KS 12-19.11.2019 PDF

workshop on
Understanding genesis of in-transit

accidents, its mitigation measures &
way forward
8-9 November 2019
Oil Industry Safety Directorate

Disclaimer
This presentation is for general informational and learning

purposes only and does not constitute or purport to render
advise. The views and opinions expressed in this presentation
are those of the author and do not necessarily represent official
policy or position. The material is intended, but not promised or
guaranteed to be current, complete or up-to-date. The author
assumes no responsibility for the content, accuracy or
completeness of the information presented.
Our Job is to….
3
…….prevent this from happening
4
Our Job is to….
5
WE ADD SAFETY
We work for you, with you, to make you more safe

AUTHOR:DEVENDRA M MAHAJAN,JOINT
DIRECTOR,OISD
In-transit Incident
Statistics
.................Oil Industries-India

Oil industry Incident Statistics
TRANSPORT ACCIDENTS IN LAST FIVE YEARS
195
139 148
127
96 TRANSPORT ACCIDENTS
DIRECTOR,OISD
19 15 8 6 7
TRANSPORT FIRES
2014-15 2015-16 2016-17 2017-18 2018-19
Transport (Fires) Transport (Accidents)
Incident Statistics
COMPANY WISE TRANSPORT INCIDENTS
180
IOCL
160
140 BPCL
120 HPCL
100
80
60
40
20
0
2014-15 2015-16 2016-17 2017-18 2018-19
Transport Total IOCL 104 110 151 114 60
Transport Total BPCL 97 159 97 58 49
Transport Total HPCL 110 170 124 119 113
Transport Total IOCL Transport Total BPCL Transport Total HPCL
Incident Statistics
FATALITIES (TRANSPORT) IN LAST FIVE YEARS
244
224
172 164
126
62 105 90 69
60 80 73 63 65
50 59 61 32 34
27
2014-15 2015-16 2016-17 2017-18 2018-19
DIRECTOR,OISD
Fatalities(Transport) IOCL BPCL HPCL

QUALITITIVE ANALYSIS

Qualitative Analysis
Poor Road Conditions
Figures in %
5.46875
6
5
4
3
2 1.282051282
0.970873786
0.862068966
1 0
0
14-15 15-16 16-17 17-18
AUTHOR:DEVENDRA M MAHAJAN,JOINT 18-19
DIRECTOR,OISD
Equipment failure Figures in %
15 13
10
6 6
4
5 3
0
14-15 15-16 16-17 17-18
18-19
DIRECTOR,OISD
Negligence by othersFigures in %
40
30
20
10
0
14-15 15-16 16-17 17-18 18-19
DIRECTOR,OISD
Negligence by TT driver
Figures in %
100
80
60
40
20
0
14-15 15-16 16-17
DIRECTOR,OISD 17-18 18-19
QUALITATIVE ANALYSISOF IN-TRANSIT ACCIDENTS
80%
70%
60%
50%
40%
30%
20%
10%
0%
Negligence by TT Equipment Natural Calamity
DIRECTOR,OISD Poor Road Negligence by
driver failure Conditions others
QUALITATIVE ANALYSIS OF IN-TRANSIT ACCIDENTS
Negligence by Last Five years

others
25%
Poor Road
Conditions
2%
Natural Calamity
2%
Negligence by TT
90 % Negligence driver
Equipment failure AUTHOR:DEVENDRA M MAHAJAN,JOINT 65%
DIRECTOR,OISD
6%
Negligence by TT driver Equipment failure Natural Calamity Poor Road Conditions Negligence by others
Genesis and Mitigation

What is this Negligence?
ROAD ACCIDENTS IN INDIA – 2017
Published by
TRANSPORT RESEARCH WING
MINISTRY OF ROAD TRANSPORT & HIGHWAYS,
GOVERNMENT OF INDIA ,
Published in July 2018
4,64,910 Accidents 1,47,913 Fatalities

4,70,975 Injuries
DIRECTOR,OISD
% % %
Traffic rules violation
accidents Fatalities injuries
Over-speeding 70.4 66.7 72.8
Driving on wrong side 6.3 6.4 6.4
Drunken driving/
consumption of alcohol & 3.0 3.2 2.5
drug
Use of mobile phone 1.8 2.1 1.7
Jumping red light 1.4 1.2 1.3
DIRECTOR,OISD
No violation & not known 17.1 20.3 15.3
ROAD ACCIDENTS IN INDIA – 2017 , GOVERNMENT OF INDIA ,MINISTRY OF ROAD TRANSPORT & HIGHWAYS,TRANSPORT RESEARCH WING-Published in July 2018
Why Over speed?
74 % Are they getting

Accidents Why Over any direct/ indirect
due to Over speeding? benefit of over
speeding speeding?
What makes the driver to drive fast? No. of trips

Morning Hrs.
Benefit of low temperature
AUTHOR:DEVENDRA M MAHAJAN,JOINT Is there any competition
DIRECTOR,OISD
ROAD ACCIDENTS IN INDIA – 2017 , GOVERNMENT OF INDIA ,MINISTRY OF ROAD TRANSPORT & HIGHWAYS,TRANSPORT RESEARCH WING-Published in July 2018
MITIGATION
Tanker Driver Environment

• Selection
• Design • Training
• Driving safety Policy
• Licensing • Motivation / Incentive • Roads
• Maintenance Scheme • Traffic density
• Trip Monitoring
• Vehicle Tracking AUTHOR:DEVENDRA M MAHAJAN,JOINT • Weather
• Counseling
DIRECTOR,OISD
• inspection • Disciplinary measures
• Time of the day
• Technical up gradation • Fatigue / sleepiness • Parking location
…………..Design/Safety features

Design & Safety features
The Petroleum (Amendment) rules, 2011.
For POL tank trucks design OISD-RP-167
Pressure vessels for transportation of LPG -The Static and
Mobile Pressure Vessels (Unfired) Rules 2016, IS: 2825,
OISD-STD-159-LPG Tank Trucks - Requirements of Safety
on Design / Fabrication and Fittings.
OISD-RP-157
STANDARD FOR SAFETY IN TRANSPORTATION OF BULK PETROLEUM PRODUCTS
Side guard for lateral protection
REAR CRASH GUARD
DIRECTOR,OISD
Design & Safety features
DESIGN
The Petroleum (Amendment) rules, 2011.
For POL tank trucks design OISD-RP-167
Pressure vessels for transportation of LPG -The Static and Mobile
Pressure Vessels (Unfired) Rules 2016, IS: 2825,
OISD-STD-159-LPG Tank Trucks - Requirements of Safety on Design
/ Fabrication and Fittings.
OISD-RP-157
STANDARD FOR SAFETY IN TRANSPORTATION OF BULK PETROLEUM PRODUCTS
DIRECTOR,OISD
…………..Driver

DIRECTOR,OISD
Training
Training
Outcome- Are we working on the root cause?

DIRECTOR,OISD
TRAINING-Emotional Quotient
Involve Family of TT crew

in health check up ,safety
पापा, धीरे training
चलाना
गड्डी
Sharing of Incident by
Victim/family
member
DIRECTOR,OISD
Video/live
TRAINING
1. DRIVING
2. TRAFFIC RULES
3. RISK INVOLVED
4. EMERGENCY
He should be aware of • Safety measures against the Risk

involved
• Fire extinguishing method/media
• The properties of the material carried,
• The handling method applicable
• Use of the fire extinguishing
DIRECTOR,OISD
equipment
• Emergency procedure to be followed.
………….. Technology

MITIGATION-Technical Upgradation
DIRECTOR,OISD
………….. Incentive and Punishment

Incentive and Punishment
DIRECTOR,OISD
Incentive and Punishment
DIRECTOR,OISD
………….. Audit

Our Initiative
We audit and ensure …..
• Vehicle Tracking System(VTS)
• Internal Valve with Excess Flow Check Valve
(IEFCV),
• Rear & lateral under run protection in TTs,
• ‘Valve box’ & ‘Crash Guard’ to be provided for
protecting ‘valves / manifold
• Defining the size of parking area in LPG Plants,
• List of safety equipment to be carried by truck
revised to 20 from existing 5.
DIRECTOR,OISD
Way Forward

DIRECTOR,OISD
Way Forward
Strengthen the training mechanism
Behaviour base safety training
Ensuring healthy and safe life to drivers
Emotional touch in training

DIRECTOR,OISD
Unsafe behaviour of TT
crew can result in….
The incident

FIRE INCIDENT
AT
LPG PLANT
IN
TANK TRUCK AT TANK LORRY

DIRECTOR,OISD
DECANTATION FACILITY
DIRECTOR,OISD
THE INCIDENT
Date & Time: 12th September, 2019 at about 10:23 hours

Location: Tank Truck (TT) at Tank Lorry Decantation Gantry
Injuries: Five persons reportedly received burn injuries and were admitted to the
hospital.
Sequence:
 1st batch of the LPG tank trucks were taken inside the plant on 12/09/2019 at
07:00 hrs.
 At around 10:00 hrs, 2nd batch of LPG tank trucks were allowed inside the plant
for the unloading operations.
 The loaded LPG tank trucks are routed through Weigh Bridge for gross
weighment and are positioned behind each bay awaiting their turn.
 Tanker no. ‘A’ was positioned behind the TLD bay no: 02
DIRECTOR,OISD
THE INCIDENT
 Tanker no. ‘A’ was positioned behind the TLD bay no: 02
 The driver of the truck then attached the male fittings on LPG liquid and LPG vapour
pipeline manifold on the LPG tank truck.
 In the meantime, TT no. ‘B’ and TT no. ‘C’ were placed behind bay no. 1 & 3
respectively.
 Similarly, loaded LPG TT’s were awaiting their turn by positioning behind the respective
TLD bays undergoing fixing of liquid & vapour male fittings.
 At 10:23 hrs, the driver of the tank truck no: ‘A’ (which is placed inside the TLD bay no:
02, and connected to TLD LPG liquid and vapour LPG pipelines via unloading arms
associated with breakaway couplings) reverses the tank truck.
 The unloading arms (liquid & vapour) are stretched to the maximum and rips the 2”
threaded ball valve on the LPG liquidDIRECTOR,OISD
pipeline of the tank truck. Immediately liquid LPG
from the tank truck starts to leak.

THE INCIDENT
 Liquid LPG leak from the fully loaded tank truck enveloped whole of the TLD and
adjacent area creating a thick white fog.
 LPG vapours were seen travelling towards Motor Control Centre (MCC), Diesel
Generator room, weigh bridge room, fire engine room and main gate.
 Sprinkler in TLD was operated and dispersal of LPG using water monitors was
undertaken.
 Around 10:50 hrs, the LPG vapour gets ignited which leads to Unconfined Vapour
Cloud Explosion (UVCE).
 The fire traced itself back towards the LPG source tank truck TT no: ‘A’ and started to
burn with high intensity.
DIRECTOR,OISD
THE INCIDENT
DIRECTOR,OISD
THE INCIDENT
 Bent Liquid LPG Breakaway Coupling inside TLD Bay: 02
DIRECTOR,OISD
THE INCIDENT
 Damaged manifold valves of TT
DIRECTOR,OISD
THE INCIDENT
 Sheared off LPG liquid manifold valve of TT
DIRECTOR,OISD
THE INCIDENT
 The leaked TT which caused the incident
DIRECTOR,OISD
THE INCIDENT
 Manifold valves & IEFCV’s of subject TT
DIRECTOR,OISD
THE INCIDENT
 Internal EFCV of incident TT
DIRECTOR,OISD
THE INCIDENT
 Internal Excess Flow Check Valve (IEFCV)
DIRECTOR,OISD
OBSERVATIONS
 Operability of Breakaway Coupling
Breakaway coupling/ emergency release couplings which have been
installed in this Plant are not designed to release in backward/ reverse
direction of the movement of the TT
 Supervision of TLD
From the CCTV footage it is observed that the fitting of the unloading
arms and opening of the LPG valves from the TLD manifold LPG
pipelines is done by the drivers and no intervention from the TLD
operators or supervision of officer.
DIRECTOR,OISD
OBSERVATIONS
 Violation of SOP’s
a) Wheel chokes are not positioned.
b) Checking of integrity of the LPG arms connection.
c) The operator was not available at his work spot.
 Breakaway coupling of the TLD unloading arm did not get activated
in reverse motion of the tank truck.
 Failure of IEFCV operation of the TT due to the bending of internal
shaft and housing of IEFCV.
 Failure of shearing of IEFCV at the provided weak spot on the outer
DIRECTOR,OISD
valve of the IEFCV.

RECOMMENDATIONS
 Adherence to SOP’s for unloading operations by TLD

operators & drivers.
 To ensure operators do not leave their work spot for any
reason unless the operation is completed.
Breakaway coupling mechanism works in
 To ensure
both directions.
DIRECTOR,OISD
QUESTIONS UNANSWERED
 The identity of the person behind the wheel of the accidented TT could
not be traced because of the lack of CCTV footage of TLD.
 Since the affected TT was the 1st of the second lot to enter the
premises, why did the driver choose to park behind TLD bay: 02 and
not TLD bay: 01 or TLD bay: 08 (towards extreme ends).
 Why did the driver move the vehicle after fixing the loading arms inside
TLD.
 Why the driver has not been traced, since he is the most critical
witness in this particular incident.
DIRECTOR,OISD
58
DIRECTOR,OISD

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workshop on

Understanding genesis of in-transit

Oil Industry Safety Directorate

This presentation is for general informational and learning

We work for you, with you, to make you more safe

Oil Industry Safety Directorate

Fatalities(Transport) IOCL BPCL HPCL

Oil Industry Safety Directorate

Equipment failure Figures in %

Negligence by Last Five years

Oil Industry Safety Directorate

4,64,910 Accidents 1,47,913 Fatalities

74 % Are they getting

What makes the driver to drive fast? No. of trips

Tanker Driver Environment

Oil Industry Safety Directorate

Oil Industry Safety Directorate

Outcome- Are we working on the root cause?

Involve Family of TT crew

He should be aware of • Safety measures against the Risk

Oil Industry Safety Directorate

Oil Industry Safety Directorate

Oil Industry Safety Directorate

Oil Industry Safety Directorate

Strengthen the training mechanism

Behaviour base safety training

Ensuring healthy and safe life to drivers

Emotional touch in training

Oil Industry Safety Directorate

TANK TRUCK AT TANK LORRY

Date & Time: 12th September, 2019 at about 10:23 hours

from the tank truck starts to leak.

 Bent Liquid LPG Breakaway Coupling inside TLD Bay: 02

 Damaged manifold valves of TT

 Sheared off LPG liquid manifold valve of TT

 The leaked TT which caused the incident

 Manifold valves & IEFCV’s of subject TT

 Internal EFCV of incident TT

 Internal Excess Flow Check Valve (IEFCV)

valve of the IEFCV.

 Adherence to SOP’s for unloading operations by TLD

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