Electrical shock to contractor welder on 7/5/2014

Incident Report
What happened:
On 7/5/2014 afternoon at about 1600 hrs., a contract welder name Shafqat
(Contractor: Malik Tariq, Section: Electrical Maintenance) reported getting an
electrical shock from a welding cable placed close to MOL Tank # 1, he was trying
to pick and take to Kiln # 3 airlock for some welding job.

Investigation:
A detailed investigation of the incident was carried out that revealed the
following sequence of events:
 Scrubber water line installation job was in progress at Kiln plant grit trolley
area just by the side of MOL tank # 1. The job was supervised by Jamshed
from Plant B and executed by Abdur Rauf Welder (Awan Brothers). PTW for
the Job was issued by Umer Hayat and received by Manzur Ahmed (Kiln
Foreman).
 During the job, Rauf wanted a valve to be installed on the line. So both he
and Jamshed left the area to look for a suitable valve. The welding cable
and holder was placed on the ground and the welding plant was not
switched off.
 Meanwhile, a contractor team from electrical department was working on
installing speed sensor on Kiln # 3 Airlock. The team required a welding lead
to fix the bracket of the sensor, so Shafqat decided to bring the welding
lead used by Rauf to his job while he was away searching for the valve.
 A small portion of the welding cable, about 1-2 ft. from the holder had its
insulation damaged. The length of damaged portion was approximately ½
inches. While trying to pull the cable, his hand came in contact with the
bare wire, and because the welding plant was still on, he got electric shock.
 Akhtar, contractual safety inspector for engineering, was close by and saw
Shafqat getting electric shock. He pulled the welding cable out of Shafqat’s
hand to rescue him.

Root Cause:
Based on this investigation, the root cause of the incident came out to be:
 Welding cable being left unattended by both Jamshed and Rauf.
  Rauf not switching the welding plant off when leaving the job site.
 Damaged welding cable being used for a job.
 Shafqat trying to drag the cable without its owner’s permission and without
ensuring that the welding plant is off.
 Shafqat not using proper PPE’s (Cotton gloves) while pulling the welding
cable.

Recommendations:
Based on this incident, the following recommendations are made:

1. Share the details and learnings of the incident with all the welders on the
plant (HK/ SAM).
2. Welding cable and holder inspection to be included as part of the
bimonthly welding plant inspection (SAM/ All area managers)
3. The practice of using repaired welding cables to be banned at the plant (All
area managers).

Investigation carried out by:

1. HK
2. SAM Report Date: 8/05/2014