Phenomen 4M Why-Why Analysis Chec Education Engineeri Enforcement Enviro

a k ng nment
Flashover Why 1 Why 2 Why 3 Why 4 Why 5
in 11kV MAN:
Metering 1. Mr.M K Mondal He was not He did not He assumed Negligenc NG 1. Re-training .
Unit during discharged the knowing confirmed by that power e during to be
discharging live circuit in the that panel seeing the was under the work provided on
in Metering metering unit by was meter in which shutdown Safe Working
unit at opening the door charged display light Procedure on
Hywa India of HT was glowing Metering unit
Pvt. Ltd, compartment. and LED was maintenance.
Phase-3, flickering. 2. Caution
Aditypur. display “USE
POWER
TESTER
BEFORE
DISCHARGE”
shall be
provided in all
6.6kV, 11kV &
33 kV HT
Metering unit.
Power was not Power tester
checked with was not
Power tester. taken during
shutdown
work.
 Door Interlock NG Interlocki Key management
opened facility was not ng facility system to be
when there to be strengthened
power was implemen
on. ted in
MU, so
that
nobody
opens the
door in
ON-
condition
MACHINE:
Power tester was Power Power tester is As per earlier NG 1. Meter section
not used before tester was not available in practice, they should have
discharging not taken Meter section. are Power tester,
during dependent Discharge rod,
shutdown on DNM Kool coat etc.
work. team 2. Availability of
They did not DNM team NG proper tools/PPE
arrange power was not to be reviewed by
tester from working in sectional head.
DNM team the same
location.
METHOD:
Work-permit was Work- Knowledge gap NG 1. It is
issued by permit was in recommended
Mritunjay Kr to not taken understanding that DNM shall
the Contract by Meter of work-permit take power
workmen. section system clearance in
from DNM between shutdown work
team. sections in and issue work
same permit to meter
shutdown. section.
2. Monthly site
visit should be
conducted by SLTs
for shutdown
activities to re-
check the
adherence of
power clearance,
work permit and
SWP
Positive Isolation Negligence NG
system was not to follow
followed during the
shutdown work in procedure
metering unit.
No isolation NG For
arrangemen future
t was consumer
available s, in
between demand
Metering note it is
unit and to be
Transformer mentione
. d for
complianc
e of
providing
linked
switch
with fuse
or circuit
breaker of
adequate
rating on
Transform
er
secondary
side as
per IE
Rule
clause no.
50.
In existing
consumer
s survey
to be
done to
check
complianc
e and a
MANAGEMENT:
Work-permit No review Monthly site
system was not found by visit should be
conducted by
followed as per sectional
leadership
procedure. head for team for
compliance shutdown
of power activities to re-
clearance / check the
work permit adherence of
system by power
clearance, work
sub-
permit and SWP
ordinate