Details of Incidents Reported during April 2016 to June 2016

1. Incident at Meesala Raja bridge, Vijayawada (BGL)

Date of Incident : 01.05.2016

Time : 07:45 hrs

Entity : Bhagyanagar Gas Limited (BGL)

Location : Meesala Raja bridge, Near Zimkhana ground, Vijayawada

Description:

On 1st May 2016 at around 07:45 hrs, a phone call was received about gas leakage from
BGL pipeline at Seethampeta, Near Zimkhana grounds, Vijayawada. Immediately, O&M
team reached the spot by 08:00 hours and found that gas was leaking from the MDPE pipe
which was damaged during the excavation. They fixed the squeezers to stop the gas
leakage. When the third party contractor’s JCB operator was enquired, they came to know
that the pipeline got damaged during their excavation works for extension of road.

Cause:

 Lack of awareness of JCB operator.

 No prior information was given to BGL O&M team regarding excavation.

Recommendations:

 “Dial before you Dig” notices should be supplemented by GIS mapping of the CGD
network so as to minimize the damage caused by the third party activities.
 The entity should continue to engage with Local Municipal Corporation to ensure that
“Dial before you Dig” process is followed by their contractors.
 The entity should continue to influence third party contractors to prevent damage to
gas pipelines during excavation activities.
 Patrolling to be strengthened.

2. Incident at Manglej Village, Vadodara (GGL)

Date of Incident : 02.05.2016

Time : 19:30 hrs

Entity : Gujarat Gas Limited (GGL)

 Location : On road near Manglej Village, Vadodara
Description:

On 2nd May 2016 at around 19:30 hrs, A GGL’s contractor LCV was returning to Mother
CNG Station (Kandari) from Daughter CNG Station (Waghodia). Due to bursting of tyre
of a Third Party’s tractor trailer ahead of LCV, the tractor and its trailer got tilted and
stopped suddenly on the road. LCV driver tried to avoid the collision with the tractor-
trailer, however, LCV collided with the tractor trailer. Due to collision, the right side of
the LCV driver cabin got damaged and the driver received. injuries on his legs. The driver
was immediately shifted to Vadodara Civil hospital. There was neither gas leakage nor
damage to CNG cascade of the LCV.

Observation:

 Tractor trailer without tail-light & light reflector was crossing the Highway and its tyre
got burst due to poor condition & heavy load.
 LCV was in fist lane, estimated speed would be between 60 to 80 kmph.
 LCV driver is trained for hazardous goods transportation and having valid driving
license.
 Notification from incident site to GGL control room and response thereafter from
Ambulance service & GGL team was prompt to provide requisite medical support to
Injured Person.
 Local highway authority patrolling staff, police on duty exhibited pro-active measures
in making the area cordoned post the incident by shifting the LCV and the tractor from
the incident location.

Cause:

 Bursting of trailer tyre at middle of the road while crossing the highway.
 Poor maintenance of third party vehicle.
 LCV speed was not safe considering the approaching crossing junction.

Recommendations:

 Training to TT crew on defensive driving, to be vigilant of traffic and reduce speed at

the crossing junctions & merging points.

3. Incident at Athevelly, Medchal (BGL)

 Date of Incident : 20.05.2016

Time : 17:45 hrs

Entity : Bhagyanagar Gas Limited (BGL)

Location : At Athevelly, Potti Sriramula statue road, Medchal

Description:

On 20st May 2016 at around 17:45 hrs, While excavating the pit for installing the
dislodged electrical pole by Electrical Department, Athevelly; M/s BGL’s 32 mm MDPE
gas pipeline got damaged. The incident occurred at around 17:45 hours, but the labor
buried the pit by putting a stone and intimated to their respective supervisor at 08:00
hours. The concerned supervisor intimated the information regarding MDPE pipe damage
to the Emergency Contact Number. After the first information report, M/s BGL’s O&M
team rushed to the site and stopped the flow of gas and rectified the damage by 20:30
hours.

Cause:

 Electricity Deptt. didn’t inform the O&M team regarding the excavation prior to
excavation.

Recommendations:

 “Dial before you Dig” notices should be supplemented by GIS mapping of the CGD
network so as to minimize the damage caused by the third party activities.
 The entity should continue to engage with Local Municipal Corporation to ensure that
“Dial before you Dig” process is followed by their contractors.
 O&M advised the residents to inform BGL emergency contact numbers prior to any
excavation in the gasified area.
 The entity should continue to influence third party contractors to prevent damage to
gas pipelines during excavation activities.
 Patrolling to be strengthened.

4. Incident at Wet Air Oxidation (WAO) Unit (MRPL)

Date of Incident : 24.05.2016

Time : 17:15
Entity : Mangalore Refinery & Petrochemicals Ltd.

Location : Wet Air Oxidation (WAO) Unit

Description:

On 24th May 2016 at around 17:15 hrs, an incident took place in ETP – 2 Wet air
oxidation unit (WAO) neutralization tank area resulting in burn injuries to 4 personnel.
There was viscous tarry material in the tank and removal of same was attempted
manually through shovel. It was decided to add NOXXALL chemical to sludge inside the
tank. Housekeeping labourer wearing suitable personal protective equipment (PPE)
started adding the chemical at controlled rate through man way supervision by ETP
manager with another three personnel in the vicinity. After addition of chemical, white
fumes were observed liberating at a slow pace. At around 17:30 hrs, ETP manager added
approx. 2 litre of chemical in one go. This resulted in vigorous reaction with splashing of
chemical alongwith evolution of hot fumes from many way of neutralization tank causing
burn injuries to 4 personnel. The injured personnel were shifted to MRPL hospital for
treatment.

Observations:

There was no written down procedure for the removal of sludge from the tank. The
following field observations were made:

 Safety shower and the eye washer provided nearby were not functioning.
 Scaffolding pipes erected for removal of Neutralization Tank (NT) insulation was
obstructing escape of personnel in case of emergency.
 Naphthenic acid disposal line is not boxed up and drained material is being removed
with gully sucker.
 Modified acid distributor line was found damaged at liquid surface level in NT.
 Accumulated tarry material was observed at the bottom of the NT.
 Internals of the NT was observed to be corroded.

Cause:

 No compliance to standard operating procedures.

 Non availability of written down procedure for removal of sludge from the tank.

Recommendations:
 a) Suitable methodology should have been confirmed from vendor for use of
NOXXALL chemical before taking up the activity. The information available in the
brochure, “Some organics react with NOXXALL very rapidly to destruction within
minutes or seconds (phenols, formic acid)” would have been considered before
applying in Neutralization tank where spent caustic rich in phenols is neutralized in
normal operation.
b) The reasons for formation and accumulation of Acid tar material in NT need to be
further analyzed by Technical Services department of MRPL.
c) Standard operating procedures for use of NOXXALL on the sludge formed in NT
should be developed in association with vendor by Technical Services department.
d) Management of Change procedure needs to be followed for the initiatives taken for
the first time where consequences are not known.
e) Standard Operating Procedure for preparing the equipments’/vessels for maintenance
to be developed and followed.
f) Suitable PPEs must be worn by the personnel as recommended before carrying out
any activity.

5. Incident at Surendranagar (GGL)

Date of Incident : 26.05.2016

Time : 11:30 hrs

Entity : Gujarat Gas Limited (GGL)

Location : Near Rajsitapur village, Surendranagar- Dhangadhra NH8E

Description:

On 26th May 2016 at around 11:30 hrs, CNG Transportation vehicle (LCV) hired on
contract was moving from Wadhwan to Dhangadhra. A two wheeler coming with high
speed from opposite side (incorrect lane) collided with the LCV. Due to this collision,
both persons riding on two wheeler were injured and were shifted to nearest hospital.
During the treatment, one of the injured person (two wheeler rider) died in the hospital.

Observation:

 Incident Spot is an accident prone area. Local villagers conveyed that in past several
road accidents took place at the same spot.
 There were no displays of warning signage before and after the curve on the road.
  The road was without divider.
 Accident between two wheeler and LCV took place just before LCV could reach the
turn / blind curve on the road.
 Two wheeler rider was driving at very high speed and was driving in wrong lane when
it struck against the LCV.
 Two wheeler rider and pillion were not wearing crash helmet.
 LCV Driver was trained for hazardous goods transportation and has valid driving
license.
 LCV driver was driving LCV on the same route from last six months.
 Tool Box Talk/ Training was provided to Driver.

Cause:

 Loss of control of two wheeler motorcycle by rider due to high speed on wrong lane at
blind curve.
 No warning signs / Road signs displayed on the route for cautioning about blind
curve.

Recommendations:

 Training to TT crew on defensive driving, to be vigilant of traffic and reduce speed at

the crossing junctions & merging points.
 Identification of accident prone spots on LCV movement routes without warning
signs.
 Alert all the drivers for known accident prone spots on the LCV movement route.

6. Incident at Medchal (BGL)

Date of Incident : 28.05.2016

Time : 11:35 hrs

Entity : Bhagyanagar Gas Ltd.

Location : Suryanagar Colony, Medchal

Description:

On 28th May 2016 at around 11:35 hrs, at Suryanagar Colony, Medchal, a labour while
excavating the trench for making a pit for rain harvesting, damaged BGL MDPE gas
 pipeline to Head Office Basheerbagh. Immediately information was passed and O&M
team reached the site and stopped the flow of gas by 1220 hrs, damage was rectified.
There was no injury / casualty reported in the incident.

Cause:

 Negligent excavation by third party.

Recommendations:

 “Dial before you Dig” notices should be supplemented by GIS mapping of the CGD
network so as to minimize the damage caused by the third party activities.
 The entity should continue to engage with Local Municipal Corporation to ensure that
“Dial before you Dig” process is followed by their contractors.
 The entity should continue to influence third party contractors to prevent damage to
gas pipelines during excavation activities.
 Patrolling to be strengthened.

7. Incident at Dakor, Kheda, Gujarat (GGL)

Date of Incident : 02.06.2016

Time : 18:00hrs

Entity : Gujarat Gas Limited

Location : Near Chhapra CNG station, on State Highway 60

Description:

On 02th June, 2016 at around 18:00 hrs, a third party CNG transportation vehicle (LCV)
was moving from Chappra to Umiya Petroleum, Dakor. An auto-rickshaw approx. 15
feet ahead of the LCV applied sudden brakes, as a reaction to avoid collision with the
auto-rickshaw, the LCV driver also applied sudden brakes & steered towards right. At the
same time, a two wheeler coming from opposite direction could not control his speed
(rider with pillion) and collided with the LCV. LCV driver sustained minor injury on his
left leg and right hand, while the third party bike rider and pillion got injuries on legs.
They were taken to the nearest civil hospital at Mahemdabad. There was neither gas
leakage nor damage to CNG Cascade of the LCV.

Observation:
  The state highway is a two lane road without divider.
 At the incident spot – Road is narrow with deep slop at the shoulders on both sides.
 There was a big tree on the edge of the road in opposite lane of the LCV travel.
 Two wheeler was at high speed and was following the LCV closely i.e. was following
at very short distance. Two wheeler riders were not wearing crash Helmet.
 LCV driver was trained for hazardous goods transportation.
 LCV driver has a valid driving license to drive transport vehicle. The driving license
had been renewed on date 26.05.2016 as per attached RTO receipt. LCV driver
started driving LCV for M/s Chaudhary Transport from 01/06/2016.

Cause:

 Sudden stoppage of the Auto rickshaw ahead of LCV to pick auto rickshaw
passenger.
 LCV driver was unable to steer LCV back quickly on the driving lane due to harsh
braking and hence LCV struck with the tree on the road edge.
 Safe following distance was not maintained by LCV driver from Auto rickshaw and
two wheeler rider from LCV.

Recommendations:

 Training to TT crew on defensive driving, to be vigilant of traffic and reduce speed at

the crossing junctions & merging points.
 Identification of accident prone spots on LCV movement routes without warning
signs.
 Do not permit the driver to drive the LCV at GGL till completion of successful
refresher training and assessment.

8. Incident at OM&S Area, Numaligarh (NRL)

Date of Incident : 09.06.2016

Time : 11:25 hrs

Entity : Numaligarh Refinery Ltd.

Location : OM&S Area

Description:
 On 9thth June 2016 at around 11:25 hrs, at the OM&S area of NRL while operating a fire
water cooling valve with a wheel key, the key got broken and the victim slipped over a
pipeline. The victim sustained pain at his back and further investigation revealed that he
had fracture injury in his lumber and was recommended to take bed rest for few days.

Cause:

 Unsafe condition i.e. non availability of operating platform & water lodging.
 Defective tool i.e. wheel not inspected before use.
 Unsafe ac i.e. operated the valve standing on pipe with wheel key without securing
himself.

Recommendations:

 Approach road and valve operating platform are to be provided.

 Operating person should be given refresher training on safe operational practices.
 Healthiness of tool should be checked before using.
 Valve should not be operated with unsafe position/posture like standing on pipelines,
standing on temporary structure.
 Housekeeping should be improved around the valve location.

9. Incident at NTR Statue, Medchal (BGL)

Date of Incident : 18.06.2016

Time : 10:55 hrs

Entity : Bhagyanagar Gas Ltd

Location : NTR Statue Medchal, Telangana

Description:

On 18th June 2016 at around 10:55 hrs, at NTR Statue Medchal, while open trenching the
road for installing water pipeline by water Department, Medchal BGL 63mm MDPE gas
pipeline got damaged and was rectified by 11:15 AM.
 Cause:

 Negligent excavation by third party.

Recommendations:

 “Dial before you Dig” notices should be supplemented by GIS mapping of the CGD
network so as to minimize the damage caused by the third party activities.
 The entity should continue to engage with Local Municipal Corporation to ensure that
“Dial before you Dig” process is followed by their contractors.
 O&M advised the residents to inform BGL emergency contact numbers prior to any
excavation in the gasified area.
 The entity should continue to influence third party contractors to prevent damage to
gas pipelines during excavation activities.
 Patrolling to be strengthened.

10. Incident at Mahatama Gandhi Marg, Delhi (IGL)

Date of Incident : 21.06.2016

Time : 12:30 hrs

Entity : Indraprastha Gas Limited (IGL)

Location : Mahatama Gandhi Marg, Ring Road, Delhi

Description:

On 21st June 2016 at around12:30 hrs, a fatal incident had occurred while shifting steel
line pipes. The said information received through news was published on 23.06.2016.
Immediately joint investigation of the incident was carried out by F&S and PNG
executives. During investigation, it came to know that the job of 12” pipeline laying from
GAIL DESU to Dhaula Kuan was awarded to M/s MP Engineering construction (India)
Pvt. Ltd. and the contractor had stacked all the required material (pipeline) at his own site.
On 21.06.2016, while shifting the stacked pipeline from the contractor’s site with the help
of Hydra crane, the labors were engaged in steel line pipe shifting work, and one of them
accidently fell on the road and hydra crane ran over him. Immediately he was rushed by
the contractor’s team to the hospital for medical assistance. Later at around 17.30 he was
declared dead by doctors. During investigation, it was told by the PNG C/R team that
 shifting work was carried out without any prior intimation and permission of IGL by M/s
MP Engineering Pvt. Ltd. at the site. The apparent reason seems to be that the contractor
wanted to prepare/get ready the site before actual start of pipeline laying work. M/s IGL is
being advised to ascertain the cause of the incident and submit the detailed investigation
report within a month.

Cause:

 Procedural lapses by contractor

 Non adherence to standard operating procedures

Recommendations:

 Although a Kick Off meeting was carried out with the contractor, still the job was
executed without Safety Work Permit System and even without any information. In
future, the same may be made clear to all the contractors while conducting Kick Off
meetings.
 For essential minimum requirements a checklist may be developed which should be filled
/signed /ensured at site by the contractor before which no material may be issued to the
contractor and no activities at site should start.
 The HSE Supervisor / HSE Engineer deputed at site shall be in line with the “Contractor
Safety Manual”. As specified in the manual – Contractor shall submit the HSE
Organization chart with responsibilities to IGL Fire & Safety Department and obtain
approval prior to start of the job.
 “Contractor Safety Manual” shall be introduced to be part of each tender document.
 The practice of taking work permit for any work with JSA should be practiced. This helps
in bringing forth safety precautions which can be covered in the tool box talk before start
of work to avoid any unsafe condition/ unsafe behavior/ human error.
 The deputed IGL Engineer for this project is responsible for day to day operation &
maintenance of PNG C/Rs and with such a dual responsibility it is difficult to do justice
with project job. The PMC personnel should be deputed on dedicated basis at site
reporting to him.
 Surprise safety checks should be conducted time to time to ensure compliance to safety /
other work related requirements.

11. Incident at Vadodara (GGL)

Date of Incident : 26.06.2016

Time : 15:45 hrs

Entity : Gujarat Gas Limited

Location : Dabhoi road, Dabhoi, Vadodara, Gujarat

Description:

On 26th June 2016 at around 15:45 hrs, a LCV was moving to a Daughter Booster CNG
station in Dabhoi road. The LCV driver observed an auto-rickshaw coming in wrong lane
from opposite direction. As a reaction, the LCV driver suddenly applied brakes and
simultaneously turned the steering to avoid collision resulting into toppling of the LCV.
LCV driver cabin got damaged and left side of cascade tubing and valves got damaged
and resulted in to gas leakage from the medium & low bank of CNG cascade cylinders.
Due to the collision, the auto-rickshaw was damaged and the auto-rickshaw driver was
injured. The auto-rickshaw driver was immediately shifted to the nearest hospital in
Dabhoi. LCV was taken upright with the help of police and parked at a safe location.
After upright of LCV, all the remaining gas in the high bank of cascade cylinders was
depressurized to make it safe.

Cause:

 LCV driver was driving at middle of the road which had no divider.
 LCV driver was driving LCV at reasonably high speed.

Recommendations:

 Lesson sharing with all LCV drivers across GGL’s operations:

 Driving in designated lane and continuously being in full alert of the traffic from the
opposite direction, especially when driving on the road without divider
 Drive at safe speed
 Refresher training on defensive driving to LCV driver.