety talk to be imparted to the fresh entrant before entering licensed area.
86
NEAR MISS NO. 37
Report Submitted
Application Name Incident Reporting System (HSSE) RINKY RANA
By
Time
Incident Type NEAR
MISS
Incident Occurred At LOCATION Root Cause Lack of training
Question List
Feedback While taking round at night at 11:15 P.M. ,security heard the alarm of GMS, he
immediately took explosive meter & checked LEL of GMS sensor at LPG pump house,
LEL was found zero, he investigated but could not found any leakage. So, he turned GMS
main switch off in pump house & forgot to report it to officer & electrician about same. In
morning the operation started, at 11 when Safety officer reach for DSA of pump house area
there it was observed that the GMS switch was put off, on further investigation the whole
matter came out. Immediately safety officer consulted system supplier. As per supplier
instruction & with the help of electrician, the voltage of circuit in sensor was adjusted to
normal value, due to which the particular sensor was alarming. Security guards were
sensitized & trained about importance of GMS system in LPG plants, as well as were told
to report each & everything to officer no matter what time it is.
10627 rinky rana
55798 Lal SIngh
Feedback Due to over volatge in LPG pump house sensor of GMS, the sensor started alarming. on
checking & not finding any leakage,security guard put siwtch off without informing officer
or electricain. next day during DSA it came to knowledge & was
rectified. Securities were given training & were sensitized about the GMS & reporting
instructions.
Others 0 0 0
50 Details of Fire
87
0 0
Feedback Electrical fault & non reporting of matter to officer & electrician by security guard.
70 Product Loss
LPG (in MT) 0 0
80 Loss Details
Indirect Loss 0
Date
Securities should report each & every securities ask to report at any time in 19-Aug-
detail to officer during off- shift addition to daily night reporting 2014
Security given training for the same. 19-Aug-2014
EXPERT COMMENTS:

1. Training to be given to security guard about importance of GMS. In case
there is an alarm, he should check for leakage and inform HSSE officer.
2. Root cause is poor maintenance.
3. GMS maintenance schedule to be followed to avoid such lapses.
88
NEAR MISS NO. 38
Incident Reporting System (HSSE) DEEPMALYA DATTA
Name By
Time
Incident Type NEAR
MISS
Occurred At
Question List
Feedback During operation of VCM for removal of valve from 14.2 kg cylinder, operator
reported minor leakage between sealing bell and cylinder surface. The VCM was
inspected and face seal of the VCM was found having a cut mark which was causing
gap in the sealing and minor LPG leakage. The face seal was changed immediately and
the problem got rectified. VCM was put back into normal operation.
55856 RAMESH CHAND DINESH
Feedback 1. Face seal was checked on previous maintenance schedule on 18.08.2014 and no
defects were observed.
2. The last 4 cylinders whose valves were changed were still in the loop and they were
inspected and one of them was detected with some hard foreign material sticking
where the sealing bell sits on the cylinder. This had probably damaged the face seal.
3. Face Seal was replaced and VCM checked for normal operation. It was found okay.
Others 0 0 0
50 Details of Fire
0 NA
89
Feedback Damaged Face Seal of VCM
70 Product Loss
LPG (in MT) 0 NA
80 Loss Details
Direct Loss 0
Cylinders to be inspected before taking Operators to be briefed. 20-Aug-2014
on VCM
EXPERT COMMENTS:

1. Details of foreign material sticking to cylinder not available for analysis.
2. It was not clear whether cylinder was new or in service from long time.
Details of cylinder missing like manufacturing date, HR date, etc.
3. Root Cause should be poor supervision instead of Design Failure.
90
NEAR MISS NO. 39
TEJESHWAR RAJ
Time
DIR No D08140028 24.08.2014
Date
Incident Type NEAR
MISS
Incident OTHERS Root Cause Non adherence to standard
Occurred At Engg practice
Question List
Feedback In Ist shift, I was taking a quick round around the shed area for general inspection.
While doing so, it was found that a street light pole near shed-C had bent from its
lower end. On inspection, it was found that the lower part of the tower had
corroded and light pole had cracked at the point of corrosion. Immediately I
contacted MCC to isolate the electrical connections of that bent light pole. Then I
contacted night shift officer and through him I came to know that Piyala
plant had witnessed light dust/thunder storm at around 5:00 am.
11195 tejeshwar raj
55424 Manoj Saini
Feedback Piyala plant witnessed a stormy weather in the very morning of 19th August 2014.
At around 6:15am, it was found during inspection round that a light tower near
Shed-C had bent from its lower end and while inspecting that area it was found
that the lower part of the tower had corroded and cracked and it had bent from
cracked area as that corroded part had become weak. Immediately the electrical
connection of that tower was isolated from MCC. The pole had bent sideways on
right side and did not cause any harm to any personnel or vehicle. The lower
concrete cover over the pole had also cracked due to excessive force of the bending
of light pole. The corrosion has slowly taken place inside the concrete portion of
pole and was not clearly visible from top.
91
Others 0
50 Details of Fire
0
Feedback NA
70 Product Loss
LPG (in MT) 0
80 Loss Details
Direct Loss NA
Daily Inspection Inspection of all light towers in the plant 24-Aug-2014
premises will be done and corrective
action will be take.
Expert Comments: 1.Walk around management to be strengthened.

2. Locations need to be make inspection schedule of light towers in plant premises.
EXPERT COMMENTS:

2. Locations need to be make inspection schedule of light towers in plant
premises.
92
NEAR MISS NO. 40
Application Report
Incident Reporting System (HSSE) ARCHANA MAHAUR
Name Submitted By
Time
Location HISSAR LPG PLANT
Incident Type NEAR
MISS
Occurred At
Question List
Feedback At around 12:00 p.m. a truck (HR 57 9677) of empty cylinders was being unloaded
at unloading point. As soon as the angles which are used to support the cylinders
were removed, all the cylinders from the top row and the middle row fell down
. The contract labour immediately moved from the point without hurting
themselves. The incident occurred due to the improper inclination of the truck floor
which was more tilted towards the end portion. The driver was immediately
instructed to take back the truck empty and get the improvements done as soon as
possible.
4059 Surinder Dogra
Feedback All the empty cylinders were removed from the truck with proper precautions and
under the supervision of the shed officer. The empty truck was then taken aside and
inspected for the shortcomings and was found that the floor of the truck was
not leveled properly. It was more tilted towards the back side causing the cylinders
to fall as soon as the angles are removed. The truck driver was informed about the
problems in the truck and was asked to get them corrected. The truck was sent out
empty so that the improvements can be done and the investigation team ordered to
inspect the truck thoroughly after it arrives again.
0 0 0
50 Details of Fire
93
0 0
Feedback Nil
70 Product Loss
0 0
80 Loss Details
0
Drivers/ transporters to take care of their Safety talk to be done 30-Aug-2014
vehicles and their maintenance. with the drivers.
Unloading labour to be cautious while Safety talk to be done 30-Aug-2014
unloading and take safety precautions. with the unloading/
loading labour.
EXPERT COMMENTS:

1. Quarterly box lorry checking to be ensured.
2. Equal load distribution to be ensured while checking of the vehicle.
3. Leaf spring to be ensured as per manufacturer norms.
94
NEAR MISS NO. 41
SARITA
FIRMAL
Location Bareilly LPG
Plant
Incident Occurred LOCATION Root Cause Non follow up
At of SOP
Question List
Feedback On 03.09.2014 around 8:30 am at TLD bay no.2 Tank lorry operator observed
minor leakage from unloading arm adaptor while unloading bulk from tank lorry
no. R55J8869. Operator immediately closed the liquid main valve & tank lorry
valve and informed the officer.
56117 sandeep kumar
Feedback While inspecting small cut was observed in o-ring inside the adaptor.
0 0 0
50 Details of Fire
0 0
Feedback Condition of adaptor was not properly checked before heading for unloading
operation.
70 Product Loss
0 Nil
95
80 Loss Details
nil
Healthy condition of equipment to be Proper check of 03-Sep-2014
used should ensure before heading for adaptor condition is
any operation & SOP to be to be included in check
list.
EXPERT COMMENTS:

1. Root cause: Non- follow up of SOP - After connecting the unloading arm,
procedure for checking leakage by passing vapour through vapour line was not
followed.
2. PMS of unloading arm was not followed.
3. Lack of training to TLD operator.
4. There may be a possibility that leakage checking is not being done in practice.
96
NEAR MISS NO. 42
Application
Incident Reporting System (HSSE) Report Submitted By DEEPMALYA DATTA
Name
Incident Incident Time 15:00 SBU/Entity LPG
04.09.2014
Date
Incident NEAR
Type MISS
Occurred At
Question List
Feedback The subject tanker was taken for decantation in 2nd shift on 04.09.2014, the lorry was
positioned at bay no.4. As per standard operating procedure, the unloading arms were
connected by our TL operator Mr. Anil Kumar. He then crack opened the vapor line
valve of plant side for checking the leakage at the joints of liquid & vapor unloading
arms. The leak test for the liquid unloading arm was found to be ok. But minor hissing
sound of leakage was observed from the vapor line of tank lorry. He depressurized the
line , disconnected the vapor unloading arm & after changing the o-ring at the
connection point , refitted the unloading arm and again tested for leakage. Again there
was hissing sound and slight leakage observed. The operator then closely inspected the
vapor line valve of the tank lorry and observed that the leakage was from the lower
flange welding at the bent pipe section of the valve. Operator had immediately informed
the same to TC, planning & HSSE officer and stopped the decantation procedures.
Alertness and following of SOP by TL operator prevented any major hazard to occur as
failure of the section during unloading process would have had much serious
consequences.
4060 PUNEESH KUMAR SOTI
Feedback The fitting was closely inspected and it was observed that the bent pipe section had
corroded at the lower flange and thick coating of M-SEAL putty was put on it and
camouflaged by painting green color on the same. The bent pipe section was removed in
the presence of officers by company technician and M-SEAL was removed partially to
check the condition of the welding. Photograph of the section is enclosed. Other empty
tank lorry was taken inside the plant and the bent pipe section of vapor line of the empty
97
tank lorry was removed and fitted on HR55P6791 vapor line. The tank lorry was then
decanted under close observation of officer and tank lorry operator. The other details of
the tank lorry and the driveras as under : All the documents of the tank lorry were found
to be in name of M/s Shree Rama Roadways whereas the vehicle is plying under
transporter M/s Chandan Roadways. DRIVER NAME: MD. RAIS S/O MD. HABIB
DRIVING LICENSE: The same is challaned by UP Traffic Police, Kanpur on
23.07.2014 vide challan no. 53. Same was shown by the driver. Training: Driver last
attended training by M/s TALATI ASSOCIATES, Baroda between 29.05.2014 to
31.05.2014. Cert No. BRD/TA 0001653. PESO Licence of Vehicle: In name of Shree
Rama Roadways - s/nc/dl/04/6159(s51779) valid till 31.03.2017. Last Half Yearly
Inspection Date: 31.03.2014 by M/s SIMO Research Engineers Pvt. Ltd. - Cert No. -
PV(R)547/cps54392/44(2)/hn/5252 dtd 11.04.2014.
1 HR55P6791.jpg image/pjpeg 0.10 LPG_TeamMember
0 0 0
50 Details of Fire
0 NA
Feedback TAMPERING OF STANDARD FITTING BY TANK LORRY DRIVER & POOR
VEHICLE MAINTENANCE.
70 Product Loss
LPG (in MT) 0 NA
80 Loss Details
0
Safety talks to sensitize drivers to refrain from Safety talk at time of 11-Sep-2014
such unsafe practices. unloading.
98
EXPERT COMMENTS:

1. Root Cause is ineffective safety training to driver instead of poor
maintenance.
2. Genuineness of Fitness certificate to be verified.
3. Detail analysis is to be carried out in regard to hydrotesting/ purging of tank
lorry.
4. In house safety training of driver to be conducted.
5. Driver’s ability test to be carried out to access his knowledge.
6. Standardized tank lorry checklist to be strictly followed.
99
NEAR MISS NO. 43
Report Submitted
Application Name Incident Reporting System (HSSE) MADAN LAL
By
Time
Location Sultanpur LPG
Plant
Incident Type NEAR
MISS
Question List
Feedback During the daily routine round of plant at 11.10 hrs on 09.09.2014, Territory
coordinator Mr. Madan Lal noticed live match sticks, live beedis and some fresh used
pieces of beedies & used match sticks under the wooden bed table in the rest
room of PCVO crews in tank truck parking area. He enquired from the drivers and
cleaners of the tank trucks available in tank truck parking area and asked that who has
done smoking in the rest room. All the drivers and cleaners denied and
told that this has been done by those drivers and cleaners who had stayed earlier in the
rest room. Then territory coordinator called security supervisor Mr. S.N Singh & one
security guard in the rest room and show them the fresh used pieces of beedies, match
sticks and live match sticks & beedies lying in the rest room. On investigation it is
found that this has been done by the second crew members of the bulk tank trucks who
was inducted recently in the system.
4279 Madan Lal
55368 Satram
Feedback During the daily routine round of plant at 11.10 hrs on 09.09.2014, Territory
coordinator Mr.Madan Lal noticed live match sticks, live beedis and some fresh used
pieces of beedies & used match sticks under the wooden bed table in the rest
room of PCVO crews in tank truck parking area. He enquired from the drivers and
cleaners of the tank trucks available in tank truck parking area and asked that who has
done smoking in the rest room. All the drivers and cleaners denied and
told that this has been done by those drivers and cleaners who had stayed earlier in the
rest room. Then territory coordinator called security supervisor Mr. S.N Singh & one
100
security guard in the rest room and show them the fresh used pieces of beedies, match
sticks and live match sticks & beedies lying in the rest room. On investigation it is
found that this has been done by the second crew members of the bulk tank trucks who
are inducted recently in the system..On further investigation it was observed that the
smoking was done by the new cleaner who was inducted in the system recently.
We also asked from the security and asked them to submit their explanation. The
security agency submitted their explanation and replaced security supervisor. New
security supervisor and other security staff was sensitized and instructed al
l security staff for strict frisking at gate no1.and gate no.2.Also instructed all security
staff for proper checking and frisking of new drivers and cleaner of bulk tank truck
and packed trucks. We started to discuss the topic during safety talk being conducted
on daily basis.
0 0 0
50 Details of Fire
0 NA
Feedback No proper frisking at gate no.1, lack of awareness about hazardous product by newly
inducted cleaner.
70 Product Loss
0 NA
80 Loss Details
0
(1) Lack of training to newly Adequate training to be 31-Dec-2014
inducted cleaner. provided to newly inducted
cleaner , do and don'ts to be
read by cleaner
Lack of Frisking by security. Frisking to be strengthened. 25-Nov-2014
Frequent visit by officers to tank All officers must take one or 25-Nov-2014
lorry parking area. two rounds
of tank lorry parking area on
daily basis.
101
EXPERT COMMENTS:

1. Root Cause is Lack of Supervision instead of Negligence.
2. Training to be provided to drivers and second crew that smoking material is
hazardous in plant area.
3. Training to be provided to security regarding proper frisking.
4. Walk around management to be strengthened in parking area.
5. Surprise visits to be carried out in parking area.
6. Night surprise inspection to be ensured on regular basis.
102
NEAR MISS NO. 44
Name By
Time
Incident Type NEAR
MISS
Occurred At
Question List
Feedback While taking round inside the plant area, near bullet area, icing was observed in the gland
area of valve -ROV of SV-8. LPG was found leaking from it. The gland nut was found
loose and the same was tightened.
4308 RAHUL SHARMA

Feedback While taking round inside the plant area, near bullet area, icing was observed in the gland
area of valve -ROV of SV-8. LPG was found leaking from it. The gland nut was found
loose and the same was tightened.
0
50 Details of Fire
0
Feedback Loos gland nut due to frequent movement of ROV
70 Product Loss
103
0
80 Loss Details
0
Date
Before & after starting any operation Supervision and Proper Preventive 11-Sep-
condition of respective equipment should be Maintenance of ROV to be 2014
critically monitor ensured
EXPERT COMMENTS:
Note: Feedback by location given is not correct as ROV does not require inspection
before and after operation.

1. OEM norms for tightened of gland not followed.
2. Adequate torque not applied while tightening of the nut.
3. Lack of supervision by Engineering Officer.
4. Periodic inspection during Real Time Analysis not carried out properly.
104
NEAR MISS NO. 45
Application Report
Incident Reporting System (HSSE) SATRAM
Name Submitted By
12.09.2014
Date Time
Location Sultanpur LPG Plant
Incident NEAR
Type MISS
Occurred
At
Question List
Feedback When planning Oficer Mr. Satram operated manual siren at gate no.2 to test the siren for
its functioning at 14: 30 hrs on 12.09.2014 , the siren did not alarm and produced
abnormal noise. Due to the abnormal noise he stopped it and asked technician plant to
check the manual siren. The technician Plant Mr. Suresh Kumar opened the handle of the
siren and found that the handle of the siren has jammed.
55368 sat ram
Feedback When complete siren was dismantled and found that split pin of gear found broken and
stuck between both gears teeth and also damage bearing. New pin and bearing was
changed and siren was made functional.

0 0 0
50 Details of Fire
0 0
Feedback Nil accident
70 Product Loss
105
0 nil loss
80 Loss Details
0
Split pin to be properly locked checked all siren 15-Dec-2014
Expert As per the description mentioned above, following inferences were made:
Comments 1) It is not a case of near miss. It is the case of poor maintenance.
EXPERT COMMENTS:

1. It is not a case of near miss. It is the case of poor maintenance.
106
NEAR MISS NO. 46
Incident Reporting System (HSSE) JAYANT KUMAR
Name By
13.09.2014
Date Time
Location Allahabad LPG Plant
Incident NEAR
Type MISS
Occurred
At
Question List
Feedback Tank Lorry no. HR 55T 0536 of Sri Rama Roadways was being taken inside Plant
for weighment on 13.09.2014 at 12:15 PM. Name of the TL driver is Shri Bheem
Singh and Shri Kaptaan Singh is cleaner. As per practice both Driver and cleaner
went inside the Gate no. 02 with the lorry. The cleaner got down before the TL
moved on the weigh bridge. While the TL was moving towards the weighbridge
slowly near Gate no.2, the cleaner walked under bottom of the moving TL and
crossed the TL. The security guard watched the cleaner doing the unsafe activity
and informed the officer doing the weighment. The officer immediately stopped the
TL and informed the TC and Safety Officer. The TL was taken out and transporter
was informed to report to LPG Plant. It was found that the authorized cleaner with
the TL was Shri Dilip Singh who was absent and the driver has managed some
other cleaner named Kaptaan Singh who was on the TL for the first time. The
driver’s training certificate is found to be valid till 31.10.2014 issued from some
M/s Talati Associates, Baroda.
10381 sameer sahgal
9182 Jayant Kumar
Feedback The TL was not decanted on 13.09.2014 and information was given to the
Transporter to report to Plant. It was found that the authorized cleaner with the TL
was Sh Dilip Singh who was on leave due to some personal reasons. The present
cleaner Sh Kaptaan Singh was not authorized and did the unsafe act. Gate pass of
Sh Kaptaan Singh was presented by the Transporter on 15.09.2014 from the
loading location Bina. After that the TL was decanted on 15.09.2014.The basic
107
reason for the near miss was that cleaner was untrained and security did not check
the authenticity of the cleaner.
Others 0 0 0
50 Details of Fire
nil nil
Feedback Untrained cleaner and lapse by security guard
70 Product Loss
Other Products (in MT) 0 nil
80 Loss Details
Direct Loss 0
Date
Only cleaners with valid gate pass strengthen security checks for TL 24-Sep-
be allowed on TL entering in Plant 2014
EXPERT COMMENTS:

1) System for tracking authorized cleaners on tank lorries to be made and
implemented.
2) Safety training to be conducted for drivers and cleaners.
108
NEAR MISS NO. 47
Report Submitted TIRTHANKAR
By MAITI
Time
Location Salempur LPG
Plant
Incident Type NEAR
MISS
Question List
Feedback Box lorry no. UP80S 9552 was being unloaded and cylinders of box lorry were
coming to carousel, then the person, positioning at inserting o-ring before
carousel filling, found that the height of valve of one cylinder was more. Further
checking, it was found that only 3 threads of valve were inside the cylinder,
Then the cylinder was taken to VCM to tight the valve.5 threads were further
tightened.
8930 Tirthankar Maiti
Feedback On 22.09.2014 at 9:30 Box lorry no. UP80S 9552 was being unloaded and
cylinders of box lorry were coming to carousel, then the person, positioning at
inserting o-ring before carousel filling, found that the height of valve of one
cylinder was more. Further checking, it was found that only 3 threads of valve
were inside the cylinder, Then the cylinder was taken to VCM to tight the valve.
The cause of that incident: 1. The operator's negligence during valve changing
at VCM. 2. After valve change when that cylinder is taken online that time it
was also not checked. 3. During loading of that cylinder it is not observed by
tallyman & loading labor. 4. There is probability of malpractice at market also.
Action taken: 1. We share the incident with the all staff and also with the labour
of in-house pressure testing unit. 2. We check the torque of the AVCM and
VCM at in-house pressure testing unit by torque wrench. 3. We sensitize all that
please check valve's thread condition before taking that cylinder online & there
should be nil deviation.
109
contractor Staff nil nil nil
50 Details of Fire
Nil NIL
Feedback NIl
70 Product Loss
LPG (in MT) 0 nil
80 Loss Details
Direct Loss 0
Date
Ensure nil deviation and follow Ensure nil deviation and follow 30-Dec-
SOP strictly. SOP strictly. 2014
ensure nil deviation and follow SOP strictly. 30-Dec-2014

1) PMS of online VCM and manual VCM at PT shed to be followed
strictly.
Expert Comments
2) Some interlocking arrangement should be provided in online VCM
such that sealing bell will lift only when required SC valve threads
are tightened.
EXPERT COMMENTS:
1) PMS of online VCM and manual VCM at PT shed to be followed strictly.

2) Some interlocking arrangement should be provided in online VCM such
that sealing bell will lift only when required SC valve threads are
tightened.
110
NEAR MISS NO. 48
Report Submitted SONVANI ARUN
By KUMAR
Time
Incident Type NEAR
MISS
Incident Occurred OTHERS Root Cause Poor Supervision
At
Question List
Feedback During visit of the tank lorry parking area it has been found that after cleaning of
water drench on the road ,steel covers provides were not fixed properly after
cleaning process by the contract workmen and found the gap of 8 inch between two
covers .Drivers , cleaners and labour were walking over the water drench even
packed lorry also moving. Since gap between two steel covers fixed after the
cleaning was high hence there is possibility of accident while moving over the
covers of the water drench.
4321 ARUN KUMAR SONVANI
4523 SUBHASH CHNADER
Feedback As per process after cleaning of the water drench steel covers need to be fixed
properly without any gap however it has been observed that covers were not fixed
properly on the drench and left a gap of around 8 inches after cleaning . Both
steel covers were fixed properly as immediate corrective action to avoid any
incident and process for checking started at others places for same scenario. During
visit of the other places it has been found that person involve in cleaning of the
trenches all around the plant are not aware about the repercussion of the leaving
gap between the trenches. We have checked the gap all around the plant and found
that rest of the plant gap is ok however cleaning person not making effort to ensure
that no gap between two trenches to be left. We have discussed in the Safety Tal at
the Plant and created awareness among all about the safe process of crossing the
pathways. Safety Officer personally verified all such gaps and corrected as well as
training provided to the cleaning person. In our plant Sunday cleaning job is being
done and the same is being verified on Monday.
111
Feedback Person No. of Man hours Lost (in Lives Lost
type injured days)
Others 0 0 0
50 Details of Fire
0 NIL
Feedback TANK LORRY PARKING AREA WATER DRENCH COVERS NOT FIXED
PROPERLY AND GAP OF 8 " FOUND BETWEEN TWO COVERS.
70 Product Loss
Other Products (in MT) 0 NO PRODUCT LOSS
80 Loss Details
Indirect Loss 0
ALL OPENING NEED TO OPENING ON ROAD OR 31-Dec-2014
CLOSED PATHWAY NEED TO BE
CHECKED AND CLOSED
EXPERT COMMENTS:
1. Walk around management is to be strengthened.

2. Drain covers to be checked for proper placement without having any gaps
between two covers.
3. Job to be supervised by trained company staff.
4. Area is to be inspected once job is completed.
112
NEAR MISS NO. 49
Report BHAGAWAT SINGH
Submitted By SANKHLA
Time
Incident Type NEAR
MISS
Incident Occurred At LOCATION Root Cause Design Failure
Question List
Feedback Our technician, Sri Bhupender Singh Fartyal had gone to the backside of the GD
unit. Engrossed in his work, he had not noticed a protruded piece of pipe for
electrical cable in the floor directly beside where he was standing. When he stepped
aside, his feet caught the pipe and he stumbled. However, he took support of the
pillar nearby, and avoided falling, thus saving himself from injuries.
5205 Rajeev VR
Feedback Our technician, Sri Bhupender Singh Fartyal had gone to the backside of the GD
unit. Engrossed in his work, he had not noticed a protruded piece of pipe for
electrical cable in the floor directly beside where he was standing. When he stepped
aside, his feet caught the pipe and he stumbled. However, he took support of the
pillar nearby, and avoided falling, thus, saving himself from injuries. The power and
control cable was laid just behind the GD unit which was obstructing the movement;
the same has been re-routed to ensure safe working at GD unit.
0
50 Details of Fire
0
113
Feedback Protruded piece of pipe for electrical cable in the floor
70 Product Loss
0
80 Loss Details
0
1. Nearby area to be 1. Obstruction to be removed in 11-Dec-2014
inspected for any obstruction working area and awareness to be
created to be
vigilant.
The cable route has been changed to ensure safe 11-Dec-2014
working at GD unit and easy movement
EXPERT COMMENTS:

1. All electric cables to be dressed properly.
3. DSA to be done more strictly.
114
NEAR MISS NO. 50
Application Incident Reporting System Report BHAGAWAT SINGH
Name (HSSE) Submitted By SANKHLA
Time
FIR No F09140154 30.09.2014
Date
DIR No D09140102 11.12.2014
Date
Incident Type NEAR
MISS
Occurred At
Question List
Feedback Mr. Babulal Nayak, one of our FOs was doing his duty as Loading Tallyman. He
had gone up to the boom to check the loading pattern, when he noticed a gap in the
checker plate platform. He immediately brought it to the notice of Shed officer.
Shed officer immediately asked to place a rubber mat on the gap, and informed
about the situation to Engineering officer.
5205 Rajeev VR
Feedback Mr. Babulal Nayak, one of our FOs was doing his duty as Loading Tallyman. He
had gone up to the boom to check the loading pattern, when he noticed a gap in the
checker plate platform. He immediately brought it to the notice of Shed officer.
Shed officer immediately asked to place a rubber mat on the gap, and informed
about the situation to Engineering officer. It was noticed that due to wear of the
plate a gap has been generated in the plate. The same was not noticed by anybody
since unloading labour used to keep rubber mat on the plate. It could only be
noticed while rubber mat was removed to clean the area. The checker plate was
repaired on next Sunday and loading/unloading labour instructed to tell any
abnormality to shed/engineering officer to correct on time and not to hide the
unsafe condition.
115
0
50 Details of Fire
0
Feedback wear of platform
70 Product Loss
0
80 Loss Details
0
Checking of structure to be done 1 Inspection to be strengthened. 11-Dec-2014
regularly.
1. Platform repaired and all other platform inspected for 11-Dec-2014
any unsafe condition
EXPERT COMMENTS:

1) Walk around management to be strengthened.
2) Proper platforms to be provided at all the points.
3) Such points should reflect in DSA.
116
NEAR MISS NO. 51
Time
Incident Type NEAR
MISS
Occurred At
Question List
Feedback As a practice to check one vehicle during DSA checking, Mr. S.K.Mittal had checked box
lorry RJ 10 G 0356 for vehicle integrity as per our norms, and found that the handbrake
was not operating properly.
5177 s.k.mittal
Feedback As a practice to check one vehicle during DSA checking, Mr. S.K.Mittal had checked box
lorry RJ 10 G 0356 for vehicle integrity as per our norms, and found that the handbrake
was not operating properly. The rear hand brake assembly was kept non functional and
also the air pressure setting to operate the brake was very high.
0
50 Details of Fire
0
Feedback Poor maintenance of vehicle
70 Product Loss
117
0
80 Loss Details
0
Date
1. All safety fittings of vehicle to be regularly 1. system to check the box 10-Dec-
check for proper functioning lorry to be continued 2014
practice of checking of one box lorry during DSA 10-Dec-2014
EXPERT COMMENTS:

1. Box lorry checking to be strengthened.
2. Effective training to be provided to the drivers.
3. Security to be trained regarding physically checking box lorry fittings as per
checklist.
118
NEAR MISS NO. 52
Time
Incident Type NEAR
MISS
Occurred At
Question List
Feedback As a part of DSA checking, Mr. Dhruba was checking condition of adapters in Purging unit.
It was found that one of the adapters connected to vacuum line was having low suction
effect. It was checked immediately and it was found that some dust material had blocked
the passage.
10666 DHRUBAJYOTI DAS
55627 B.S.SANKHLA
5205 RAJEEV VR
Feedback Mr. Dhruba was checking condition of adapters in Purging unit. It was found that one of the
adapters connected to vacuum line was having low suction effect due to some blockage in
the suction hose. During inspection it was found that some dust material had blocked the
passage of hose, Bikaner LPG plant is situated in desert and surrounded by POP industries.
The accumulation of fine dust on equipments and instrument is a common problem.
0
50 Details of Fire
0
119
Feedback Accumulation of dust in suction hose.
70 Product Loss
0
80 Loss Details
0
1. Dust accumulation can also affect the 1. Regular cleaning to be 10-Dec-2014
performance of machine. done.
Regular cleaning being ensure 10-Dec-2014
EXPERT COMMENTS:

1. PMS of equipments to be followed religiously.
2. Performance of equipments to be monitored daily by staff.
120
NEAR MISS NO. 53
Report Submitted KUMAR
By RAJNISH
Time
05.10.201 Region/Refinery NR
FIR No F10140011 FIR Date
4
03.02.201 Location Code 3110
DIR No D10140136 DIR Date
5
Location Salempur
LPG Plant
Incident Type NEAR
MISS
At
Question List
Feedback Box lorry no.HR46B1149 was filled and ready to move from gate no.1 at 0510
hr. the driver of box lorry came down to tell the box lorry no. to security, (without
shut off the engine of box lorry) As soon as he left the box lorry, the box lorry
started to move then immediately he climbed up the box lorry and stopped the
box lorry.
5007 Rajnish Kumar
Feedback Driver left the vehicle without shut off the engine. Hand brakes were not used.
PCVO Crew nil nil nil
50 Details of Fire
nil
Feedback The engine of B/L was not shut off by driver when he left the B/L and hand
brakes was not used.
121
70 Product Loss
nil nil
80 Loss Details
nil
Engine of B/L should be Through safety talk the same were 06-Feb-2015
shut off if driver is not in conveyed to Drivers on 10 Oct,
B/L and hand brakes should 2014 and will cover all the
be used. drivers.
All the drivers will cover through the safety talks. 20-Feb-2015
EXPERT COMMENTS:
Note: Details like three day safety training dates and last refresher course dates
not available for analysis.
1. Training effectiveness of drivers to be ensured.
2. Root cause is Ineffective training.
122
NEAR MISS NO. 54
Incident Reporting System (HSSE) HIMANSHU JAIN
Name By
07.10.2014
Date Time
Incident NEAR
Type MISS
Occurred
At
Question List
Feedback A non-working pole light was needed to be replaced by new one. Permit had been
issued for working at height after site inspection for carrying out the job.
Electrician, properly equipped with PPE was about to climb on the ladder, however
he didn’t properly fixed his safety belt’s hook on the ladder. Immediately we have
stopped him and directed to properly fix his hook on the ladder. This could have led
to serious incident if electrician slipped off his leg or unbalance his body at height
while climbing.
10444 Himanshu Jain
4279 Madan Lal
Feedback We have investigated the whole incident and following has been found :- 1)
Contractor has been provided a job to replace the non-working pole light with new
ones 2) Permit has been issued to Contractor for working at Height. 3) All Safety
precautions and SOP has been followed by Contractor. 4) Minor Negligence by
electrician while climbing upstairs could have led to Accident 5) Same has been
observed by Safety officer and the risk has been averted 6) Contractor has be
en instructed to follow all Safety guidelines and SOP .
NIL NIL NIL
50 Details of Fire
123
0
Feedback Negligence by Contractor in following safety measures
70 Product Loss
0 0
80 Loss Details
0
Date
To ensure the contractor should To ensure the contractor should 29-Nov-
follow all safety measures follow all safety measures 2014
EXPERT COMMENTS:

1. Safety training to be imparted to the staff.
2. Use of PPE to be ensured.
124
NEAR MISS NO. 55
Incident Reporting System (HSSE) SHRI CHAND
Name By
01.10.2014
Date Time
Location Udaipur LPG Plant
Incident NEAR
Type MISS
Occurred
At
Question List
Feedback During surprise night inspection, off-shift fire drill was conducted at Udaipur LPG Plant.
During the drill one security guard operated nearest available 10Kg DCP fire extinguisher
of TL No. GJ12Z9790 (M.R. Shah Transport). When the security guard hit the plunger of
the fire extinguisher to operate it, the cap of the fire ex. broke with a loud sound and the
broken cap along with co2 cartridge had blown away. The cap of the extinguisher was
sheared off from the round corner leaving the threaded portion of the cap at its original
position.
10142 Shri Chand
Feedback The details of the failed fire extinguisher are as under : Make: HITESH, SR No.2661,Year
of Mfg:2012,powder condition :OK Sr No. of Co2 Cartridge:4015 Wt of cap:325gm
Nil
50 Details of Fire
NIL
Feedback Failure of material in shear strength (non-standard equipment)
125
70 Product Loss
NIL
80 Loss Details
NIL
Certificates to be checked prior to Regular checking of certificates 17-Nov-2014
operate the 3rd party fire extinguishers. of fire extinguishers of packed
trucks & bulk lorries.
EXPERT COMMENTS:

1. Genuineness of fire extinguishers (internal/external) to be ensured.
2. Only BIS certified fire-ex to be allowed inside plant area.
3. Upkeep of fire-ex to be ensured as per OISD-142 and IS 2190.
4. Quarterly test record of fire-ex (third party) to be checked.
126
NEAR MISS NO. 56
Incident Reporting System (HSSE) ABHISHEK YADAV
Name By
08.10.2014
Date Time
Incident NEAR
Type MISS
Incident LPG PKD LORRY IN TRANSIT Root Cause Over Speeding
Occurred
At
Question List
Feedback In Packed/Tank lorry parking area ,driver of truck no.HR58A2884,Shri Balaji
Transport was driving truck at very high speed (approx.30 to 40 KM/Hr).Also
whiling taking turn speed of truck was high, fortunately there was no other truck
/persons on turn otherwise it can lead accident.
9358
Feedback In Packed/Tank lorry parking area ,driver of truck no.HR58A2884,Shri Balaji
Transport was driving truck at very high speed (approx.30 to 40 KM/Hr).Also
whiling taking turn speed of truck was high, fortunately there was no other truck
/persons on turn otherwise it can lead accident.
PCVO Crew NA
50 Details of Fire
NA
127
Feedback Basic cause for accident was over speeding in plant area.
70 Product Loss
NA
80 Loss Details
Direct Loss NA
Date
Random check of truck Training was provided to drivers and 30-Nov-
movement in parking area. security guard regarding the speed limit 2014
in
plant.
EXPERT COMMENTS:

1) Strict monitoring of speed of box lorries to be done by security staff and
officers.
2) Boards of speed limit inside plant to be placed at all the necessary places.
3) Root cause is ineffective training.
128
NEAR MISS NO. 57
Name By
10.10.2014
Date Time
Incident NEAR
Type MISS
Occurred
At
Question List
Feedback Filling operation was going on. Filling shed officer observed that bonding wire of
LPG hose of Filling Machine no. 17 was broken. He stopped the filling operation
and arranged for rectification of the same.
9182 jayant kumar
20176 rajeev kannojiya
Feedback It was observed that the lugs of the bonding wire were not properly crimped, hence
the wire detached from the lugs.
0 0 0
50 Details of Fire
0 0
Feedback Bonding wire of LPG Hose was not connected
70 Product Loss
129
0 0
80 Loss Details
0
Date
All necessary checks to be done All bonding wire to be checked for 23-Oct-
before commencing filling intactness before commencing filling 2014
operations. operations.
EXPERT COMMENTS:

1. All the daily checks related to condition of bonding wire to be ensured
before the start of the shift.
130
NEAR MISS NO. 58
Incident Reporting System (HSSE) RINKY RANA
Name By
11.10.2014
Date Time
Incident NEAR
Type MISS
Occurred
At
Question List
Feedback At 9:30 AM, Safety officer was on DSA round. While making round of loading
shed at around 9:20A.M. , she observed the Soap solution was overflowing out
of tray of a chain conveyor. This chain conveyor was prior to loading boom. The
leakage was so heavy that the soap solution was running out of tray & flowing
on the floor. On making enquiry to soap solution person, matter came that he
open the valve of soap line of this chain conveyor & proceed for other conveyors
soap. Generally he does crack opening of all valves in a round & serially closes
all in same return round, but by mistake in this case the valve was fully opened
by him & he proceeded for other soap trays. Thus the tray filled before estimated
time &started overflowing.
10627 rinky rana
55796 mohd. shameem
Feedback At 9:30 AM, Safety officer was on DSA round. While making round of loading
shed at around 9:20A.M. , she observed the Soap solution was overflowing out
of tray of a chain conveyor. This chain conveyor was prior to loading boom. The
leakage was so heavy that the soap solution was running out of tray & flowing
on the floor. On making enquiry to soap solution person, matter came that he
open the valve of soap line of this chain conveyor & proceed for other conveyors
soap. Generally he does crack opening of all valves in a round & serially closes
all in same return round, but by mistake in this case the valve was fully opened
by him & he proceeded for other soap trays. Thus the tray filled before estimated
time & started overflowing.
131
Others 0 0 0
50 Details of Fire
nil nil
Feedback ignorance by person on sopa duty & tally man
70 Product Loss
LPG (in MT) 0 0
80 Loss Details
Indirect Loss 100
Lack of patience. Open the soap line & fill the tray in hi 30-Nov-2014
s presence only.
Ignorance of tallyman & Before leaving soap line in crack 30-Nov-2014
soap filler & lack of open position, assign any person from
communication. loading shed to look after.
Tally man & soap filler has been given instruction 29-Nov-2014
Tally man & soap filler has been given instruction 29-Nov-2014
EXPERT COMMENTS:

3. Training to be provided to contract labour regarding procedure for putting
soap solution in trays so that there is no spillage.
4. Safety awareness to be improved amongst all.
5. Overflow arrangement to be done.
132
NEAR MISS NO. 59
Report Submitted
Application Name Incident Reporting System (HSSE) SANKALP
By
Time
03.11.201 Region/Refinery NR
FIR No F11140007 FIR Date
4
03.11.201 Location Code 3104
DIR No D11140002 DIR Date
4
Location JAIPUR LPG
PLANT
Incident Type NEAR
MISS
Incident Occurred At OFFICE Root Cause Poor
Housekeeping
Question List
Feedback On Sunday 02nd November 2014, maintenance activity was carried out in plant.
Officer Mr. Shiv Kumar and Rohit Rohilla were present in the plant in office.
Suddenly one contract staff saw snake in the admin block gallery moving slowly.
He immediately shouted snake and informed officers in the admin block. All
officers and labour/security rushed in the gallery and found approx 6 ft black
snake in the gallery. Officer immediately alerted the security and evacuated the
admin block and kept watch on the snake that slowly moved inside the Ladies
Washroom. Officer then kept two guards with sticks outside the admin block (
both front and back) to counter snake in case he escapes from back. Snake
remained inside the washroom .Officer then informed TC and HSSE Officer who
reported to the plant. Snake catcher was called by contractor who then caught the
snake and took it away.
4145 Rajkumar Singh
Feedback 1) From the circumstances it is concluded that the snake could have come inside
the admin from nearby green belt /garden area. 2) It is also possible that snake
could have come inside admin after chasing mouse.
NIL 0 0
133
50 Details of Fire
0 0
Feedback green belt/ garden area in close vicinity of admin block.
70 Product Loss
0 0
80 Loss Details
0
Closure of drains with Jalis to be checked in drains. 06-Nov-2014
Jali.
Waste material to be Waste material to be properly 05-Nov-2014
removed. disposed for clear visibility of areas.
Proper Illumination to be Proper illumination to be checked in 05-Nov-2014
checked. operating areas.
Gum Boots to be made Gum boots to be ensured by labour 06-Nov-2014
available working in housekeeping and
security for night rounds.
Availability of Anti Explore possibility of anti venom 11-Nov-2014
Venom Injections injections at location.
EXPERT COMMENTS:

1. Proper PPE to be ensured while doing work.
2. Proper housekeeping and grass cutting to be ensured.
3. Availability of anti-venom to be ensured.
134
NEAR MISS NO. 60
Application Report
Name Submitted By
Time
Incident Type NEAR
MISS
Incident LOCATION Root Cause Poor housekeeping
Occurred At
Question List
Feedback While walking from car parking towards admin bldg main gate , one drain chamber
cover made of CI material near the canteen doorway was found broken . Though the
depth of the drain chamber is only around 10 cm , the same could have resulted
in tripping or falling of any person whose foot got trapped in it. Hence this is being
reported as near miss. The cover has now been replaced and the pathway is now safe.
Feedback As the drain chamber is in vehicular driveway in front of admin bldg, it seems that the
cover got broken due to some vehicular load. The CI cover has now been replaced with a
MS cover fabricated from plant scrap to ensure no such recurrence in future.
0
50 Details of Fire
0
Feedback Broken Cover of Drain Chamber
70 Product Loss
135
na
80 Loss Details
0
Safety Talk to Housekeeping Staff to be Safety Talk to be 06-Nov-2014
aware about such unsafe conditions during given
their daily jobs.
EXPERT COMMENTS:

1. Walk around management to be followed strongly.
2. The cover of drain should be of proper strength and quality.
3. Housekeeping staff should be made accountable for such a case.
Root cause is Poor Supervision instead of Poor Housekeeping.
136
NEAR MISS NO. 61
Report Submitted DEEPMALYA
By DATTA
Time
Incident Type NEAR
MISS
Question List
Feedback During daily safety round by TC and HSSE Officer, following observation was
made at TL parking area. Tank Lorry nos. UP78CN7779 & GJ6AT0219 found
parked side by side with the rear bumper of UP78CN7779 in fouling line with the
rear bumper of GJ6AT0219 in case movement is made first by GJ6AT0219. As per
security serial nos. this was exactly the case as GJ6AT0219 was due for decantation
first. Hence being reported as near miss. Photographs have been taken for easy
visualization. On enquiry with both the drivers it was understood that UP78CN7779
had parked later than GJ6AT0219 and had not taken due care while parking though
helper was available with the vehicle. The unsafe condition has been taken care of
by changing the parking position of the vehicle UP78CN7779 under security watch.
1 WP_20141105_003.jpg image/pjpeg 0.37 LPG_TeamMember
2 WP_20141105_007.jpg image/pjpeg 0.29 LPG_TeamMember
4060 PUNEESH KR SOTI
Feedback On enquiry with both the drivers it was understood that UP78CN7779 had parked
later than GJ6AT0219 and had not taken due care while parking though helper was
available with the vehicle. The unsafe condition has been taken care of by changing
the parking position of the vehicle UP78CN7779 under security watch.
137
0 0 0
50 Details of Fire
0 NA
Feedback DRIVER NEGLIGENCE / OVER CONFIDENCE OF DRIVER
70 Product Loss
0 NA
80 Loss Details
0
Sensitize drivers on need of Safety Talk to be delivered at TL 24-Nov-2014
correct parking positions. parking to all available drivers.
EXPERT COMMENTS:

1. Root cause is poor supervision instead of negligence.
2. TL should not be allowed to be parked back to back.
3. Proper ear marking to be done for vehicle placement.
4. Dish end of vehicle is not supposed to face towards the dish end of other vehicle.
5. Proper security supervision while parking tank lorries should be done.
138
NEAR MISS NO. 62
Incident Reporting System (HSSE) ASHISH KUDOPA
Name By
05.11.2014
Date Time
Incident NEAR
Type MISS
Occurred
At
Question List
Feedback The incident was happened at high mast tower near fire water pump house. The
High mast tower is having 16 no of lights. The lights are holding with the help of
two no. of metal ropes. Today in a sudden one of the metal ropes was broken out
and the lights are hanging with another metal rope. Immediately electrician isolated
the high mast tower from the MCC panel, and the area demarcation was done
around the high mast tower area.
10186 Ankur Maloo
9473 Ashish Kudopa
Feedback During Investigation we fund that the rope was corroded at joint of lights and
tower, due to this the rope was broken out and the light was hanging by one rope on
the high mass tower in the plant.
Employee 0 0 0
50 Details of Fire
0 0
139
Feedback corrsion on the rope
70 Product Loss
LPG (in MT) 0 0
80 Loss Details
Direct Loss 0
During testing wire rope joint have Done during the inspection 27-May-2015
to be checked properly. of safety audit at plant.
Testing and repairing job done for high mass tower at plant. 12-Oct-2015
EXPERT COMMENTS:

1. Checking and testing of high mast rope to be ensured as per schedule.
140
NEAR MISS NO. 63
RAMESH
Incident Reporting System (HSSE) CHAND
Name By
DINESH
Time
Plant
Incident LOCATION Root Cause Poor
Occurred At Maintenance
Question List
Feedback The isolation valve of TSV no. 12 on bullet no. 6 liquid line was found
improperly locked as the locking chain was loose and despite locked condition,
valve could be easily operated for opening/closing. The condition is unsafe and
thus categorized as near miss. The condition was rectified immediately by
replacing the locking chain with a shorter one to prevent unauthorized
operation of the isolation valve of TSV.
55856 Ramesh Chand Dinesh
9107 Deepmalya Datta
Feedback The locking chain used was longer than required and was found to be tied in
loop to shorten the length, however , the loop got opened easily when tried to
pull with hands. The chain was then replaced with a shorter one and proper
locking was ensured.
0 0 0
50 Details of Fire
0 na
141
Feedback Locking arrangement not proper.
70 Product Loss
LPG (in MT) 0 na
80 Loss Details
Direct Loss na
One time checking of locking One time checking to 07-Nov-2014
arrangement of Isolation valves of be done and proper
TSV's/SRV's. locking ensured.
EXPERT COMMENTS:

1. Sealing procedure for TSV should be adequate.
2. Person sealing the TSV should be aware of the sealing procedure.
3. Proper sealing arrangement to be used as per standards.
4. Regular inspection to be carried out by Process operator.
5. After annual inspection, TSV to be inspected by Engineering Officer.
142
NEAR MISS NO. 64
Name By
11.11.2014
Date Time
Incident NEAR
Type MISS
Occurred
At
Question List
Feedback During daily round of plant, one loose stone slab was observed on the access
pathway for double hydrant point no. 17 in TLD area. The pathway is made of red
stone slabs laid side by side. The loose stone could have resulted in tripping,
falling or injury of plant personnel during accessing the double hydrant through the
pathway in case of emergency , hence being reported as near miss. The condition
has been rectified immediately and pathway is now safe for access.
Feedback The soil below the stone had settled down substantially causing the stone to
become loose. Compaction and leveling of the soil was done and the condition was
rectified.
0 0 0
50 Details of Fire
0 na
Feedback Loose Stone Slab on pathway
143
70 Product Loss
0 na
80 Loss Details
0
All pathways for accessing FF All pathways to be checked on 24-Nov-2014
systems to be checked on one one time basis and rectification
time basis. to be done as required.
EXPERT COMMENTS:

1. Monthly checking of double hydrants to be carried out as per PMS.
Pathways to be monitored.
144
NEAR MISS NO. 65
Application ARCHANA
Incident Reporting System (HSSE) Report Submitted By
Name MAHAUR
Location HISSAR LPG
PLANT
Incident Type NEAR
MISS
Occurred At
Question List
Feedback While TC was on round of the plant, he observed a broken neutral wire of 11 kVA
line running besides the boundary wall of packed lorry parking area.
4059 Surinder Dogra
10511 Sukirti Gupta
Feedback During investigation it was found that the wire could have been broken by the
monkeys. As the neutral wire was found broken, there was a cut off of earthing. The
broken wire could have touched the fencing wire of the boundary wall and shorting
could have taken place which was dangerous as packed lorries were parked in the
area.
0 0 0
50 Details of Fire
0 0
Feedback NA
70 Product Loss
145
0 0
80 Loss Details
0
Cut off of earthing is immensely The broken wire to be fixed, 13-Nov-2014
dangerous and to be taken care of such things to be observed in
while doing DSA. DSA.
Broken cable fixed, electrician ordered to keep regular monitoring 14-Nov-2014
& officers to look up such point during DSA
EXPERT COMMENTS:

1. Walk around management to be done strictly.
2. Schedule for observing the health of neutral of HT line to be prepared and
followed.
146
NEAR MISS NO. 66
Incident Reporting System (HSSE) RAMPRIT
Name By
16.11.2014
Date Time
Incident NEAR
Type MISS
Incident OTHERS Root Cause Third party fault
Occurred
At
Question List
Feedback The plant was under maintenance on 16.11.2014, Sunday. Huge Flames arising from outside
the boundary walls were noticed by security guards at 1330 hrs. The Plant was manned by
three nos. security guards, Sh. Pankaj Singh (Management Trainee) two skilled contract
labor and two number of unskilled contract labours. One of the guards immediately reached
to the site and found that fire has already covered a large area due to presence of dry grass
just outside the main boundary wall in the south direction of the plant. Coincidently the
wind direction was also such that the flames were directed towards the bullet area.
Immediately Fire Hoses were connected to reach to the farthest end of the wall for fire
fighting, hydrants were operated and jet of water was sprayed to the area under fire.
Simultaneously the Dry grass around the affected area was cooled to stop the spread of fire.
It was difficult to judge the origin of fire from the inside of the wall and only flames were
visible so Sh. Pankaj Singh climbed the nearest watch tower to direct the hose handling
team and point the water spray in a proper direction. The team was successful in
extinguishing the fire by 2:30 pm under the leadership of our management trainee Sh.
Pankaj Singh who had undergone three weeks intensive ops course and Hands on Fire
fighting training in Sept 2014. The remaining area of dry grass was sprinkled with water as
precautionary measure. Later one security guard was sent for inspection of the area outside
the boundary wall to look for any unsafe conditions. The wild dry grass outside the plant
along the perimeter the boundary wall were cut and cleared. The wild grass inside the Plant
has been already been cut and cleared. The fire broke out because of burning Bidi thrown by
a villager in the dry grass outside the Boundary wall. Security guards were advised to be
more vigilant and enhance the patrolling of the plant.
20151 Pankaj Singh
147
Feedback The plant was under maintenance on 16.11.2014, Sunday. Huge Flames arising from outside
the boundary walls were noticed by security guards at 1330 hrs. The Plant was manned by
three nos. security guards, Sh. Pankaj Singh (Management Trainee) two skilled contract
labor and two nos unskilled contract Labours . One of the guards immediately reached to the
site and found that fire has already covered a large area due to presence of dry grass just
outside the main boundary wall in the south direction of the plant. Coincidently the wind
direction was also such that the flames were directed towards the bullet area. Immediately
Fire Hoses were connected to reach to the farthest end of the wall for fire fighting, hydrants
were operated and jet of water was sprayed to the area under fire. Simultaneously the Dry
grass around the affected area was cooled to stop the spread of fire. It was difficult to judge
the origin of fire from the inside of the wall and only flames were visible so Sh. Pankaj
Singh climbed the nearest watch tower to direct the hose handling team and point the water
spray in a proper direction. The team was successful in extinguishing the fire by 2:30 pm
under the leadership of our management trainee Sh. Pankaj Singh who had undergone three
weeks intensive ops course and Hands on Fire fighting training in Sept 2014. The remaining
area of dry grass was sprinkled with water as precautionary measure. Later one security
guard was sent for inspection of the area outside the boundary wall to look for any unsafe
conditions. The wild dry grass outside the plant along the perimeter the boundary wall were
cut and cleared. The wild grass inside the Plant has been already been cut and cleared. The
fire broke out because of burning Bidi thrown by a villager in the dry grass outside the
Boundary wall. Security guards were advised to be more vigilant and enhance the patrolling
of the plant.

none 0 0
50 Details of Fire
60 Burning Bidi
Feedback Dry Wild Grass out side the boundary wall.
70 Product Loss
0 nil product loss
80 Loss Details
0
Date
148
There should not be Dry Grass in Green Belt Dry Grass in the Plant to be cut 29-Nov-
& License area & removed 2014
Patroling in Green Belt to be enhanced Security to be sensitized 29-Nov-
2014
EXPERT COMMENTS:

1. Walk around management around plant boundary to be strengthened.
2. Safety clinics to be conducted for persons residing near plant premises.
149
NEAR MISS NO. 67
Application Report
Incident Reporting System (HSSE) ARCHANA MAHAUR
Name Submitted By
Time
Location HISSAR LPG PLANT
Incident Type NEAR
MISS
Occurred At
Question List
Feedback During entry of tank lorries through gate no. 2, the end portion of the chassis of the tank
lorry got entangled with the gate. The gate moved ahead with the tank lorry, which was
noticed by the conductor of the lorry as well as the security guard. The tank lorry was
immediately halted and the angle of the gate which got entangled was removed. Had the tank
lorry moved ahead a little further, it could have sheared off from the back side giving all
possible chances to leakage. Spark generation was also possible because of the metal to
metal contact.
4059 Surinder Dogra
10511 Sukirti Gupta
Feedback After receiving the information, Mr. Surinder Dogra, TC went to the site to enquire about the
incident. He was informed by the security guard at gate no. 2 that during the entry of that
tank lorry the locking of one portion of the gate was not proper and due to slight wind
current the gate flew forward and got entangled with the lorry. The conductor had noticed
the incident and immediately shouted to stop the vehicle. The tank lorry was also checked by
TC for any damages but found none.
0 0 0
50 Details of Fire
150
0 0
Feedback Negligience of security guard for not checking the locking of the gate properly
70 Product Loss
0 0
80 Loss Details
0
Date
During such vehicular movements, gate Security guards to be informed about 27-Nov-
lockings should be firm the 2014
same and to remain alert
Presence of the conductor proved the Follow up to be done for presence of 30-Nov-
significance and importance of the same the conductors with bulk trucks 2014
All the security guards have been informed to lock the gate 01-Dec-2014
properly & be alert
Follow up is being done for presence of second crew with TT' 01-Dec-2014
s
EXPERT COMMENTS:

2. Locking system of gates should be proper.
151
NEAR MISS NO. 68
Application Report DEEPMALYA
Name Submitted By DATTA
Time
Incident Type NEAR
MISS
Occurred At
Question List
Feedback Six tank lorries taken for unloading in 1st shift and TL no. UP17T6501 of M/s
Shree Rama Roadways was placed at Bay No.4. After connecting the unloading
arms, TL operator followed SOP and after ensuring integrity in all respects
operated the valve handles of the Internal EFCV valve for starting decantation.
However, as soon as he opened the valve, he observed minor leakage from the
valve and immediate icing occurring near the operating lever. He shut off all the
valves of the TL and the bay and called production and planning officer to the
gantry for further action. As the condition of even minor leakage from internal
EFCV valve is highly unsafe hence it was reported as near miss.
4060 PUNEESH KR. SOTI
Feedback The details of the Internal EFCV valve is as below FISHER Internal Valve EPM
Chennai Ltd. India S.No. LP15463 DATE: 30.01.2014 CCE REF NO. PV(M) -
789 CLOSING FLOW - 150 GPM - PROPANE/LPG Test Certificate for the
Valve from manufactured is enclosed as attachment . The valve was fitted in the
Tank Lorry in March 2014 and online testing certificate issued by Safety &
Quality Inspection Services under Rule 43. Test Cert No. PV(R)
55/CPS54371/43/HN/286 dated 11.03.2014. Competent Person Mr. SK
Bhattacharya , Ref No. - PV(R)-255/CPS54371-1 The PESO License for Tank
Lorry, license no. S59280 is valid till 31.03.2016. After going through the
available documents, it appears that the minor leakage is due to some fault of the
valve itself. Remarks have been put on the Tank Lorry checklist released by the
location apprising the loading location of the leakage from the EFCV and that
152
the tank lorry should be loaded only after necessary rectification. The transporter
Mr. Naresh Kumar was also apprised of the findings and he submitted the test
certificates for the valves fitted in the tank lorry from the manufacturer.
1 tc fisher 2inch.pdf application/pdf 2.50 LPG_TeamMember
0 0 0
50 Details of Fire
0 NA
Feedback LEAKAGE FROM EFCV
70 Product Loss
LPG (in MT) 0 NO LEAKAGE
80 Loss Details
0
All technical details to be collected fo To be ensured 23-Jan-2015
r any such recurrence is observed in any
other tank lorry.
EXPERT COMMENTS:

1. Manufacturer & testing party reports to be cross verified for quality/standard
of EFCV valves.
153
NEAR MISS NO. 69
TEJESHWAR RAJ
Time
Incident Type NEAR
MISS
Occurred At
Question List
Feedback In 1st shift, Sh. Tejeshwar Raj was involved in some maintenance related work at 19kg
SQC point at around 08:00AM. The loading point of commercial cylinders was hardly
10m away from the SQC point. The contract labours were loading the commercial
cylinders to box lorry. It was found that the surface on which rubber mat was placed for
handling of cylinders got tilted when a contract labour tried to stand on it. He was about to
topple over but saved himself by balancing himself. He did not suffer any injury.
9076 Praveen Yadav
11195 Tejeshwar Raj
55807 Suraj Bhan
Feedback In Piyala LPG plant, there is a manual filling arrangement for commercial cylinders i.e.
5/19/35/47.5kg and having separate loading point for the same. The iron grating has been
provided at loading point to extend the length of loading platform and it was covered with
the rubber mat. The central area of the iron grating was found deteriorated due to rusting.
This area faces maximum weight of commercial cylinders while loading as compare to
other area. As it was covered with the rubber mat it did not come in to notice earlier.
Immediately after witnessing the condition, the loading activity was stopped and that
deteriorated portion was replaced by the new iron grating. The loading activity was
resumed at 9:15 AM.
Others 0 0 0
154
50 Details of Fire
0 NA
Feedback no accident
70 Product Loss
Other Products (in KL) 0 NA
80 Loss Details
Indirect Loss 0
Date
inspection schedule for all iron gratings replacement of deteriorated part 25-Dec-
provided in the premises of iron gratings 2014
EXPERT COMMENTS:

1. Observation like corrosion on Iron grating to be come in walk around
management & safety meeting.
2. Locations need to be make inspection schedule for Iron grating in plant.
155
NEAR MISS NO. 70
Application Report
Name Submitted By
Time
Incident Type NEAR
MISS
Occurred At
Question List
Feedback During the TLD decantation process on 21.12.2014(Sunday), the second shift of tank lorry
was under decantation. At around 1305 hours, tank lorry gantry operator called planning
officer and production officer to the gantry communicating that some minor leakage is
taking place from liquid unloading arm of Bay No.5. It was immediately communicated
by both the officers to stop the decantation in the affected bay no. 5. On reaching the site,
it was observed that some minor leakage had happened from first swivel joint of the liquid
unloading arm from tank lorry side. The affected joint had some icing on it. The affected
unloading arm was shutdown for investigating the cause of the leakage.
4060 PUNEESH SOTI
8702 MANJU GAUR
Feedback Keeping in view that even minor leakage from swivel joint of tank lorry unloading arm is
a potential unsafe condition, the joint was inspected thoroughly by the team members and
it was found that the sealant ring was deteriorated causing the minor leakage. As the spare
part was not readily available, the bay was taken back in operation only after replacing the
sealant ring and O-rings after procuring them from OEM. Make of Unloading arm -
Technika; Year of Commissioning - May 2013.
0 0 0
50 Details of Fire
156
0 NA
Feedback DETERIORATED TEFLON SEALANT RING
70 Product Loss
0 NA
80 Loss Details
0
Date
Spare part kits to be kept in reserve for Spares to be maintained from 02-Feb-
unloading arms. OEM Technika 2015
EXPERT COMMENTS:
1. Normally swivel joint does not fail after 1.5 years but this case it has
happened. Proper analysis to be carried out by the location in consultation
with OEM for quality/lubrication/strength/alignment of swivel joint.
157
NEAR MISS NO. 71
TEJESHWAR RAJ
Time
Incident Type NEAR
MISS
Occurred At
Question List
Feedback In 1st shift operation of Shed-C, the cylinders were in use for filling purpose from
the empty cylinders stock that has been stocked in 2nd shift of 28.12.2014.
Suddenly a huge leakage has been observed at Carousel. While checking the
cylinder, it is found that the SC valve of that cylinder is loose. It has been tightened
by hand immediately and the cylinder was shifted to Valve change machine for
proper tightening of valve as per prescribed torque.
11195 tejeshwar raj
9076 praveen yadav
55975 vinod garg
Feedback The SC valve of that particular cylinder was loose. The cylinder could have
detected at de-capping point by the manpower deployed at de-capping position if
the delrin cap were fixed to the valve but the same was not fixed to the valve.
Immediately after observing the leakage, the labour positioned at introduction point
had disconnected the filling gun of Carousel. The SC valve was tightened by labour
with the hand immediately to avoid any major leakage from the cylinder and t
he cylinder was shifted to the VCM for proper tightening.
Others 0 0 0
50 Details of Fire
158
0 0
Feedback The unloading labour is not educated to detect such cylinders.
70 Product Loss
0 0
80 Loss Details
0
Date
Imparting education to all contract labour to Imparting training to all 31-Jan-
detect such cylinders having valve contract labour 2015
s with loose thread
EXPERT COMMENTS:
1. PMS of online VCM and manual VCM at PT shed to be followed strictly.

2. Some interlocking arrangement should be provided in online VCM such that
sealing bell will lift only when required SC valve threads are tightened.
3. The operator's negligence during valve changing at VCM.
4. After valve change when that cylinder is taken online that time it was also
not checked.
5. During loading of that cylinder it is not observed by tallyman & loading
labor.
6. There is probability of malpractice at market from which cylinder was
received.
159
NEAR MISS NO. 72
Location LONI LPG
PLANT
Incident Occurred At OTHERS Root Cause Poor
Maintenance
Question List
Feedback During the ISA 2014-15 of Loni LPG Plant, the ISA team has recommended to clean fire
water tanks as per schedule In view of above ISA recommendation, we had started the job
of water tank cleaning vide work permit no.HP-14-3114-0010. After decanting the water
tank, man holes of the water tank were opened to assess the internal condition of water tank
structure. During visual inspection, it was found that roof support as well as structure
/trusses of tank have sunk and fallen down to the bottom of tank. Roof sheet is currently
held by weld joints with side walls. As a result, there is depression in roof sheet & it needs
to be lifted & If a person goes on roof of water tank for visual inspection and roof support
as well as structure /trusses of tank have sunk and fallen down to the bottom of tank and
roof sheet is currently held by weld joints with side walls so there might be chances to fall
down of roof sheet with the person. Also there is heavy corrosion on roof sheet.
9358 Abhishek Yadav
Feedback During the ISA 2014-15 of Loni LPG Plant, the ISA team has recommended to clean fire
water tanks as per schedule In viewof above ISA recommendation, we had started the job
of water tank cleaning vide work permit no.HP-14-3114-0010 . After
decanting the water tank, man holes of the water tank were opened to assess the internal
condition of water tank structure. During visual inspection, it was found that roof support
as well as structure /trusses of tank have sunk and fallen down to the bottom of tank. Roof
sheet is currently held by weld joints with side walls. As a result, there is depression in roof
sheet & it needs to be lifted & If a person goes on roof of water tank for visual inspection
and roof support as well as structure /trusses of tank have sunk and fallen down to the
bottom of tank and roof sheet is currently held by weld joints with side walls so there might
be chances to fall down of roof sheet with the person . Also there is heavy corrosion on
roof sheet.
160
Employee NIL NIL NIL
50 Details of Fire
NA
Feedback Poor maintenace of fire water tank.
70 Product Loss
Other Products (in MT) NIL
80 Loss Details
Direct Loss NIL
It is must to cleaning of fire water tank as Started to cleaning & 02-Feb-2015
per schedule, i.e. every three year, maintenance of fire water
maintenance and visual inspection. tank as per schedule
EXPERT COMMENTS:

1. Maintenance schedule to be prepared and implemented for above ground fire
water tanks.
161
NEAR MISS NO. 73

Application SONVANI
Name ARUN KUMAR
Location Bhatinda LPG
Plant
Occurred At
Question List
Feedback At gate no.2, cylinder counting platform lorry no. PB0419708 of M/s ANMOL
TRANSPORT driver name Inderpal Singh mob no.9814605122 reported with fallen down
cylinders at lorry back side and cleaner started correcting same from counting platform
itself by moving into the truck dalla . The same was immediately pointed out by the
Security Supervisor and said vehicle is parked at parking area for corrective action.
Security supervisor informed the lorry driver that cylinders arrangement supposed to be
corrected at distributor’s premises and before reaching at plant with proper stacking
arrangement in lorry. The message was also send to planning to find out the reason for the
said lorry and other lorries also for proper arrangement of cylinder stacking in the truck.
55676 SANJAY KUMAR
Feedback Planning officer has been advised to check details in all lorries with such related issue
related to negligence / awareness and ensure necessary modification/training if required to
avoid such issues. In order to take immediate corrective action driver along with security
supervisor has been asked to discuss this problem to all the packed lorry drivers and share
among each other to avoid the same and create awareness. At planning side we have taken
immediate corrective action and find out that dalla of the packed lorry at the end was not
properly supported hence the near miss happen and during checking of the other lorries it
has been found out that one other lorry also not properly set for cylinder stacking and same
lorry sent for corrective action for placing of the cylinders as per stacking process. We
have discussed the other drivers also and found that many times casually they are not
properly providing the support at end due to which while moving the lorry cylinders are
also not firmly positioned resulting falling of one or two cylinders at packed lorry.
We have analyzed all lorries and taken corrective action and instructed all drivers to ensure
162
firmly fixing of the cylinders in the lorry with proper support. As to create more awareness
the defaulter drivers also involve to discuss the issue with all the drivers and to submit the
details of discussion to Planning officer and after a week all drivers covered again for the
awareness. The near miss occurred due to negligence while loading the cylinders at
distributor’s godown and not fixing proper support while moving and over and above not
corrective the details even while moving into the plant premises. Details training and
awareness programm conducted for Security guards and Packed lorry driver in Jan’15
month to avoid such incidents.
Others 0 0 0
50 Details of Fire
0 0
Feedback Drivers are not properly provoding the support at end of the lorry for stacking
70 Product Loss
Other Products (in MT) 0 NO LOSS
80 Loss Details
Indirect Loss 0
Date
STACKING OF CYLINDERS TO BE REGULAR CHECKING OF 05-Feb-
PROPER EACH LORRY 2015
CREATE AWARENESS AMONG THE REGULAR TRAINING NEED 05-Feb-
DRIVER TO PROVIDED 2015
163
EXPERT COMMENTS:

1. During induction of box lorry and during quarterly box lorry checking,
wooden planks and their health need to be ensured at all the three tiers of
cylinder stack.
2. All vehicles to be checked for proper placement of cylinders with stoppers to
avoid falling of cylinder in route.
3. Repositioning of cylinders in trucks from top should be avoided.
4. In parking area, designated place to be defined along with placing of rubber
mat on the ground for such vehicles.
164
NEAR MISS NO. 74
Application
Incident Reporting System (HSSE) Report Submitted By SARITA FIRMAL
Name
30.12.2014
Date
Incident NEAR MISS
Type
Occurred At
Question List
Feedback On 30.12.2014 around 11:45 am underground tank cleaning work was going on. During
the cleaning process one contract labour narrow escaped from colliding on the floor due to
slippery tank floor.
9129 sarita firmal
Feedback Tank floor became slippery due to sludge accumulation.
0 0 0
50 Details of Fire
nil 0
Feedback sludge accumulation due to non cleaning of tank since long time.
70 Product Loss
0 0
80 Loss Details
165
0
timely cleaning of tank to be ensured. tank cleaning as per schedule 30-Dec-2014
EXPERT COMMENTS:

1. Six monthly cleaning of underground water tank cleaning not followed.
2. Work Permit not followed in spirit.
3. Non-use of PPEs (gum boots and non skid suits).
4. Life rope support was not provided to avoid skidding.
5. Root Cause: Non-adherence of PMS for tank cleaning.
166
NEAR MISS NO. 75
Name By MAHAUR
Time
Location HISSAR LPG
PLANT
Occurred At
Question List
Feedback While on round inside the plant, TC Hisar observed that in the immediate
vicinity of the carousal periphery the floor is of concrete cement. Wherein there
is mastic flooring all over the filling and filled shed, immediate area around the
carousal is devoid of it. Since sometimes it is required to remove cylinders from
the carousal, it is highly unsafe if there is no mastic present near the carousal.
55291 Tarsem Chand Ragho
Feedback During the investigation it was found that immediately around the periphery of
the carousal the floor is of concrete cement instead of mastic. It is such, since
the commissioning of electronic carousal. The cemented portion is around half
meter wide. As sometimes it is required to remove the cylinders from the
carousal it is highly unsafe to remove these cylinders and keep them on concrete
floor. This may generate spark which is dangerous at the most crucial area of
filling shed.
0
50 Details of Fire
0 0
167
Feedback NA
70 Product Loss
0
80 Loss Details
0
Each and every small As mastic is not possible at 04-Jan-2015
portion of the shed that portion, whole of the
should be covered cemented area will be
with mastic. covered by rubber mats.
Standard Rubber mats have been kept all over the immediate 06-Jan-2015
area around the carousel.
EXPERT COMMENTS:

1. Mastic flooring to be ensured till rail of the carousel.
2. In case of broken mastic flooring, rubber mats to be provided till the mastic is
repaired.
3. SOP is to be followed for cylinder handling.
168
NEAR MISS NO. 76
Report Submitted HIMANSHU
By JAIN
Location Sultanpur LPG
Plant
Incident Type NEAR
MISS
At
Question List
Feedback On 31.12.2014, security was entering Box lorries as per daily schedule. When all
lorries entered through Gate no. 2. Security forgot to close the barrier and it was
remained open for 15 minutes. During that period, one of the helper of lorry was
found entering the Gate – 2 through the barrier side road. It was observed by HSSE
officer – Himanshu Jain while having plant visit. Any incident could have occurred
due to negligence of security guard, we have strictly instructed the Security
supervisor and guards to follow all security and safety measures while performing
duties.
10444 Himanshu Jain
4279 Madan lal
Feedback On 31.12.2014, security was entering Box lorries as per daily schedule. When all
lorries entered through Gate no. 2. Security forgot to close the barrier and it was
remained open for 15 minutes. During that period, one of the helper of lorry was
found entering the Gate – 2 through the barrier side road. It was observed by HSSE
officer – Himanshu Jain while having plant visit. Any incident could have occurred
due to negligence of security guard, we have strictly instructed the Security
supervisor and guards to follow all security and safety measures while performing
duties.
0 0 0
169
50 Details of Fire
0 0
Feedback Negligence by Security in following safety measures
70 Product Loss
0 0
80 Loss Details
0
Negligence from Security To ensure the Security should follow all 15-Jan-2015
guards. safety measures.
EXPERT COMMENTS:

1. It is not a near miss. It is a case of security lapse and unsafe act by security
supervisor.
170
NEAR MISS NO. 77
Name By MAHAUR
Time
Location HISSAR LPG
PLANT
Occurred At
Question List
Feedback On the way from gate no. 1 to staff vehicle parking area, there were some stones
of comparatively large size lying on road. While a staff was driving to the
parking area one of the stones slipped from beneath the tyre and flew to a
certain height. Another staff who was passing by could have been hurt by that
stone but was just missed.
Feedback The parking area was investigated and it was found that it was not properly
cleared after road repair work. After repairing work of parking road, although
site clearance was done but still some large size stones were lying there which
can give rise to some incidents or accidents.
0
50 Details of Fire
0
Feedback NA
70 Product Loss
171
0
80 Loss Details
0
Site clearance after any work is The area will be 12-Jan-2015
mandatory which if neglected may cleared on immediate
lead to incidents/ accidents. basis.
The area has been cleared for any obstacles. 21-Jan-2015
EXPERT COMMENTS:

2. Housekeeping to be maintained at all the times.
172
NEAR MISS NO. 78
SANKALP
Time
Incident Type NEAR
MISS
Occurred At
Question List
Feedback At around 1500 hrs during plant visit TC Jaipur observed HSD minor leak spilled
on speed breaker at gate 2. He then observed packed lorry RJ19G9413 ( M/s Kani
Ram Tak transporter) ahead at security counting tower. The lorry was checked and
found leakage from return line of HSD pipe. The lorry was immediately moved out
of the plant for rectification. The lorry was taken inside plant after proper
maintenance of the return line and checking of return line hose/Oil tank cap /other
fittings by us.
4145 Rajkumar Singh
8663 Sankalp
Feedback During Investigation following was found: 1. return line of HSD tank was found
partially crack
0 0 0
50 Details of Fire
0 0
Feedback Near Miss is caused due to improper maintenance and supervision by driver.
173
70 Product Loss
0 0
80 Loss Details
0
Date
Proper inspection of Lorries to be Strengthening Security 19-Jan-
ensured by Security. Inspection (through Mirror 2015
trolley use etc).
Enrolling drivers to ensure Sensitizing drivers to ensure 20-Jan-
supervision of their lorries during proper fitness of their lorries. 2015
maintenance work.

EXPERT COMMENTS:

1. Quarterly box lorry inspection to be strengthened.
2. Security to be trained for doing proper inspection of box lorries while allowing
them to enter inside plant premises.
3. Effective training to be imparted to the drivers.
174
NEAR MISS NO. 79
Application Report Submitted ANKUR
Name By MALOO
Location Ajmer LPG
Plant
Incident Type NEAR
MISS
Incident LOCATION Root Cause Lack of
Occurred At training
Question List
Feedback The incident happened near carousal in filling shed. There was leakage from
filling gun of filling machine no. 20. The contract technician removed the leaky
gun from filling machine for servicing. As he removed the gun there was
leakage of LPG from the hose after few seconds. Immediately the operator at
tare weight punching pressed the ESD and the contract technician tightly closed
the LPG valve of the filling machine. The LPG leaked was removed by vapor
extraction unit and operation was started after checking the LEL.
10186 Ankur Maloo
Feedback While removing the gun from filling machine the valve behind the filling
machine was not tightly closed by the contract technician. The Gas stop valve of
the machine was also passing because of which there was leakage from the
filling gun. The Gas stop valve was last serviced in Nov during the KOSAN
AMC visit.
0 0 0
50 Details of Fire
Feedback Duration in min. (put "0" in case of no Source of fire
fire)
0
175
Feedback no accident
70 Product Loss
LPG (in MT) 0.02
80 Loss Details
Direct Loss 0.01
Extra precautions should be taken The contract technician 24-Jan-2015
while doing the maintenance jobs training program to be
organized.
EXPERT COMMENTS:

1. PMS schedule of filling guns to be ensured.
176
NEAR MISS NO. 80
SANKALP
Time
DIR No D01150028 21.01.2015
Date
Incident Type NEAR
MISS
Occurred At
Question List
Feedback Surprise Inspection of packed Lorries was carried out on 20.01.2015 and 10 kg
DCP fire-ex was tested, Total 4 nos of fire-ex was operated and one fire-ex failed to
operate of packed Lorry No RJ05GA2720. On operation the CO2 cartridge gas was
expelled from the cap due to improper cap washer.
4145 Rajkumar SIngh
8663 Sankalp
Feedback 1. CO2 gas was expelled from the cap due to improper washer.
0 0 0
50 Details of Fire
0 0
Feedback Improper maintenance of Firex
70 Product Loss
177
0 0
80 Loss Details
0
Strengthening of Inspection of Transporters. Letters for proper 22-Jan-2015
fire-ex by 3rd party. inspection by transporters to be
issued.
Inspection of lorries fire-ex to be Inspections to be increased at 22-Jan-2015
increased. plant.
Fire-ex inspection Camp to be Fire-ex Inspection camps to be 25-Feb-2015
organized every 6 months at plant. organized.
EXPERT COMMENTS:

1. Effective training to be imparted to box lorry driver.
178
NEAR MISS NO. 81
Application Name Incident Reporting System (HSSE) Report Submitted By RINKY RANA
Incident Type NEAR
MISS
Incident Occurred LOCATION Root Cause Poor Maintenance
At
Question List
Feedback Today at 1115 hrs cylinders filling operations were under progress. HSSE officer
Ms. Rinky Rana was on plant round at DPT shed. She observed heavy leakage
from a cylinder which was under filling in a machine of carousal. Operator
working over there, immediately stopped the filling from that particular machine.
After checking of cylinder, it was found that the o-ring was missing in the cylinder
valve, which resulted in heavy leakage of LPG while filling.
7795 Kumar kamlesh
Feedback After making investigation with technician it was observed that, the filling gun
0ring was cut due to which it was causing leakage to the cylinder filling nozzle
while filing some cylinders.
Others 0
50 Details of Fire
0 nil
Feedback Poor maintenance
70 Product Loss
179
LPG (in MT) .002 LPG
80 Loss Details
Direct Loss .002
Routine maintenance to Routine 26-Dec-2015
improve maintenance
Maintenance schedule strictly adhered to. 26-Dec-2015
EXPERT COMMENTS:
1. PMS of filling guns to be followed strictly.

2. Contract labour at introduction and decapping to be sensitized for putting O-
rings in cylinders without O-rings through safety talks.
180
NEAR MISS NO. 82
Application
Incident Reporting System (HSSE) Report Submitted By RINKY RANA
Name
24.01.2015
Date
Incident NEAR
Type MISS
Question List
Feedback During normal filling operation, a cylinder was on filling machine, started leaking
profusely as soon as gun got latched to the cylinder for filling. Its filling was stopped
immediately. After making investigation it was found that, the
o-ring was missing from the valve of that cylinder. When this cylinder was put on
filling due to non-sealing of valve &gun LPG started leaking in between. Manpower at
Capping also missed to segregate the cylinder without o-ring.
7795 Kamlesh Kumar
10627 Rinky Rana
Feedback During normal filling operation, a cylinder was on filling machine, started leaking
profusely as soon as gun got latched to the cylinder for filling. Its filling was stopped
immediately. After making investigation it was found that, the O-ring was missing
from the valve of that cylinder. When this cylinder was put on filling due to non-
sealing of valve &gun LPG started leaking in between. Manpower at decapping also
missed to segregate the cylinder without o-ring. Manpower at decapping was given o-
rings , o-ring inserter & was given instruction to check each & every cylinder for any
missing o-ring after decapping . If he found any o-ring missing cylinder then either
mark it with a red flag or insert a new o-ring, in order to avoid leakage due to o-ring
missing cylinder. Distributor was communicated to check any such events which
results in o-ring missing actions.
nil
181
50 Details of Fire
0 nil
Feedback O-ring missing cylinder came at the Filling machine
70 Product Loss
LPG (in MT) .0002 LPG leaked during filling
80 Loss Details
Direct Loss .0005
Date
Presence of O-ring should be Manpower at capping was given o-rings 24-Jan-
checked before filling a ,o-ring inserter & was given instruction 2015
cylinder. to check each & ever.
Presence of O-ring should be Distributor was communicated to check at 24-Jan-
checked before filling a Godown & market for such actions. 2015
cylinder.
Manpower at decapping was given o-rings, o-ring inserter & to 24-Jan-2015
ld to check cylinder for O ring.
Distributor was communicated to check such actions 24-Jan-2015
EXPERT COMMENTS:
1. Filling guns should not leak even in case of without O-ring cylinders. If
filling gun leaks, then its Oring should be checked/ replaced.
2. Contract labour at decapping and carousel introduction to be sensitized
through safety talks to put O-rings in cylinders without O-ring.
3. A marketwise database over a sample period to be captured for without O-
ring cylinders being received from distributors. Appropriate action/direction to
be issued to those markets from where large number of without O-ring
cylinders is being received at plant.182
NEAR MISS NO. 83
Application
Name
Incident Type NEAR
MISS
Occurred At
Question List
Feedback After checking, our electrician found that the switch was found damage at the
point of contact, which was not very clearly visible. Last month Drill was done in
parking area during which the MCP was broken. At that point of time the new
glass was fitted on MCP, but for any damage it was not checked. Electrician
immediately changed the switch. On operating, it started functioning & emergency
message appeared on Page phone.
10627 Rinky Rana
55798 Lal Singh
Feedback Last month Drill was done in parking area during which the MCP was broken. At
that point of time the new glass was fitted on MCP, but for any damage it was not
checked. Electrician immediately changed the switch. On operating, it started
functioning & emergency message appeared on Page phone.
Others 0
50 Details of Fire
0 0
Feedback nil
183
70 Product Loss
LPG (in MT) 0 nil
80 Loss Details
Indirect Loss 0
MCP should be operated As a rule it was made 31-Jan-2015
immediately after any mandatory to operate MCP
emergency operations like immediately after any
drills etc. emergency operations.
FWPH operator will check MCP after drills in the presence of 31-Jan-2015
HSSE officer
EXPERT COMMENTS:

1. It is not a case of near miss.
184
NEAR MISS NO. 84
Application Report
Incident Reporting System (HSSE) HIMANSHU JAIN
Name Submitted By
Time
Incident Type NEAR
MISS
Occurred At
Question List
Feedback On 10.02.2015, New flex boards has arrived at plant for display, vendor and his labour
were digging holes and developing a appropriate area for fixing the board on earth. During
the visit inside the plant by HSSE officer – Himanshu Jain, it was found that labour was
working in that area and were wearing safety shoes and Helmet. However the board was
kept aside with support on the wall and the “Work in progress” board was also missing
from the area. Wind was blowing with bit high speed, which could have fall the flex board
& would have led to minor incident. Work has been put on hold and strict instructions
have been made to put “Work in Progress” board and Flex to be put on ground. Any
incident could have occurred due to negligence of labour, we have strictly instructed the
Supervisor and labour to follow all safety measures while performing job work.
4279 Madan Lal
10444 Himanshu Jain
Feedback Negligence by Supervisor and Contract Labours in following safety measures
0 0 0
50 Details of Fire
0 0
185
Feedback Negligence by Contract Labours
70 Product Loss
0 0
80 Loss Details
0
To ensure all safety measures to be To ensure all safety measures to be 26-Feb-2015
followed while performing any followed while performing any civil
civil jobs inside licensed area. jobs inside licensed area.
EXPERT COMMENTS:

1. Proper job analysis to be provided on work permit.
186
NEAR MISS NO. 85
Application
Name
Incident LOCATION Root Cause Non follow up of
Occurred At SOP
Question List
Feedback During ongoing hydro testing of bullet on 11.02.2014, our shed officer climbed up the
bullet no-3 to see how the purging operation is being done. When he was coming down the
iron stairs, due to the limited space available to put the feet, his foot fell on the edge of one
of the stairs, due to which he almost slipped but I grabbed the side railing of the stairs and
pulled himself up and balanced. This could have caused some serious injury to him.
56117 SANDEEP KUMAR
9129 SARITA FIRMAL
Feedback During ongoing hydro testing of bullet on 11.02.2014, our shed officer climbed up the
bullet no-3 to see how the purging operation is being done. When he was coming down the
iron stairs, due to the limited space available to put the feet, his foot fell on the edge of one
of the stairs, due to which he almost slipped but I grabbed the side railing of the stairs and
pulled himself up and balanced. This could have caused some serious injury to him.
0 0 0
50 Details of Fire
0 NIL
Feedback wrong method of getting down from stairs.
70 Product Loss
187
0 NIL
80 Loss Details
0
Extra care should be taken Session on safe method of working at 28-Feb-2015
while parking at heights. heights to be covered in training programs
to educate staff.
EXPERT COMMENTS:

1. Step size is not proper.
2. Root Cause should be design fault.
3. Precautionary boards to be displayed (Please use railing while using stairs’,
‘Mind your feet’, etc.)
188
NEAR MISS NO. 86
Application
Name
Incident LOCATION Root Cause Lack of training
Occurred At
Question List
Feedback On 12.02.2015 during testing and setting of SRVs in bullet cluster – 1. When one SRV
was pressurized by nitrogen gas at a pressure of 16.1 kg/cm2 and it was set to pop up,
then just out of curiosity our trainee officer looked directly into the SRV from the top
of it with a minute difference of pop up time. He was immediately asked to remove his
face from the top of it. As soon as he removed his face it popped up which may turn to
a serious incident.
56117 SANDEEP KUMAR
9129 SARITA FIRMAL
Feedback As the officer trainee was witnessing the procedure for the first time & he was not very
aware about the associated hazards of that particular operation so out of curiosity he
directly looked into SRV during testing which may lead to a serious incident.
0 0
50 Details of Fire
0 NIL
Feedback negligence & lack of training
70 Product Loss
189
NIL nil
80 Loss Details
0
Date
New officers should always attend/supervise Proper training about work 16-Feb-
any critical job along with senior permit, SOPs, JSPs to the 2015
experienced officers trainee officers.

EXPERT COMMENTS:

1. Any officer/staff apart from responsible officer/ staff visiting the site of work
should first go through the work permit.
190
NEAR MISS NO. 87
Name By
13.02.2015
Date Time
Incident NEAR
Type MISS
Occurred
At
Question List
Feedback Segregation of defective cylinder (without bottom or bottom of cylinder corroded) just
before filling carousel.
9358 Abhishek Yadav
Feedback Cylinder without bottom reached at tare weight punching point and stuck at the stopper.
The bottom was corroded to such extent that the complete sheet was damaged and broken
but foot ring was intact. The incident could have converted to an accident if it reached to
carousel for filling but the operator present at the tare weight punching was alert and took
out it before filling at carousel.
Employee 0 0 0
50 Details of Fire
na 0
Feedback Suspected mishandling of cylinder at customer premises. Possibly cylinder was kept in a
moist condition.
70 Product Loss
191
Other Products (in MT) 0 0
80 Loss Details
Direct Loss 0
Date
To cover topic during training of Action at plant end & Sales Officer 04-Apr-
Delivery Boys training. 2015
EXPERT COMMENTS:
Note: Complete details of cylinder in near miss reporting is missing for carrying out
proper analysis like test date, HR cylinder, new cylinder, etc.

1. Lack of supervision at distributor end.
2. Loading/unloading process was not proper as per standard practice.
3. Inspection of cylinder not carried out at plant properly.
4. Inspection of bottom of the cylinder is to be further strengthened.
192
NEAR MISS NO. 88
Incident Reporting System (HSSE) ANUSHI GUPTA
Name By
14.02.2015
Date Time
Incident NEAR
Type MISS
Occurred
At
Question List
Feedback While Admin officer was on green belt round along with gunman in the shift to carry
surprise check of watch tower patrolling registers, while climbing watch tower no.1, it was
found that one of the foot step of staircase of watch tower no.1was loosely attached from
one side. As a result, when officer stepped on it, it shook a little and officer lost balance
and suddenly, gripped the railing for support and restored balance. Since watch towers are
at a height and any such recurrence may lead to injury if the officer/gunman etc looses
balance and slips.
9358 Abhishek Yadav
10057 Anushi Gupta
Feedback After the incident of imbalance at the footstep of stairs of watch tower No.1 took place,
the stairs of all the watch towers were checked by investigating team and corrective action
for repairs and maintenance was also taken at watch towers no. 3 and 5 where there three
damaged footsteps of stair were noticed. To completely eliminate the chances of such
occurrence, all stairs were repaired. Security Gunman was also advised to be cautious
while climbing up the stairs and bring any required repairs in infrastructure to the notice
of plant officers immediately.
Employee 0 0 0
50 Details of Fire
193
0 0
Feedback Not being vigilant and cautious while climbing stairs, else it could be identified before.
70 Product Loss
LPG (in MT) 0 0
80 Loss Details
Indirect Loss 0
Look before you leap. To be vigilant and To be vigil and active 18-Feb-
cautious while we walk n climb to ensure self (eyes and ears open). 2015
safety.
To take frequent surprise checks of watch To take frequent surprise 23-Feb-
towers and facility. checks of watch towers 2015
and facility.
Feedback Mechanism from Guards: to check Ensure that even the 23-Feb-
their first hand findings of patrolling. smallest finding of 2015
patrolling is recorded.
EXPERT COMMENTS:

1. Schedule of maintenance and inspection to be made and followed.
2. Root cause is poor maintenance instead of negligence.
194
NEAR MISS NO. 89
Name By
14.02.2015
Date Time
Incident NEAR
Type MISS
Occurred
At
Question List
Feedback Mishandling of uncapped cylinders at loading points of shed.
9358 abhishek Yadav
Feedback At around 13:55 hrs, at the road /ground below loading finger of shed A , it was found
that around 15 nos. of filled cylinders without cap are lying on road one over another.
These cylinders were thrown by loading labour because they were reached for loading
without safety cap & seal.
Others 00 00 00
50 Details of Fire
NA 0
Feedback Non adherence of SOP by Loading Tallyman.
70 Product Loss
195
80 Loss Details
Direct Loss 0
Strengthen monitoring & To strengthen training of operators at 04-Apr-2015
regular behavior & safety loading point regarding safety,
training. counseling to follow SOPs.
EXPERT COMMENTS:
1. Loading operator counseling to be done on regular basis.

2. Unsealed/ uncapped cylinders should not reach at loading point.
3. None of the facility/equipment should be bypassed.
196
NEAR MISS NO. 90
Application Report
Name Submitted By
Time
Incident Type NEAR
MISS
Occurred At
Question List
Feedback Negligence by Bulk Lorry Driver while driving on weighbridge of plant.
9358 Abhishek Yadav
Feedback While weightment of bulk lorry no.HR 55E2044, Eagle Road line, when bulk truck
reached weighbridge and driver applied brakes to stop, it resulted in one front tyre getting
slipped from the weighbridge platform leading to unbalance in bulk lorry.
Others 0 0 0
50 Details of Fire
na 0
Feedback Negligence of driver .
70 Product Loss
197
80 Loss Details
Direct Loss 0
Training need be given Training to provide to drivers to be extra 04-Apr-2015
to Bulk lorry drivers. cautious while taking lorry on to weigh
bridge.
EXPERT COMMENTS:
1. Effective training to be given to bulk lorry drivers.
198
NEAR MISS NO. 91
Application
Name
Occurred At
Question List
Feedback Today on 15.02.2015 around 12:10 pm fire hose testing job was being carried out inside
the licensed area by plant technician with help of contractor staff. When contractor staff
was taking fire hose out from the hose box during that moment hose nozzle kept along
with the fire hose accidently dropped on the foot of contractor staff but as he was wearing
the safety shoes no injury caused to him.
9129 SARITA FIRMAL
55609 DHARAM CHAND
Feedback Due to limited space inside hose box there was very much possibility of dropping of hose
nozzle while taking the fire hose out hence contractor staff should have taken the fire
nozzle first then only needed to remove the fire hose.
0 0 0
50 Details of Fire
NIL NIL
Feedback Negligence, Hurriedness & lack of guidance
70 Product Loss
199
0 nil
80 Loss Details
0
It is necessary to educate Prior to start of any job through 16-Feb-2015
contractor staff about the job contractor staff, it is to be ensured
related guidelines & SOPs. to educate them about all job related
safety.
EXPERT COMMENTS:

1. Proper training to be conducted for fire hose handling.
2. Nozzle should be kept properly in hose box slot.
200
NEAR MISS NO. 92
Application Name Incident Reporting System (HSSE) Report Submitted By SARITA FIRMAL
At
Question List
Feedback On 16.02.2014 around 09:45 am it was observed that entire floor around air receiver
vessel got slippery due to liquid (mixture of oil &water) drained by auto drain valve
system of air receiver vessel. This slippery floor has potential hazard which can be
caused to any unwanted incident.
9129 SARITA FIRMAL
Feedback floor got slippery due to presence of oil in the drained liquid which indicates poor
functioning of air oil separator filter.
0 0 0
50 Details of Fire
0 NIL
Feedback poor equipment maintenance & poor housekeeping.
70 Product Loss
0 nil
80 Loss Details
201
NIL
Equipment maintenance to be Replacement of oil water 21-Feb-2015
ensured as per PMS & housekeeping separator filter & to provide
to be strengthened. proper system to drain the
liquid.
EXPERT COMMENTS:

1. Drain line to be extended to a safe distance.
202
NEAR MISS NO. 93
Report Submitted SACHIN
By KUMAR
Location Code 3114
Location LONI
LPG
PLANT
Incident Occurred At LOCATION
Question List
Feedback Today in DPT repair shed one cylinder was not properly hanged on the hanger of the
overhead conveyor. It was engaged with only one hook (of the three hooks) of the hanger
and it was about to fall.
Feedback Overhead conveyor of repair shed.
Feedback 0
Comment Nil
4 Estimated property loss in INR (lacs) (Enter "0" in case of no property loss or if it is yet
to be estimated)
None NA NA
None NA NA
7 Product Loss
Other Products (in MT) Nil Nil
Comment Nil
203
EXPERT COMMENTS:
DIR is not available.

1. SOPs to be followed strictly.
2. Effective training to be provided to staff/ labour.
3. PMS to be followed strictly.
204
NEAR MISS NO. 94
Report Submitted
Application Name Incident Reporting System (HSSE) ABHISHEK YADAV
By
Time
Incident Type NEAR
MISS
Incident Occurred LOCATION Root Cause Non follow up of SOP
At
Question List
Feedback Uncapped valve leak cylinder found on valve change machine during surprise check
in night.
9358 Abhishek Yadav
Feedback During the night surprise inspection of plant on 17.02.2015 at around 01:05 AM,
one valve leak cylinder was lying horizontally near valve change machine in shed A.
Leakage was very low and there was no accumulation of LPG in shed floor,
also checked LEL by explosive meter & from GMS and found zero. We placed the
cylinder vertically and cap placed on valve. High valve leak cylinder of similar
position can lead to an accident or incident.
Employee 0 0 0
50 Details of Fire
NA 0
Feedback SOP was not followed by Valve Change Operator in which operator has to place cap
on all cylinders.
70 Product Loss
205
80 Loss Details
Direct Loss 0
Conducted safety talk on SOPs of Valve Shed Officer 04-Apr-2015
Change Machine.
EXPERT COMMENTS:

1. All valve leak cylinders to be capped after segregation.
2. Safety talk to be conducted with all staff and contract labour.
206
NEAR MISS NO. 95
Application
Name
Location Roorkee LPG
Plant
Incident Type NEAR
MISS
Occurred At
Question List
Feedback Cable laying job in extended DPT shed was undergoing. A bundle of Electrical cable was
kept in entrance of DPT shed for measurement purpose. The labour went for a while to get
inch tape. Suddenly, other labour that was assisting him crossed the entrance pathway &
walked to DPT shed to get the Chalk for marking. While walking, He was looking at other
end of shed & could not see the bundle of cables. He was about to fell down on DPT shed
floor, but managed to balance his weight.
10627 Rinky Rana
7795 Kamlesh Kumar
Feedback After seeing this safety officer & TC over there called both labour & electrician. They
were told to mark area while doing any job & material upkeep is of utmost importance. If
they would have kept cable away from main pathway it would have prevented the
nearmiss. Other labour was told strictly to be alert & attentive while walking.
Others 0 nil
50 Details of Fire
0 0
207
Feedback NIL
70 Product Loss
LPG (in MT) 0 NIL
80 Loss Details
Indirect Loss 0
We should be very careful while Labour was sensitized about such 28-Feb-
walking incidents 2015
Labour were shown Videos of such incident to sensitize them. 28-Feb-2015
EXPERT COMMENTS:

1. Detailed job analysis to be done while making work permit.
2. All pathways to be kept cleared off all materials and obstacles.
3. Toolbox talks to be conducted in true sense.
208
NEAR MISS NO. 96
Report Submitted RAGHAV
By RAVINDER KUMAR
Time
Incident Type NEAR
MISS
At
Question List
Feedback Mr. Amarjeet Singh (contract labour - electrical) was on duty in the 2nd shift on
22.02.2015. At around 18.00 hrs. he noticed that the machine; Oil Test Bath used
for Temperature Gauge Calibration was in switched on condition. The Oil inside
the machine was hot and was about to come out of it. He immediately switched
off the machine and informed the security guard on duty to reach
MCC/Substation room. The alertness of the persons on duty has averted an
incident.
5178 Ravinder Raghav
Feedback On further investigation it was found that following points are existing which
needs further corrective action: 1) The control supply of the Oil Test Bath used
for Temperature Gauge Calibration was common with the room’s light & exhaust
fan and each facility was given individual switch for On/Off. 2) The Thermostat
of the Oil Test Bath used for Temperature. Gauge Calibration was not in working
condition. 3) During normal working the Oil Test Bath used for Temperature
Gauge Calibration might have been switched on by mistake. All the above
anomalies have been rectified. Now the system is working as per the standard
requirement.
0 0 0
50 Details of Fire
209
0 0
Feedback The thermostat was not working properly
70 Product Loss
0 0
80 Loss Details
0
Regular preventive maintenance of Utility Maintenance 09-Jul-2015
the equipment. Officer
Being Ensured 09-Jul-2015
EXPERT COMMENTS:

1. It is not mention in report that whether work permit was issued or not.
For non routine jobs work permit is to be ensured and it will contain all
safety precautions needed.
2. Training to be provide to staff /labor about do & don’t while working on
machine.
3. Location to ensure a individual switch for On/Off for oil test bath, not a
combined switch with light.
210
NEAR MISS NO. 97
Report Submitted
Application Name Incident Reporting System (HSSE) HIMANSHU JAIN
By
Time
Incident Type NEAR
MISS
At
Question List
Feedback On 18.02.2015, 160KVA DG set was running which is used for power supply of the
plant. A contract labour was doing housekeeping job in DG room and he noticed
minor leakage of Diesel from pipeline. Suddenly he informed the technician about th
e situation and the engine was stopped for the maintenance. Engineering and HSSE
officer was informed about the same and the maintenance of the engine has been
initiated. After opening the diesel line it was found that thread of one end has
been completely worn out and the same need to replaced on urgent basis. If the
leakage could have persisted for long time, it would have accumulated near DG and
could cause risk of Fire. We have strictly instructed the Plant Technician to keep
daily monitoring on the DG working and to increase the frequency of visual
inspection, so that same doesn’t occur in future.
0 0
Feedback On 18.02.2015, 160KVA DG set was running which is used for power supply of the
plant. A contract labour was doing housekeeping job in DG room and he noticed
minor leakage of Diesel from pipeline. Suddenly he informed the technician about
the situation and the engine was stopped for the maintenance. Engineering and HSSE
officer was informed about the same and the maintenance of the engine has been
initiated. After opening the diesel line it was found that thread of one end has
been completely worn out and the same need to replaced on urgent basis. If the
leakage could have persisted for long time, it would have accumulated near DG and
could cause risk of Fire. We have strictly instructed the Plant Technician to keep
daily monitoring on the DG working and to increase the frequency of visual
inspection, so that same doesn’t occur in future.
211
0 0 0
50 Details of Fire
0 0
Feedback Negligence by Technician in following all checks during daily monitoring.
70 Product Loss
0 0
80 Loss Details
0
Date
To ensure all Checks to be To ensure all Checks to be followed whil 27-Feb-
followed while daily monitoring e daily monitoring of DG set 2015
of DG set
EXPERT COMMENTS:

1. It is a case of incident and not near miss.
212
NEAR MISS NO. 98
Name By
27.02.2015
Date Time
Incident NEAR
Type MISS
Occurred
At
Question List
Feedback On 27.02.2014, 18:10 pm, our shed officer just managed to escape the fall due to loosely
lying GI strip which was coming in the way near pump house. The GI strip near pump
house was found loose protruding towards the walk way thus causing an obstruction while
moving. The GI strip was immediately clamped to the ground to prevent reoccurrence of
foot tangling.
20091 VIKAS SINGH
Feedback The clamping of GI strip was not proper due to which it had got displaced from its place.
0 0 0
50 Details of Fire
0 NIL
Feedback The GI strip clamping was not done.
70 Product Loss
213
0 NIL
80 Loss Details
NIL
Maintenance standard of earthing system To ensure clamping of all 07-Mar-2015
needs to be improved. earthling strips.
EXPERT COMMENTS:

1. All pathways to be cleared off the earthing strips.
2. Earthing strips should run underground in this case.
214
NEAR MISS NO. 99
Name By
28.02.2015
Date Time
Incident NEAR
Type MISS
Occurred
At
Question List
Feedback On 28.02.2014 around 09:20 during DSA Safety round slight oil leakage was observed from
DU no.11 (First Conveyor of Filled Shed) making the floor slippery which was potential
hazard and for undesirable incident. Technician was immediately asked to attend & stop the
leakage.
9129 SARITA FIRMAL
Feedback Leakage was due to worn out oil seal.
0 0 0
50 Details of Fire
0 NIL
Feedback worn out oil seal
70 Product Loss
0 NIL
215
80 Loss Details
0
Date
Maintenance standard of driving unit needs To ensure maintenance of DUs 07-Mar-
to be improved. as per PMS. 2015
EXPERT COMMENTS:

1. PMS schedule for DUs to be followed strictly.
2. Oil level and grade of oil being used to be checked properly.
3. Condition of shaft to be monitored.
216
NEAR MISS NO. 100
Name By
Time
Incident NEAR
Type MISS
Occurred At
Question List
Feedback On 28.02.2014 around 12:15 contractor labor was putting neck label on cylinder bung.
Suddenly one label slipped from his hand and due to wind gust it flew away to a distance.
While trying to chase that label, he lost the balance but managed to be stable thereby
avoiding possible slipping on the shop floor. He was immediately counseled by shed
officer to avoid such incidences in future & work with calm & safety in mind.
20199 KARTAR SINGH
Feedback soap water spillage near the conveyor railings.
0 0 0
50 Details of Fire
0 NIL
Feedback poor housekeeping
70 Product Loss
217
0 NIL
80 Loss Details
0
Housekeeping standard to be To ensure nil soap water spillage 06-Mar-2015
improved. inside shed.
EXPERT COMMENTS:

1. Soap spillage to be attended.
2. Effectiveness of collection tray to be checked.
3. Safety talks to be conducted with labour.
4. Checking of conveyor chain length and dead weights to be done.
218
NEAR MISS NO. 101
Application Report Submitted SARITA
Name By FIRMAL
Location Bareilly LPG
Plant
Occurred At
Question List
Feedback On 28.02.2014 around 10:45 in Utility Section, extension of air receiver‘s water drain
line work was being carried out by the contractor. In the process, the solenoid valves of
auto drain was removed & kept aside. Our Officer Kartar Singh observed a spark in
solenoid. He Immediately isolated the supply to the solenoid by removing the plug from
the socket. Thereby, the possible chances of fire were averted.
9129 SARITA FIRMAL
20199 KARTAR SINGH
Feedback It was found that solenoid connected for auto drain system was not isolated before
starting the job.
0 0 0
50 Details of Fire
0 NIL
219
Feedback Negligence
70 Product Loss
0 NIL
80 Loss Details
0
Never to start any critical job Isolation of any equipment shall be 28-Feb-2015
without required isolation. ensured by the officer only.
EXPERT COMMENTS:

1. Root Cause: Non-adherence to work permit.
2. Electrical Isolation permit not prepared.
220
NEAR MISS NO. 102
Report Submitted KUMAR
By RAJNISH
Time
Location Salempur LPG
Plant
Incident Type NEAR
MISS
Incident Occurred LOCATION Root Cause Non follow up of
At SOP
Question List
Feedback On checking the TT no. HR55E 4650 at gate no2,its mater switch was found
defective, therefore the TTs was not taken for decantation. Then driver of TT
tried to back the TTs without helper, the rear tyre of cabin of TT was stuck on the
drain near by the parking area.
00
Feedback Detailed investigation of the incident was carried out. Since TT was without
Master switch which itself is a safety concern, we had communicated the
discrepancy of vehicle to Transporter. Corrective action was taken by the
transporter for master switch. We further on investigation that vehicle being
running without second crew member, driver has not taken assistance of any one
to take his vehicle back and in hurry made the mistake. We could also conclude
from the investigation that security failed to assist to tank lorry driver and
properly monitor for which we have done safety talk on SOP for security
personal on floor and strengthen their safety training.
Feedback Person No. of Man hours Lost (in Lives Lost
type injured days)
0 0 0
50 Details of Fire
221
0 0
Feedback Missing Srew Member and Improper Master switch
70 Product Loss
LPG (in MT) 0
80 Loss Details
0
Strengthening of Checking Tank Lorries Already implemented 07-Oct-2015
EXPERT COMMENTS:
Note: Discrepancy in FIR and DIR observed as in FIR, it is mentioned that master
switch was defective and in DIR, it was mentioned that master switch was not
available.
1. Locations to ensure that a driver and a second crew should always be present
with each tank lorry.
2. Condition of master switch to be clearly mentioned in checklist from loading
location.
222
NEAR MISS NO. 103
Application Report
Incident Reporting System (HSSE) NASRUL KAMAR
Name Submitted By
Time
Location Salempur LPG Plant
Incident Type NEAR
MISS
Occurred At
Question List
Feedback We have observed difference in Servo gauge and radar gauge readings by 500 mm level
which have taken our attention towards its actual level. While inspecting further we have
observed that Radar gauge reading was hanged.
1 Sh Nasrul Kamar
2 Sh Rakesh Chandra
Feedback While inspecting the two levels, we have observed that reading of Radar gauge was in
hanged position and there was no change in its reading with respect to actual condition. We
have checked another Radar gauge located at MSV, which again
was giving same results and was in hanged position too. First we tried the "Level
operation" to check the instruments attached. At servo gauge it was working fine and in
radar gauge it did not take any input, which strengthen our idea of system got hanged. Then
we switch off the power of Tank Farm Management System and restarted it again. System
started working smoothly and now the reading of two gauges was approximately same.
This way we could remove ambiguity in the readings and rectified the problem.
0 0 0
50 Details of Fire
0 Nil
223
Feedback Radar gauge got hanged.
70 Product Loss
LPG (in MT) 0 Nil
80 Loss Details
0
To check reading of all Level gauge at Action already taken and 07-Mar-2015
Control room & field. problem got rectified.
EXPERT COMMENTS:
Note: It is not the case of near miss.

1. Poor maintenance.
2. Non-adherence to PMS.
3. It appears that reading was being taken by servo gauge only. Radar gauge
was not monitored for long.
4. Supply to be ensured through UPS.
224
NEAR MISS NO. 104
Report Submitted SONVANI
By ARUN KUMAR
Time
Location Bhatinda LPG
Plant
Incident Type NEAR
MISS
At
Question List
Feedback During visit at the Plant on 07.03.2015 in afternoon session, it has been found
that in filled cylinder shed three 19 kg filled cylinders duly sealed and ready
for dispatch to distributorship delrin caps thread found open at end and not
tied up with stay plate of the cylinder which potential hazard to the market in
case of the leakage.
Feedback While investigating the process of filling sometimes it has found that no cap
on the cylinders and cylinders with valve leak reaching at SQC point. As
team member we have immediately checked up other stock and on line
cylinders and found that all cylinders were properly tied up delrin caps with
stay plate of the cylinders after sensitizing the staff on filling lines. I have
discussed this issue with all staff and contract workmen for finding out
cylinders with properly tied up delrin cap with cylinders and other safety
checks for their awareness. I have also shared the repercussion of the sending
cylinder in market without proper tying up of delrin cap with the cylinders on
stay plate and other safety check as immediate corrective action. More focus
approach and action points need to be developed in order to ensure that no
cylinders without proper tying of delrin cap with stay plate of the cylinder
and other safety checks move to filled cylinder shed. As per investigation
carried out that sensitizing the all staff on quality filling is important and must
be done on weekly basis sharing about the accident details at the customer's
premises due to negligence only.
225
Others 0 0 0
50 Details of Fire
0 nil
Feedback Negligence in the Safety Checking of the Cylinders moving in the process as
potential hazard.
70 Product Loss
LPG (in MT) 0 nil
80 Loss Details
Indirect Loss 0
NEGLIGENCE IN SAFETY AWARENESS FOR 08-Sep-2015
FILLING PROCESS. QULITY CHECK CAN AV
OID ACCIDENT.
EXPERT COMMENTS:

1. Standard practice of tightening of cap with cylinder stay plate should be
ensured.
2. It is not the case of near miss as the cap was already placed on the cylinder
valve.
3. Standard nylon thread to be ensured while reconditioning of the caps.
226
NEAR MISS NO. 105
Name By
Time
Incident Type NEAR
MISS
Occurred At
Question List
Feedback Fire Drill was conducted on 07.03.15 in LPG Pump House. During the drill when hose
handling team reported at site and opened the hose box .The hose when removed from
Hose Box by operator and tried to connect hose coupling with the hydrant valve, then
suddenly a lizard popped out from hose and fall on the legs of operator. The operator
was slightly misbalanced and hose reel fell from his hand and he remained balanced by
holding the Hydrant Valve.
8663 sankalp
4145 rajkumar singh
Feedback During investigation it has been found that 1) Hose Box maintenance was not proper
due to which there was gap. Gasket was broken due to which there was gap in the hose
box.
0 0 0
50 Details of Fire
0 0
Feedback Poor maintenance
227
70 Product Loss
0 0
80 Loss Details
0
Proper inspection of Hose Boxes as per Inspection to be ensured. 07-Oct-2015
PMS.
EXPERT COMMENTS:

1. PMS of fire hoses to be followed strictly.
2. Packing of hose boxes should be proper in order to ensure that lizards do not
enter hose boxes.
228
NEAR MISS NO. 106
Incident Reporting System (HSSE) SHRI CHAND
Name By
Time
Location Udaipur LPG Plant
Incident Type NEAR
MISS
Occurred At
Question List
Feedback As per Daily safety Audit (D-03) when earthing connection of tank lorries checked, It was
found that bonding wire across flanges of vapour valve of tank lorry no GJ12AT5259 was
broken during Tank lorry decantation operation. Immediately the unloading operation of
the tank lorry was stopped. After disconnecting the hoses fixed to unloading point
,bonding wire was provided across the flanges of valve.
m10142 Shri Chand
Feedback Operator connected unloading Arm without checking bonding wire across the flange of
vapour valve of Tank lorry.
NA
50 Details of Fire
NIL
Feedback Tank lorry decantation SOP was not followed by Tank Lorry Operator
70 Product Loss
229
NIL
80 Loss Details
NIL
SOPs to be followed. Training regarding SOPs of TLD & 10-Mar-2015
Bonding connection.
EXPERT COMMENTS:

1. Checklist for tank lorries to be filled and followed meticulously.
230
NEAR MISS NO. 107
Application Report Submitted SONVANI ARUN
Name By KUMAR
Time
Incident Type NEAR
MISS
Occurred At
Question List
Feedback While visiting in filling shed area in morning around 09:45 hrs it has been found that
chain conveyor before washing was not properly running and creating sound due to
chain conveyor was not running through 8 teeth sprocket and touching the sprocket
shaft. Operator near the chain conveyor driving unit stopped the chain conveyor and
asked the technician to resolve the issue, since technician working on carousal hence
attended by the contact workmen who was supporting technician. He started working
after switching off the chain conveyor unit without locking the conveyor driving unit
switch.
Feedback After detail discussion it was found that contract workman started the work on the
chain conveyor without positive isolation of the chain conveyor electrical switch.
Contract workman also did not request for positive electrical isolation of electrical
switch for the chain conveyor from MCC and started the work and not properly
informed to technician and shed officer. This was also earlier pointed out during visit
at Filling Shed and work was stopped immediately on chain conveyor and positive
electrical isolation was requested from MCC by officer production and thereafter
maintenance work again started. After completion of the work again same chain
conveyor switched on from MCC and work completed as per maintenance process as
immediate corrective action. This wrong process adopted by the contract workman
shared by all in Filling Shed as immediate learning and also shared monitoring of
chain conveyor while running and in case of any maintenance related to electrical
equipment proper process need to be adopted to avoid any incident. Correct
maintenance practice need to be followed which is to repeatedly discuss among the
231
staff contact workmen during safety clinic and associated hazards also need to be
discussed. The major finding of the investigation is contract workmen are not
properly following the process of the maintenance which may lead to accident.
Others 0 0 0
50 Details of Fire
0 nil
Feedback The contract workmen involved are not properly following the process of the
maintenance
70 Product Loss
LPG (in MT) 0 nil
80 Loss Details
Indirect Loss 0
CASUAL APPROACH ON SAFE PRACTICE NEED 03-Sep-2015
MAINTENANCE TO ENHANCED
EXPERT COMMENTS:

1. Electrical work permit is to be issued for electrical isolation.
2. LOTO to be followed while doing isolation.
3. JSP to be prepared and followed strictly.
232
NEAR MISS NO. 108
Incident Reporting System (HSSE) RINKY RANA
Name By
10.03.2015
Date Time
Incident NEAR
Type MISS
Incident LOCATION Root Cause Poor Safety Awareness
Occurred
At
Question List
Feedback Today in the morning at 9:00 A.M. our planning assistant Mr. Rajeev Kumar parked his car
in parking shed. The shed platform has little downside slope. He parked the car & went in
office to start his routine job. After five minute our TC noticed his car was standing near to
fountain of admin building & little damage was found on fountain walls. He suddenly
called Mr. Rajeev Kumar to site. It was found that in rush due to delay to office he, skipped
to apply handbrake & since plant cycle was already standing there, so to prevent cycle he
parked his car little outside parking shed, i.e. near to slop area.
10627 Rinkhy Rana

Feedback Due to little delay, he rush to the parking area & in a hurry he skipped to apply handbrake
& parked his car little outside parking shed to protect cycle standing on back side of
parking shed. Since there was no handbrake & car was standing in neutral gear, blowing of
little wind gave push to car & car went straight to fountain in down slope direction. Car got
hit to fountain wall & little damage to fountain wall & dent on car bumper noticed.
Others 0
50 Details of Fire
0 Nil
233
Feedback Negligence & casual approach
70 Product Loss
LPG (in MT) 0 nil
80 Loss Details
Indirect Loss .0002
We should not do any job in Line for parking is made so that car did not 26-Sep-2015
hurry. fall under slope.
Line for parking is made so that car did not fall under slope. 26-Sep-2015
EXPERT COMMENTS:

1. Safety awareness to be enhanced.
2. Strict action to be taken after observing such cases of casual approach.
234
NEAR MISS NO. 109
Application
Incident Reporting System (HSSE) Report Submitted By KARTAR SINGH
Name
12.03.2015
Date
Incident NEAR MISS
Type
Incident OTHERS Root Cause Poor Maintenance
Occurred
At
Question List
Feedback On 12th march 2015 at approx 09:30 AM, To check and ensure the proper running of the
Carousal and Filling Machines, I was standing near the carousal’s ejection. Then I found
that the earthing wire of F/M-13 was disconnected from its position.
56117 sandeep kumar
Feedback The earthing wire was broken at the gun clamp point and the residual part was stuck in the
clamp, which was still bolted to its position.
0 0 0
50 Details of Fire
0
Feedback Breakage of wire at the Gun clamping point due to vertical movement of FM.
70 Product Loss
nil
235
80 Loss Details
0
Checks to be strengthened so A small rubber sleeve to be 31-Mar-2015
that condition of clamps/ provided to hold the wire straight
earthing wires are attended on and in line with its metallic clamp.
time and fixed.
EXPERT COMMENTS:

1. Electrical integrity of all earthing cables of carousel filling machines to be
checked and ensured during the start of the shift.
2. PMS of filling machines not followed.
236
NEAR MISS NO. 73
Name By
Time
Incident Type NEAR
MISS
Incident CONSTRUCTION SITE Root Cause Non adherence to
Occurred At standard Engg practice.
Question List
Feedback At Allahabad LPG Plant , civil work for Hydrotesting Unit is in process. Erection of
truss on columns ( 10 M span) was under progress on 19.03.2015 at around 1600 hrs
with the help of crane. Truss on column no. 02 (about 3 m height) was placed by crane
and the base plate was being fixed on column by a skilled labour standing on a wooden
ladder. The other helper holding the ladder on the ground left the same and moved to
fetch some tool. The ladder suddenly began to slip on the floor. The skilled labour who
was fastening the truss on the column on top , immediately caught hold the truss and
hanged to avoid falling down. Everyone ran to hold the ladder and the contract labour
were brought down safely.
9182 jayant kumar
4494 Ramprit
Feedback The reasons for incident were investigated. It was found that labour holding the ladder
left the same for fetching some tool and the ladder slipped on the newly constructed
mastic flooring. As many people were standing nearby, ladder was immediately caught
and fixed into position. The labour standing on the ladder saved him from falling by
holding the truss.
0 0 0
50 Details of Fire
237
0 na
Feedback carelessness of contract labour holding the ladder
70 Product Loss
0 na
80 Loss Details
0
Exclusive labour to be deployed for holding Proper training to 15-Apr-2015
ladder while working on height. staff/labour for working
on height.
EXPERT COMMENTS:
Note: It is not mentioned in report whether work permit at height was not made or
not.

1. Work permit for working at heights to be issued and followed in true spirit.
2. Necessary PPEs (safety belt, safety helmet, etc) to be ensured.
3. Proper scaffolding to be provided as per standards.
4. Proper job safety analysis to be carried out.
5. Toolbox talks to be conducted.
238
NEAR MISS NO. 111
Application Report Submitted DEEPMALYA
Name By DATTA
21.03.2015
Date
Plant
Incident NEAR MISS
Type
Occurred At
Question List
Feedback 2nd Shift of Tank Lorries being connected for decantation. Tank Lorry no. GJ6Z6299 of M/s
Shri Shakti Enterprises was placed at Bay No. 3, unloading arms connected and checked for
leakage by the operator by crack opening of plant side vapor line valve. The tank lorry vapor
line unloading arm is found okay. However , as soon as liquid line was checked for leakage
by crack opening of plant side vapor line valve, it was found to be leaking. The line was
vented , reconnection done and checked once again but even then leakage did not stop. The
line was to be checked a third time but this time the operator forgot to vent the line (though
the valve of lorry and our pipeline were in closed condition). As soon as the connection point
was loosened, the residual LPG vapor gushed out at the point which soon dispersed on its
own. However , the operator had immediately informed planning and HSSE officer about the
same over VHF and also called the PO for assistance. The line was properly vented for
complete de pressurization and then reconnected by changing the rubber O-ring at the
connection point. The vapor line and liquid line unloading arm connections were again
checked in presence of the officers and no leakage was detected. The decantation was started
only after that.
56126 AMIT KUMAR
Feedback The connection of the liquid unloading arm to TL Liquid line was to be checked a third time
when the incident happened. The operator forgot to vent the line (though the valve of lorry
and our pipeline were in closed condition). As soon as the connection point was loosened, the
residual LPG vapor gushed out at the point which soon dispersed on its own. However, the
operator had immediately informed planning and HSSE officer about the same over VHF and
239
also called the PO for assistance. The line was properly vented for complete de pressurization
and then reconnected by changing the rubber O-ring at the connection point. The vapor line
and liquid line unloading arm connections were again checked in presence of
the officers and no leakage was detected. The decantation was started only after that.
0 0 0
50 Details of Fire
0 na
Feedback Operator forgot to follow the complete procedure for checking the leakage on the third
instance.
70 Product Loss
NA
80 Loss Details
0
The standard procedure has to be Safety Talk for all operators 23-Mar-2015
followed each and every time even if and share the incident.
need is repetitive in nature.
EXPERT COMMENTS:

1. Training on SOP to be conducted on regular basis.
2. Root cause is Non-follow up of SOP instead of negligence.
240
NEAR MISS NO. 112
Name By
23.03.2015
Date Time
Incident NEAR
Type MISS
Occurred
At
Question List
Feedback While taking safety round in the plant , it is observed that earthing strip is exposed and
protruding above ground near the pathway of old carousel shed. As the protruding strip
is a potential hazard for tripping and injury to any personnel in the plant, the same is
taken as a near miss incident. The same has been rectified by burying the earth strip
below ground.
Feedback Top surface of the pathway had eroded to natural elements and earthing strip exposed
and protruding above ground near the pathway of old carousel shed. The same has been
rectified by burying the earth strip below ground.
0
50 Details of Fire
0 na
Feedback Protruding Earthing Strip
70 Product Loss
241
na
80 Loss Details
0
Access pathways to be kept free Regular housekeeping and 28-Mar-2015
from any potential hazard. maintenance of the pathways.
EXPERT COMMENTS:

1. Six monthly checking of earth pits and earthing strips to be done properly.
3. Regular housekeeping and maintenance of pathways to be ensured.
242
NEAR MISS NO. 113
Incident Reporting System (HSSE) NASRUL KAMAR
Name By
Time
Location Salempur LPG Plant
Incident Type NEAR
MISS
At
Question List
Feedback Today while fitting Vapor arm of Tank lorry (TT No HR557898) at TLD area prior to
decantation operation, TLD operator Sh. Rajinder Singh has observed that vapour line
body valve was loose and was getting rotated with manual force simply by h
and. He immediately informed the condition to Planning officer and Process operator.
Situation being risky, plant TC and Engineering officer reached to site to attend it. While
inspection body Vapor valve was found loose. We tightened it, checked it for any leakage
and when everything found OK, Decantation was started.
1 NIRMALYA CHAKRABORTY
1 RAJNISH KUMAR
1 NASRUL KAMAR
1 RAKESH CHANDRA
1 RAJINDER SINGH
1 VINOD KUMAR
Feedback While inspection, it was found that Body Valve is loose at Thread and is in position to
rotate with manual force (free hand). We have carefully rotated the Valve until it got fully
tight (which took approximately 150 Deg shift from its initial position). We then checked
the Joints/ Thread for any leakage with soap solution. There was no leakage. We then
resumed our operation of Tank lorry Decantation. We have mentioned our observation in
Tank lorry check-list for re-inspection prior to loading point before loading.
243
Nil
50 Details of Fire
NA
Feedback Loose Vapor Valve of Tank Lorry
70 Product Loss
Nil
80 Loss Details
Nil
100 % and Religious Inspection of TT Already taken in this case. 23-Mar-2015
before Decantation operation.
Alertness Enhancement of Staff Recognition of TLD operator, 23-Mar-2015
PO and Storekeeper giving
smileys.
Alertness Enhancement of Staff Safety Talk on SOP at TLD 23-Mar-2015
Area by Shed officer.
EXPERT COMMENTS:

1. Details of checklist issued by loading location needs to be mentioned in report
for proper analysis.
2. There may be a possibility that driver had indulged into malpractice.
3. Proper investigation/analysis to be carried out and suitable action to be
initiated against TT driver or transporter.
244
NEAR MISS NO. 114
Report Submitted
Application Name Incident Reporting System (HSSE) SHRI CHAND
By
Time
Location Udaipur LPG
Plant
Incident Type NEAR
MISS
Incident Occurred LOCATION Root Cause Equipment failure
At
Question List
Feedback During Inspection of residual current circuit breakers, it was found that RCCB
of MCC Room DB was found not operated while pressing the Test Button.
The ELCB details: 63Amps, 4pole & I: 300mA
10142 Shri Chand
Feedback 1. Following are the details of RCCB: 63Amps, 4 poles, 240/415Volt, 50Hz,
Rated residual operating current: 300mA, Make: MDS As per I?n, It is
medium sensitivity RCCB & used for fire protection. 2. It was found that the
RCCB is not work
ing due to failure of trip coil. 3. The RCCB has been replaced with new
RCCB of same rating. 4. We are having 14Nos RCCB (4pole:12Nos &
2pole:2Nos) at Udaipur LPG Plant.These RCCBs were installed in 1995.We
are inspecting the RCCBs on monthly basis. 5. To provide extra protection in
the event of direct contact with an (unearthed) live part, High Sensitive
RCCB's with a rated residual operating current of 30 mA or less (I = 30 mA)
can be used instead of 300mA.
Others nil
50 Details of Fire
245
nil
Feedback Failure of RCCB due to faulty trip coil
70 Product Loss
NIL
80 Loss Details
NIL
The RCCBs to be inspected Inspection/checking to be 31-Mar-2015
regularly at shorter intervals done.
(15days).
EXPERT COMMENTS:

1. RCCB to be checked as per IE rules.
2. Regular maintenance as per OEM to be carried out.
3. RCCB of correct ratings to be used.
246
NEAR MISS NO. 115
Application Report Submitted BHAGAWAT SINGH
Name By SANKHLA
Time
Incident Type NEAR
MISS
Occurred At
Question List
Feedback Box lorry RJ 06 GA 8710 was stationed at Loading boom. As per standard procedure, the
2 fire extinguishers of the truck has to be unloaded from the fire ex stand and put in
demarcated place. While the driver was doing the same, 1 no. fire ex slipped from his
hands and fell on the paver block surface below. The fire ex immediately got operated.
55627 B.S. Sankhla
5205 Rajeev VR
Feedback On investigation it was found that the plunger lock was not fixed in its proper place;
rather it was hanging by a string. The sudden drop to the ground, head downwards,
caused the plunger to press the cartridge on impact, resulting in operation of fire ex.
0
50 Details of Fire
0 nil
Feedback Plunger lock was not in place.
70 Product Loss
247
0
80 Loss Details
0
Checking of fire ex is Fire ex to be checked properly 23-Mar-2015
critical. before entry.
Fire extinguisher of box lorry has been checked 30-Mar-2015
EXPERT COMMENTS:

1. Effective training to be imparted to the drivers.
3. Training to be given to security staff regarding physical checking of fire-ex
while checking the lorry as per checklist.
248
NEAR MISS NO. 116
Report Submitted MANOCHA
By RAJESH
Location Code 3102
Location Piyala LPG
Plant
Incident Type NEAR
MISS
Incident Occurred OTHERS
At
Question List
Feedback While on the way to office at 0820 am in the morning in the pickup, the driver got a call
on his mobile. He picked up the call. Meanwhile another vehicle coming from the
opposite side suddenly took a U turn from the divider in which there was a gap about 50
m ahead. The driver of our pickup swerved sharply to the left thus avoiding an accident.
Driver has been advised not to attend to calls on hic mobile while driving but park the
vehicle safely and then receive the call.
Feedback None
Feedback 0
Comment NA
4 Estimated property loss in INR (lacs) (Enter "0" in case of no property loss or if it is yet
to be estimated)
none
none
7 Product Loss
na
249
Comment NA
EXPERT COMMENTS:

1. Locations need to carry out basic safety training of drivers of car on hire.
250
NEAR MISS NO. 117
Report Submitted ARVIND KUMAR
By CHAKRAWATI
Time
Location MICRO LPG PLANT -
GONDA
Incident Type NEAR
MISS
Incident Occurred LOCATION Root Cause Non follow up of SOP
At
Question List
Feedback DAMAGE OF NEWLY BORING AND DITCH. WE HAVE DONE ONE BORING
FOR SUBMERSIBLE PUMP. WHEN WE STARTED LOWERING SUBMERSIBLE
PUMP WE FOUND THAT PUMP GOT STUCK INSIDE THE PIPE AT A DEPTH
OF APPROX 15 FIT. WITH THE HELP OF TORCH WHEN IT WAS INSPECTED
WE FOUND THAT PIPE GOT DENTED AT THE DEPTH OF 15 FIT. A DITCH
AROUND BORING WAS CONSTRUCTED FOR RECTIFICATION OF ORING.WE
HAVE LEFT THE DITCH FOR FORTHER ACTION. IN THE EVENING IT WAS
OBSERVED THAT SOME PORTION OF DITCH GOT DAMAMGED. IT MAY
HARM THE PERSON WORKING INSIDE DITCH.THERE IS NO LOSS OF
PROPERTY AND LIFE.
1 IMG_20150326_112908.jpg image/pjpeg 2.51 LPG_TeamMember
M9348 Arvind Kumar Chakraw
M11360 Ankur Gupta
Feedback 1.DUE TO DAMAGE OF BORING TUBE INTERNALLY A DITCH WAS DIG TO
RECTIFY THE DAMAGED BORING. 2.DITCH WAS NOT SUPPORTED BY P
ROPER MEANS TO PROTECT FALLING OF LOCAL SOIL. 3.LOCAL SOIL FELL
IN THE DITCH DUE TO LOCAL SOIL SETTLING.
251
1 IMG_20150326_112908.jpg image/pjpeg 2.51 LPG_TeamMember
0 0 0
50 Details of Fire
0 0
Feedback 1.DUE TO DAMAGE OF BORING TUBE INTERNALLY A DITCH WAS DIG TO
RECTIFY THE DAMAGED BORING.
70 Product Loss
0 0
80 Loss Details
0
DITCH WALLS MUST BE DITCH WALLS WAS 16-Oct-2015
PROPERLY SUPPORTED TO PROPERLY SUPPORTED TO A
AVOID LOCAL SETTLING OF VOID LOCAL SETTLING OF
SOIL. SOIL.
DITCH WALLS WERE PROPERLY SUPPORTED TO AVOID 16-Oct-2015
LOCAL SETTLING OF SOIL.
EXPERT COMMENTS:

1. Job safety analysis to be done properly while making work permit.
2. Toolbox talk to be conducted before proceeding for any job.
252
NEAR MISS NO. 118
Application DEEPMALYA
Name DATTA
Incident Type NEAR
MISS
Occurred At
Question List
Feedback During the safety round of the plant , it was observed that the cylinder unloading
grating for unloading cylinders from Overhead CC near unloading point was
having some dislodged strips on the platform. This is a potential hazard for the p
ersonnel working on the platform as the foot may get caught in the gap and cause
tripping etc.. Hence this is taken as a near miss incident. Rubber mats have now
been placed on the gratings for cylinder unloading purpose to prevent any furt
her dislodgement of the strips. The dislodged strips to be fixed back suitably.
9107 D DATTA
55856 RAMESH CHAND DINESH
Feedback 1. It was observed that cylinders being offloaded directly on platform despite
availability of rubber mats nearby. 2. On enquiring and assessing the area , it was
found that there is need for additional rubber mats. 3. However , till additional
mats are provided , the labor working in the area have been told to ensure rubber
mat at place of offloading cylinder.
0 0 0
50 Details of Fire
0 0
253
Feedback Dislodged metal strips on cylinder unloading grating near unloading finger.
70 Product Loss
0 0
80 Loss Details
0
Feedback Learning Action to be Target
Taken Date
Dislodged strip to be fixed back suitably by welding Completed 07-Oct-
etc./ (already done) 2015
Provide additional rubber mats (already Provided 07-Oct-
purchased and placed) 2015
EXPERT COMMENTS:

2. Rubber mats to be used on metallic grating frame for cylinder unloading.
254
NEAR MISS NO. 119
Application
Name
Occurred At
Question List
Feedback In filling Shed- Shed technician Lokram was tightening the bolt of the shaft and
sprocket assembly of DU-10 near the Hot air sealing machine. For doing so he asked
for the wrench from a labour person. When labour person was giving the wrench Mr.
Lokram could not grab it properly and it fell near his foot. This could have caused
injury to him.
20199 KARTAR SINGH
Feedback loose grip while holding the instrument.
0 0 0
50 Details of Fire
0 NIL
Feedback negligence, hurriedness & lack of guidance
70 Product Loss
0 NIL
80 Loss Details
255
0
Before getting done any job Prior to start any job through 31-Mar-2015
through contractor staff it is contractor staff ensure to
necessary to educate contractor educate them about all
staff. job related safety
EXPERT COMMENTS:

1. Technician to carry portable tool box consisting of basic tools whenever
breakdown is attended.
256
NEAR MISS NO. 120
Application
Name
Incident NEAR MISS
Type
Occurred At
Question List
Feedback In fire engine room-iron platform aside the FE no-3 flipped when shed officer stepped on
it. He somehow balanced himself and stepped back otherwise he would have been fallen
into the pit on which it was put. Later he asked the labour person to put the platform
properly.
20091 VIKAS SINGH
Feedback iron platform was removed during maintenance work in fire engine room.
0 0 0
50 Details of Fire
0 NIL
Feedback Platform was not kept in proper place.
70 Product Loss
0 NIL
80 Loss Details
257
0
Maintenance standard needs to To ensure site clearance after 31-Mar-2015
be improved. completion of maintenance activities.
EXPERT COMMENTS:

1. Root Cause: Platform was clamped/grouted with structure.
2. Site clearance certificate to be provided after completion of job.
3. Permit to be closed only after site clearance.
258

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LEARNINGS

NEAR MISS REPORTING

We are in the process of expanding our LPG plant operation by introduction of

Investigation process should be in place for senior management at locations to make

We thanks to team members namely Mr Sunil Brar, Mr Praveen Yadav, Mr Abhishek

SAFETY PYRAMID- HEINRICH THEORY

As per the description mentioned above, following inferences were made:

1. Supervision to be done at distributor’s end.

As per the description mentioned above, following inferences were made:

As per the description mentioned above, following inferences were made:

1. All locations should ensure timely hydro testing of fire-extinguishers.

As per the description mentioned above, following inferences were made:

1. Electrical work permit system to be followed strictly.

As per the description mentioned above, following inferences were made:

As per the description mentioned above, following inferences were made:

1. Walk around management to be strengthened.

As per the description mentioned above, following inferences were made:

1. Walk around management to be strengthened.

As per the description mentioned above, following inferences were made:

1. Unsafe conditions should be identified and arrested immediately so that no

As per the description mentioned above, following inferences were made:

1) PMS of online VCM and manual VCM at PT shed to be followed strictly.

As per the description mentioned above, following inferences were made:

1. Walk around management to be strengthened.

As per the description mentioned above, following inferences were made:

As per the description mentioned above, following inferences were made:

Note: Driver training details to be mentioned while reporting incident related to

As per the description mentioned above, following inferences were made:

As per the description mentioned above, following inferences were made:

As per the description mentioned above, following inferences were made:

As per the description mentioned above, following inferences were made:

As per the description mentioned above, following inferences were made:

1. Safety clinics to be conducted for persons residing in nearby places.

Incident Date 20.06.2014 Incident Time 03:00 SBU/Entity LPG

Note: It is not the case of near miss.

As per the description mentioned above, following inferences were made:

As per the description mentioned above, following inferences were made:

As per the description mentioned above, following inferences were made:

As per the description mentioned above, following inferences were made:

1. All operating points to be checked for clear visibility of wind socks.

As per the description mentioned above, following inferences were made:

1. Monthly and quarterly tripping of equipment to be ensured.

As per the description mentioned above, following inferences were made:

As per the description mentioned above, following inferences were made:

1. Insulation testing of all the cables to be done annually.

FIR Delay Reason

Note: DIR is not available.

As per the description mentioned above, following inferences were made:

As per the description mentioned above, following inferences were made:

As per the description mentioned above, following inferences were made:

1. To be check with LERC whether such cylinders technical spurious or not.

As per the description mentioned above, following inferences were made:

3. To be check with LERC whether such cylinders technical spurious or not.

As per the description mentioned above, following inferences were made:

As per the description mentioned above, following inferences were made:

FIRDelayReason Due to busy schedule the matter is being

Note: DIR is not available.

As per the description mentioned above, following inferences were made:

1. Job safety analysis to be done properly while preparing work permit.