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Leadership and Management of Safety

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35th DAE Safety Occupational Health Professionals’ Meet Monograph
 Part-A:
Leadership and Management of
Safety

 
Contributors:

Shri A. Varshney, CE (I&FS), NPCIL

Shri A. S. Vajarekar, Head, IHSS, BARC
Shri Jagdish Nageshri, GM (SH&E), HWB
R Sureshkumar, Executive Engineer (I&FS), NPCIL
Shri Lakshman N. V., OPSD, AERB
Dr Diptendu Das, AERB
Smt. Pammy Goswami, AERB
Shri Phani Karthik, AERB
Smt. Garima Singh, BARC
Smt. Pinki Chaudhary, AERB
Shri Vora Allarakha, AERB
Kum. Paridhi Aggarwal, AERB
Shri Vishvajit Bhatkhande, AERB
Shri Avimanyu Banerjee, AERB
Shri Kailash Gharat, BARC

 
 CONTENT

Sr. Title Page

No.

1 Introduction 1

2 Responsibility for safety 3

3 Leadership for safety 5

4 Management for safety 7

5 Safety Culture 10

6 Involvement of stakeholders in safety management - 12

Managers, Contractors & Workers

7 Effects of socioeconomic factors on safety management 15

8 Regulations for Management of Safety 17

9 Safety Management Review Process 20

10 Case Studies

1. Fatal Accident occurred due to H2S exposure 29

2. Explosion and Fire at British Petroleum Texas City 31

Refinery

3. Fatal Incident due to electrocution 37

 
 1.0 INTRODUCTION
Safety at the workplace is the responsibility of both employer and employee. It is one of the
fundamental responsibilities of all the personnel working in an organization, irrespective of their
organizational hierarchy. Every individual working in an industry shall own the responsibility to make
workplace safe by following safety practices and procedures.

From the onset of industrialization, need for safety management also originated. However, this need
came in light only after some major industrial disasters took place. One can say that major disasters
gave birth to safety management principles. And to implement these principles effectively, leadership
and management of safety is must.

Leadership and management of safety are of prime importance for organizations that are responsible
for facilities and activities involving risks to public and the environment. Therefore an effective and
sustainable leadership and management for safety shall be established.

‘Leadership’ means use of an individual’s capabilities and competences to give direction to

individuals and groups and to influence their commitment to achieve safety by means of shared goals,
values and behaviour. ‘Management’ is a formal, authorized function for ensuring that an organization
operates efficiently and that work is completed in accordance with requirements, plans and resources.

‘Leadership of safety’is often based on different notions of the most effective leadership. Concepts on
leadership vary from ideas on how leadership influences followership, to those based on more
coherent theories of leadership.

Leadership is about certain traits, but also in that leadership would be a possession of an individual or
a group of individuals. If leadership is about managing change, or at least the potential of change, a
useful concept of leadership should look at informal as well as formal leaders, across all
organizational hierarchies. In conventional approaches to leadership, it is assumed that leader abilities
are possessed by the top management, the leader of a work team or whoever is designated as the
leader in a particular context. But if leadership is a social relation and the concern is its performance,
leadership could just as well be seen as a relation distributed throughout the organization. The view of
leadership as a deep relation within the organization claims that change is achieved through members
of the organization at all levels. Safety leadership can just as well be the occupier changing formal
safety policies, as an operator persuading his co-workers to do things in a different way than
previously done.

Effective safety leadership positively affects employees’ safety behaviour and attitudes, helps reduce
injury rates and contributes to increased productivity by eliminating production bottlenecks. However,
it can be difficult to create a consistent safety climate in an environment that is continuously
changing: staff turnover, time constraints etc. Especially, for a complex organization like DAE, safety
management requires everyone in organization to be both committed to the idea, and that they

1
 
understand the complexities of the situation. This requires the ability to explain and simplify concepts
so that all staff is brought up to the same level for ensuring safety.

In order to increase the safety of personnel and manage technological risk, DAE units have, for many
years, implemented measures focused on the optimization of facilities & activities and the
implementation of safety management systems. However, outcomes of these systems seem to have
reached a plateau where further improvement goes beyond technical approaches and procedures and
requires greater attention to human and organizational factors. It is often that, especially in small
units, health, safety & environment responsibilities are assigned to individuals who have many
responsibilities, and the focus on safety gets lost.

Management of safety includes establishing and applying an effective management system. It has to
integrate all elements of management so that requirements for safety are established and applied
coherently with other requirements, including those for human performance, quality and security; and
so that safety is not compromised by the need to meet other requirements or demands. Safety
measures shall be applied in an integrated manner. The management system also has to ensure the
fostering of a strong safety culture, the regular assessment of safety performance and the application
of lessons learnt from experience. The management system also supports the development of
proactive and responsive management.

Objective

The objective of this monograph is to provide simple principles related to ‘leadership & management
of safety’ and provide practical examples & case studiesfor better understanding of all individuals of
the organization.

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 2.0 RESPONSIBILITY FOR SAFETY

The prime responsibility for safety rests with the person or organization responsible for facilities and
activities. Generally a license (may be in the form of license, consent, authorization or registration) is
issued under the provisions of various acts and rules in which responsible person or the organization
is identified. Such person/ organization (licensee, occupier, employer, etc. depending on the statutory
provisions under which it is issued, henceforth referred to as licensee) is primarily responsible for
ensuring the safety throughout the lifetime of facilities and activities, and this responsibility cannot be
delegated.

It is the general duty of the licensee to ensure, as far as

is reasonably practicable, the safety of all workers
during work. This may be achieved by

1. Provision and maintenance of plant and systems

of work that are safe;

2. Verifying appropriate design and the adequate

quality of facilities and activities and of their
associated equipment;

3. Arrangements for safe use, handling, storage and

transport of articles and substances;

4. Provision of information, instruction, training and supervision necessary to carry out work safely;

5. Maintenance of all places of work in a safe condition, maintenance of safe means of access to,
and egress from places of work, maintenance and monitoring of safe working environment, and
ensuring safe disposal of wastes;

6. Ensuring health surveillance (medical examination) pre / during and post-employment as

necessary.

The licensee is generally responsible to ensure safety. Not having a license would not exonerate the
person or organization responsible for the facility or activity from the responsibility for safety.

Other groups, such as designers, manufacturers & constructors, employers, contractors, and
consignors & carriers also have legal, professional and functional responsibilities with regard to
safety. The designers and suppliers shall ensure that the equipment or article is so designed and
constructed as to be safe when properly used and provide adequate information and conditions
necessary for safe use.

3
 
Employees of organization shall adhere to safety procedures and should be aware of statutory/ legal
provisions. It is also a moral responsibility of the employee to maintain safety at his/ her workplace.
Though the prime for workplace safety rests with the individual or a group of individuals responsible
for the facility and activities; there are some statutory provisions the employee should adhere to. The
Factories Act, 1948, prescribes the involvement of workers in safety management through
participation in safety committees constituted at the facilities and also prescribes following
responsibilities of workers:

No worker in factory -

1. shall interfere with or misuse any appliance, convenience or other thing provided in a factory for
the purposes of securing the health, safety or welfare of the workers therein;
2. shall endanger himself or others; and
3. shall neglect to make use of any appliance or other thing provided in the factory for the purposes
of securing the health or safety of the workers therein.

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 3.0 LEADERSHIP FOR SAFETY

Safety performance is driven by the leadership of the organization. Leaders establish values, develop
procedures, and enforce accountability for their safety programs i.e. safety leaders set the standards of
safe behaviour within their domain. Leadership is more than just managing one’s own safety
behaviour. A safety leader also motivates his or her co-workers to strive for minimal risk exposure.
Safety leadership is defined as the process of interaction between leaders and followers, through
which leaders can exert their influence on followers to achieve organizational safety goals.

Terms ‘leadership’ and ‘management’ are used

interchangeably. However, there are critical
differences between these roles and the vital functions
of each in building strong safety performance.
Specifically, managers exist as part of the
organization’s structural hierarchy and exert formal
influence over their subordinates, while leadership is a
voluntary activity by which an individual motivates
co-workers by setting an example of appropriate
behaviour to elicit shared goals and effect positive
change in the organization. Certainly, one individual
can be both a manager and a leader, but this only occurs through conscious efforts to effectively
perform both roles. Therefore, any individual in the organization can be a safety leader if they so
choose to be.

Even though it is crucial for organizations to have safety leaders at every work site, every department,
every work team, etc. across levels of the structural hierarchy if they want to create a strong safety
culture that leads to improved safety performance. In fact, senior management may not be the most
knowledgeable about the hazards of a particular job. Thus, management should impress on their
workforce that a safety leader is anyone who cares enough about the individuals and organization to
take the actions that will keep themselves and others free from danger or injury through guidance,
persuasion, direction, and setting the example. Safety leaders do not influence others through power,
status, or authority; they demonstrate high safety attitude and inspire their co-workers.

What it means to be a safety leader?

Leadership is not about the attributes of an individual, but rather their behaviours. Just because an
employee is not charismatic does not mean that he or she cannot be a safety leader. Safety leaders
exhibit a variety of behaviours that, often unintentionally, influence co-workers to improve their
attitude towards safety, such as:

5
 
• Being an example, by knowing and following the rules
• Avoiding complacency for the dangers of the job
• Reporting hazards, violations, and incidents
• Maintaining open communication with co-workers and management about safety concerns
• Implementing change to improve safety and working conditions
• Encouraging co-workers to exhibit safe behaviours
• Appreciating co-workers for a safe job done
• Making co-workers aware that unsafe behaviour is unacceptable
• Being involved in safety initiatives and committees

Although this may appear to be a burdensome obligation that some employees may shy away from
but they must realize that safety leaders take on no greater share of the responsibility than their co-
workers. The main difference is that safety leaders are more cognizant of their environments and
throughout the day are more likely to take the correct and safest actions based on training and
experience. Management should support the decisions made by safety leaders and empower them to
guide others to strong safety performance.

Safety leadership is more about providing the room to perform a job safely than about making it
impossible to do the job unsafely. To assume that people will do things wrong if they are not told
exactly how to do things, is not the point. The assumption should rather be that people will do things
safely unless the conditions for this are unfavourable. Safety leaders who want to increase resilience
should focus on construction of roles which allow people to do things safely.

Effective Leadership for safety may be reflected: by establishing and integrating the organization’s
vision, goals, strategies, plans and objectives; by advocating individual commitment to the protection
of people and the environment from harmful effects; and by advocating the safety principles,
establishing behavioural expectations and fostering a strong safety culture.

Managers at all levels need to be leaders for safety. Management of the work environment and the
measures that ensure safety is a key concern for managers, both for ethical reasons and because safety
is a legal responsibility. The conduct of managers themselves with respect to safety carries much
more weight with workers than any slogans that can be devised by the company. Through their
behaviour managers demonstrate the real value the company places on safety and it is a determining
factor in the motivation of staff to take an active interest in safety. It is essential that safety
improvements as collective mobilization go hand-in-hand with managerial leadership. Important
lessons can be learnt from Fukushima Nuclear Disaster in which not only wasmanagerial leadership
unprepared for a tsunami following a major earthquake, they also failed to anticipate both the damage
inflicted on the nuclear plant. In the midst of chaos, they should stop looking for control and start
looking for answers.

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 4.0 MANAGEMENT FOR SAFETY

Management for safety is managing activities and applying principles, framework, processes to help
prevent accidents, injuries and to minimise other occupational risks. Management for safety can be
achieved by:

a) Establishing goals that are consistent with the safety

policy;
b) Integration of all elements so that safety is not
compromised;
c) Determining the competences and resources necessary
to carry out the activities of the organization safely;
d) Clear assignment of responsibilities to individual for
carrying out work safely;
e) Effective management of processes and activities to
achieve the organization’s goals without compromising
safety;
f) Arrangements with suppliers for specifying, monitoring and managing the supply of items,
products and services that may influence safety;

Management for safety is prioritized in nuclear and aviation industry due to inherent high risk
potential. Recent incidents in aviation and process industry are explained briefly to emphasize the
importance of management for safety.

A. Accidental drop of cabin pressure in aircraft:

The accident of drop of cabin pressure in aircraft that occurred on August 14, 2005 involving aircraft
of Cypriot airline. The accident occurred as result of Captain and Crew incapacitation due to loss of
pressurization, followed by fuel exhaustion.

Understanding the pressurization system of aircraft is crucial to understand the above accident. The
purpose of the pressurization system in aircraft is to provide a safe comfortable cabin at all aircraft
altitudes. The pressurization system uses bleed air supplied by the engines and distributed through the
air conditioning system.

The previous flight crew earlier reported a frozen door seal and abnormal noises coming from the
service door of the aircraft and requested for a full inspection of the door. The inspection was carried
out by a ground engineer by carrying out pressurization leak check by setting the pressurization
system to ‘Manual’. However, the engineer failed to reset it to "auto" on completion of the test. After
the aircraft was returned into service, the flight crew overlooked the pressurisation system state on
three separate occasions: during the pre-flight procedure, the after-start check, and the after take-off

7
 
check. During these checks, no one in the flight crew noticed the incorrect setting. The aircraft took
off with the pressurisation system still set to "manual". As the aircraft climbed, the pressure inside the
cabin gradually decreased. Several warning lights on the overhead panel in the cockpit illuminated
indicating the low air flow through cooling fans of equipment and deployment of oxygen masks in the
passenger cabin.

In the above incident, it appears that the direct causes of the accident are due to non-recognition that
the cabin pressurization mode selector was in manual mode, non-identification of alarms in cockpit
and incapacitation of the flight crew due to hypoxia.

One of the latent causes is deficiency in maintenance (Omission of returning the pressurization mode
selector to AUTO after unscheduled maintenance on the aircraft). Generally the accident investigators
focus on the direct cause and the identification of direct cause will not prevent any recurrence of
similar accident/incident. Instead the focus should be on the identification of latent causes which will
have positive impact for accident prevention.

If the maintenance personnel were trained properly regarding aircraft safety, then they would not have
left the selector switch to manual mode. Therefore, safety should be integrated in all management
systems including operation and maintenance, fabrication, procurement and quality assurance (QA).

The flight crew was lacking adequate training to address the probable situation of loss of
pressurization. This indicates that the personnel employed in risk potential jobs should be given
adequate training to deal with probable emergency scenarios and assessed for their performance
before being placed in actual job conditions. The competence of the personnel should be determined
and augmented for carrying out the activities of the organization safely.

The recent incident of sudden drop of air pressure in aircraft of Indian airliner that occurred on
September 20, 2018 is similar to Cypriot airliner. However, the incident fortunately resulted in safe
landing of aircraft with minor injuries to some of the passengers. Every incident may or may not
result in serious consequences, as it is a matter of chance. However safety precautions are mandatory.

B. Accident ingress of water from breathing air line:

Breathing air lines are generally provided in Chemical Industries handling toxic gases as well as in
Nuclear Industry for habitation of plant personnel. The incident related to breathing airline after
maintenance is referred for importance of safety during maintenance activities.

In a plant, a special network of air lines was installed for use with air masks only. The source of air
was taken from the top of the compressed air main. For 30 years this system was used without any
complaint. One day a man experienced water while wearing an air mask. Fortunately he was able to
signal to the stand-by man that something was wrong, and he was rescued before he suffered any
harm.

8
 
 Figure 1: Arrangement of breathing air lines before and after maintenance

Investigation found that the compressed air main had been renewed and that the branch to the
breathing apparatus network had been moved to the bottom of the main. When a slug of water got into
the main, it all went into the catch-pot, which filled up more quickly than it could empty.
Unfortunately, everyone had forgotten why the branch came off the top of the main, and nobody
realized that this was important.

The above incidents emphasizes the importance of ‘Management for Safety’ in risk potential jobs.

Management for safety can prevent safety and health risks at the workplace. Three underlying
management principles, which are key for enhancing safety and health are:

• Effective and strong leadership;

• Involving workers and their constructive engagement;
• Ongoing assessment and review.

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 5.0 SAFETY CULTURE

Safety culture is the assembly of characteristics and attitudes in organizations and individuals which
establishes that, as an overriding priority, safety issues receive the attention warranted by their
significance. Establishing safety culture is a fundamental management principle. Safety Culture has
two major components: the framework determined by organizational policy and by managerial
action, and the response of individuals in working within and benefiting by the framework.

Good practices are not sufficient if applied mechanically. Safety Culture requires all duties important
to safety to be carried out correctly, with alertness, due thought and full knowledge, sound
judgment and a proper sense of accountability. Safety consciousness, an inherently questioning
attitude, the prevention of complacency, a commitment to excellence, personal accountability and
self-regulation are the key elements of safety culture.

One of the tests of leadership is the ability to recognize a problem before it becomes an emergency
and here comes the importance of safety culture. To explain this a famous story from Panchatantrais
described below, where the leader of monkeys foresighted an imminent danger and addressed a safety
issue before it happened.

Once there was a king who had monkeys and sheep in his palace as pets for the prince. One of the
sheep used to enter the kitchen whenever it got a chance. The cook then used to hit it with whichever
thing he could find. One day the leader of monkeys saw this and he told them, "Listen! One day, when
cook would find nothing, he would try to hit the sheep with a burning stick. The fleece of the sheep
would surely catch fire. The sheep would then try to run towards the stable to extinguish the fire. The
grass and straws kept in the stable
would catch fire. The horses would
be severely burnt. The physician
will prescribe the fat of the
monkeys as a medicine. The king
would then order slaughter of all
the monkeys. So let us leave this
place at once and go to the forest."
But the troop of monkeys did not
pay any attention to his advice and
perished.

What the leader of monkeys did was an event analysis, an important tool of safety culture. Based on
his experience, he reasoned out single event sequences so-called event building blocks, made a
sequence of events based on contributing factors, analyzed human behavior, various possibilities,

10
 
suggested course of action, then selected the remedial measure as moving to the forest based on his
hypothesis. He was the chief of the troop of monkeys but this practice of safety culture gave him the
leadership quality.

From above story it is evident that an active safety culture prevents accidents before they occur and
becomes the key component in ongoing safety success. The practice of reconstruction of an accident
by safety & occupational health professionals through investigation should be supplemented by
hypothesizing or building the chain of events from work conditions that can lead to an accident. This
is vital for the protection of and improvement in the quality of life for everyone who works in the
organization. While continuing to maintain and improve engineered safeguards and operating in a
well-developed system for managing safety, organizations need to strive for a culture in which
there is real commitment from the top of the organization to a safety vision, a set of values
and ways of working that are developed and identified by the workforce. In addition, utilization
of Operating Experience Feedback (OEF) for risk reduction and enhancement of operating safety
further brings improvement in safety culture.

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6.0 INVOLVEMENT OF STAKEHOLDERS IN SAFETY MANAGEMENT -
MANAGERS, CONTRACTORS & WORKERS
Although Occupier is solely responsible for the safe operation of the facility, other stake holders
contribute significantly in achieving this goal. The principle stakeholders in safety are Managers,
Contractors and Workers.

Everyone in the workplace ─ from senior

management to frontline workers ─ needs to
understand his/her responsibilities when it
comes for implementing and maintaining a
healthy and safe workplace. Senior Managers
including Occupier are responsible for
establishing and maintaining the safety
management system. Their roles and
responsibilities primarily include establishing
levels of acceptable risks, formulating HSE
policy, dissemination of necessary information
relevant to safety to other stake holders,
allocating adequate resources essential to effectively manage the health and safety management
system requirements and overseeing system performance. They must also ensure that workers put to a
task are trained, qualified and competent to perform it. Line managers are responsible for execution
of activities and also for health and safety in the work under their control. Workers need to work
safely, according to how they were trained. Based on the experience (hurdles) of execution of work at
the bottom level (like worker and line manager level) safety/HSE policy or responsibilities may be
reframed.

1) Contractor Management: The use of independent contractors (hired for their own specialized
skills and experience) is increasing day by day in any facility. Whilst there are significant
advantages of using contractors, a facility’s safety management system must be geared to manage
the potential imported risk. Major risks associated with the contractors are:
a) Contractors may not have the same level of safety commitment or safety culture as the facility.

b) Contracts can be agreed on the lowest cost bid criteria which may not be in line with the best
overall contractor safety performance.

c) If adequate due diligence is not undertaken, issues within the contractor (such as lack of
resources, poor safety performance etc.) may not be identified before a contract is signed.

d) The facility may not be adequately resourced to effectively manage contractor activities from
project planning through to completion.

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 Risk increases further in case of sub-contractors/petty contractors. Contractors may use sub-
contractors which may not be apparent to the facility; these sub-contractors may not be under the
effective control or supervision of the principle contractor and may deviate from contractual
standards. It is often difficult for the facility to accurately assess the extent of principle contractor
control over their sub-contractors. A facility’s contractor safety management process must be
designed to manage the risk profile that contract works introduce into any facilities operations.

Contractor management is the managing of outsourced work performed for an individual facility.
Contractor management refers to the selection, management and analysis of these outsourced
employees and their work for the facility.

The basic framework to oversee contractor management can be broken down into five phases:

1. Planning for contractor works.

2. Assessing and choosing contractors.

3. Communication of health and safety requirements to the contractors and commitment

obtained from them on meeting the requirements.

4. Supervision of contractor works.

5. Reviewing and assessing contractor performance.

Open, proactive and effective HSE communication and consultation has to be maintained with the
stakeholder regarding the HSE aspects for achieving the set health and safety objectives and
targets. Joint endeavour by all the stakeholders’ aid in promoting a positive health and safety
culture at the facility.Common forum may be made by the utility to ease out experience sharing
among all contractors in the project.

2) Graded approach in application of safety management systems training & skill management,
equipment and machinery
Graded approach in application of safety management system should be based upon the hazards
and the magnitude of the potential impacts associated with the safety, health and environmental
elements of each facility/activity. Few examples are listed below to demonstrate the use of graded
approach in application of safety management system:

i) Risk assessment has to be done only for the hazardous job having the potential to adversely
affect the health and safety of the worker and the work environment.
ii) Apart from safety induction training, skill based training has to be given only to the workers
required to be put in specialized work.

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 iii) The level of supervision required in the workplace has to be increased if the level of safety
control put in place to reduce a risk is low, i.e. the less effective the control measure used,
the higher the level of supervision necessary.
Penal provisions/ token of appreciation for accident free tenure during the contract phase/some part
of the contract cost may be allocated to accident free execution of contracted work depending upon
the scope of the contract.

3) Provisions and utilization of resources for safety

Senior management has to provide adequate resources essential to effectively manage the health
and safety management system requirements of the facility. The resources include human
resources, infrastructure, the working environment, knowledge and information and financial
resources.

Senior management has to ensure that competence requirements for individuals at all levels
(including workers) are specified. Training has to be conducted or other actions taken, to achieve
and to sustain the required levels of competence. An evaluation has to be done periodically to
monitor the effectiveness of the training and of the actions taken.

In case of petty contractors, the occupier has to facilitate them with the necessary resources so as
to ensure safety at the workplace e.g. providing infrastructure, training, safe work methodology
etc.

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 7.0 EFFECTS OF SOCIOECONOMIC FACTORS ON SAFETY MANAGEMENT

In India, traditional labour-oriented markets have changed toward more automation and
mechanization. Workers are categorised three broad categories of permanent, temporary, and contract
workers In this section the socioeconomic factors affecting the safety management are discussed.

Social factors

It is observed that most of the poor families,

are engaged in low-level occupations,
unskilled labour job are mostly migrant
labourers, coming from the different states
and they are not educated thus very difficult
to educate them on safety aspects. It may be
noted that nearly 92% of the workforce is
from the unorganized sector.

The ‘contract labour,’ is the most deprived,

and is found to have escaped most of the provisions of Labour Acts, especially the Factories Act, the
payment of Wages Act, the maternity Benefit Act, and so on. The petty contractor and sub-contractor
are always ill-equipped with the safety gadgets.

It is also observed that ‘unskilled labour’ mostly lived in unhygienic environments, resulting in a high
rate of malnutrition and communicable diseases. In this social hierarchy, another group, namely,
women were well discriminated from the society. They were absorbed in housekeeping job of labour
in peak requirement seasons, at almost one-third of the salary as compared to an adult male.

Therefore, social inequality has serious implications, not only at the work places. Labour from low
socioeconomic families have to do unskilled jobs and jobs that no one else takes up because of the
associated hazards related to poor environmental conditions, and therefore, become depressed and
exposed to poor safety culture .

Other socio economic factors

a) Under funding and poor economy

In developing countries, the legislation designed to deal with safety matters is broad and even
profuse in many cases. However, sometimes it cannot be applicable even to basic matters. Some
of the most obvious problems are the lack of national and international funding, human and
technical resources, weak strategies and policies, and more reasons, thereby weakening the idea of
implementing health and safety programs. India has taken safety management on board by
enacting legislation and creating structures for its implementation.

15
 
b) Role of Management and trade unions at work places
Lack of implementation, however, seems to be an effective agreement between trade unions
resulting in a formation of a new kind of conflict between workers and management in both the
organized as well as the unorganized sectors. Sometime Department / contractor promises to
provide personal protective device to every worker. However, these promises remained on paper
only, hence, the plants had to provide only a few workers with personal protective devices.
Corruption, greediness, and lack of knowledge of health and safety among the workers not only
fails to bring about a successful escape from poverty, but also pushes both the informal and
formal sectors of economy toward vulnerabilities.

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 8.0 REGULATIONS FOR MANAGEMENT OF SAFETY

Historically, the process of safety management in the production process was imposed upon by the
society through legislative interventions. Thus, the study of the history of safety management turns
out to be a history of safety legislation. While management process evolved to be an integral part of
the manufacturing process, safety management never emerged to be an essential part of it, except in
highly hazardous industries. Even in twenty first century, the trend continues and there is the need for
invoking the legislative intervention for injury prevention in the society since safety management is
yet to be an integral part
of the manufacturing
process.

Role of Legislation

In most of the cases,

significant advances in
safety have taken place
through legislative
intervention. Safety
legislation, to a vast
extent, is engaged in an
examination of the actual
state of affairs within 'man- machine- environment system' to determine whether and to what extent
modern technology can be accepted by law. The legal system can never abandon the life and the
health of the citizens to the dangers inherent in modern technology.

Occupational health and safety laws and standards are based on a technical approach to the
management of occupational health and safety risk. In the technical literature, risk management is
defined as a three staged process. First, hazards in the work environment are identified; second, the
risks posed by these hazards are assessed; and finally, appropriate controls for risks are selected
according to a risk control hierarchy. According to the principle of this hierarchy, the control
measures that target hazards at their source and act on the work environment are more effective than
controls that aim to change the behavior of exposed workers. Thus, technological control measures,
such as the substitution of hazardous substances or processes and engineering controls, are preferable
to individual/ administrative controls such as the introduction of safe work practices or the use of
personal protective equipment.

Constitutionally, labor is a concurrent subject. The main objectives of the Factories Act 1948 are to
ensure adequate safety measures and to promote health and welfare of the workers employed in
factories. It is the main legislation governing safety, health and welfare of persons employed in

17
 
factories. It is a central enactment but is enforced by the State governments. The power of making
rules under the act is also vested in the State governments. The Factories Act empowers the Central
government to issue directions to the State governments with regard to the execution of the provisions
of the Act. In DAE, AERB is empowered to administer the provision of the Factories Act and rules
framed thereunder.

For the enforcement of various provisions of the Act, the State governments appoint persons with the
prescribed qualifications as Inspectors/Certifying Surgeons in respect of the local limits assigned to
each of them. In addition, every District Magistrate is the 'Inspector' for his district. For DAE units,
Inspectors are designated by Chairman, AERB. The inspector possesses requisite powers such as
those relating to entry into the factory, inspection of premises, plant, and machinery, making on the
spot enquiries, requiring production of documents, etc., for effective enforcement of the Act. The
duties of the Certifying Surgeons are to examine employees and to issue the certificate of fitness, to
conduct periodical examination of persons engaged in dangerous occupations in factories and to
exercise general medical supervision.

Model rules are framed under the relevant provisions of the Act in order to maintain uniformity in the
administration of the Act in various states. These rules were framed by the Directorate General of
Factory Advisory Services and Labour Institutes (DGFASLI) which is an attached office of Ministry
of Labour, Government of India. In order to achieve uniformity in the standards of enforcement,
DGFASLI on behalf of the Ministry of Labour, enlists the co-operation and involvement of the state
governments by convening annual conference of the Chief Inspectors of Factories of all the states.

In 1984 the infamous Bhopal disaster took place. Consequent to this disaster, the comprehensive
changes were made in the Factories Act. In its 1987 amendment, for the first time the Act had made
provisions related to the physical location of the industry in the context of its neighbourhood. The
amendments hadthree principal objectives namely,

a) To locate the factory in such a manner it does not cause adverse effect to its neighbourhood.

b) To provide for the measures of protection against the danger of handling hazardous substances.

c) To enable the participation of workers in the safety management.

Historically, in the initial stage of legislation, the onus of responsibility for remaining safe at work
was thrust on those who operated the machinery. Accordingly, in the event of an accident it was
considered that the operator working on the machine had caused accident and therefore was not
eligible to get any compensation. In the middle of the twentieth century the onus shifted from the
worker to the occupier as the occupier is in the position of control of what is being done and how it is
being done.

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In the present times, there is a growing realization of the positive role that employees have to play in
health and safety. The catalyst for this realization seems to be the knowledge that is being imparted
systematically to all the employees in the plant through well-planned safety, health and environment
related training programmes. There are many examples that similar attempt is made to make the
community outside the plant to be knowledgeable about safety, health and environment aspects of the
product and the plant. Some of these attempts have been made legally obligatory for manufacturers
and suppliers to pass the information to their customers about hazards and safe operating techniques
for the products they supply. This obligation is met by preparing and issuing manuals, material safety
data sheets, statutory warnings etc.

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 9.0 SAFETY MANAGEMENT REVIEW PROCESS

Safety management System

The new accident causation models are based on assumptions that, most of the time, the root cause of
accidents and incidents are the management decisions or organizational practices. The systematic and
well planned management driven activity which control the safety and health hazards is called as
Safety Management System. An effective Safety Management System comprises the following
elements. It may vary from industries to industries. But the major elements will be almost similar.

Fig.: Safety Management System

Why to review Safety Management System?

A variety of Safety Management Review techniques have been developed and disseminated over the
past years. Safety Management System usually refers to organisational structure, governance
structure, planning activities, clear responsibilities, job practices, work procedures, processes
evaluation, resources for developing, implementing, achieving, reviewing and maintaining the system.

Performance evaluation of the systems are an important area which are to be reviewed periodically.
Critical examination of the systems by a team of experienced personnel in all functional areas will
give a clear picture of the actual performance overview. The outcome of any review process shall
finally trend towards organizational improvements.

The point of performing a Safety Management Process review is not just to make sure that, the
systems are working normal. Instead, the review process shall ensure the continual improvement of
Safety Management Program which encompasses monitoring, evaluating, and correcting the system
by means of an effective arrangement. It is very important to include top management in this review
process because it has the authority to make necessary decisions about actions, resources, and
resource allocation. All members of line management shall also be the parties in the review process.

20
 
An Effective Review Process will have the following advantages:

 To identify the strength and weakness in Safety Management Process

 To understand and bring out effectiveness of existing programmes, policies and practices
followed in the organization.
 To enable optimum use of resources and reduction in wastage.
 To help the line management for identifying the gaps in the system and to initiate appropriate
action in right time.
 To help the top management for achieving higher level of excellence along with safety
requirements
Various type of review processes can be suitably applied for Safety Management System. Selection
of review process shall be based on the depth, complexity and risk levels in the systems. In any
review process, the items important to safety and items important for operations shall be reviewed
critically.

How to conduct Reviews

Conduct of review is a team work in which the top management & line managers and reviewers, are
the counterparts. Selection of review program and review team shall be carried out carefully.

Type of Reviews

There are many review

systems available for Safety
Management Systems. The
selection of the systems will
be based on many
parameters. The Safety
Management Review
Systems shall be external or
internal. The External
Reviews shall be by an
external agency, either a third party safety review or some specialised team constituted for the
purpose. The internal review team shall be a team constituted by the top management for the purpose.
The main advantage of internal review is that, there will not be any masking of gaps. But in many
cases, external review will be more effective as there will not be any biasing. The reviews even if of
any type shall be as per some pre-stated performance objectives and targets. Some examples of
reviews are:

 Self-Assessment Programme

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  ISO Audits and National Safety Council (NSC) reviews
 Corporate Review and Follow up Review
 Independent Review cum Exchange Visits for Construction Sites

Self-Assessment Programme

Self-assessments shall be carried out once in a

year by the persons or agencies of other section
in the same organization. Self-Assessment
iscarried out by same section personnel also as
per a pre-drafted procedure. Self-assessments is
normally carried out by the Functional Heads in
the organization to evaluate and assess
performance of their work and safety culture.
Procedures and work instructions for
implementing the self-assessment processes are
developed in detail, commensurate with the
complexity of the process, activity and
importance to safety as required. Results of self-assessment are communicated to top management of
organization. Management level self-assessment identifies, corrects and prevents management
problems that hinder achieving the objectives of organization for safety, in addition to regulatory
compliances, meeting product standards and established procedures etc.

ISO Audit Programme and NSC Reviews

ISO Audit basically carried out to ensure “what are actually doing” with respect to what the
organization declared in the plan. Organizations usually will have Quality Management System
(QMS) Documents, which clearly give the outlines of missions and quality policies. It will be in line
with the Corporate Management Systems. Corporate Management System containing Policy
Statement of organizations, Statements on Management System, Organization Structure, Resource
Management, Measurement, Assessment & Improvement and Implementation of these systems.
Usually, the audits are carried out by external certifying agencies after detailed technical examination
of the documents. This ensures that all the inputs and design basis criteria have been incorporated in
QMS. Examinations are carried out as per prefixed Audit Criteria. Set of Policies, procedures or
requirements used as a reference all called Audit Criteria. Records, statements of fact or other
information, which are relevant to the audit criteria and verifiable are known as Audit Evidence. It is a

22
 
systematic, independent and documented process for obtaining audit evidence and evaluating it
objectively to determine the extent to which audit criteria are fulfilled.

Agencies like National Safety Council (NSC) conduct safety audits in industries. NSC offers the
comprehensive guidance in improvement on health, safety and environmental issues for industries.
Audits are carried out by experts in the respective fields and prepare recommendations to upgrade
safety inputs to prevent mishaps and limit consequences.

Independent Review and Corporate Reviews

Independent Reviews and Corporate Reviews are carried out as an instrument to examine the safety
performance critically in action level. The review process starts with fixation of Performance
Objective and Targets. A clear stated policy is the base of Performance Objectives and Targets. After
finalising the review team, proper planning is chalked out as per the requirements identified. All team
members are clearly informed about the plan. The implementation of this plan is a key process of the
review. Management of review process will start from review preparation to the report presentation.
This will help to finalise the action plan. Duties and responsibilities are clearly marked in the action
plan with follow up strategy and completion period.

The review process for construction site defers from operating plant. In construction sites, the systems
are in transit mode. The manpower is in floating mode. The chance of language barrier also exist
there. But in operation units, the systems are in established condition. Manpower is regular. So the
review methodology and frequency may differ for construction site when compared with operating
units.

Performance Objectives and Criteria

Corporate Review or Internal Review or Self-

Assessment is usually conducted almost in line with
the “Corporate Review Guidelines”. Corporate
Review or Internal Review or Self-Assessment
involves Plant Inspections, Observations for
identification of weaknesses and good practices.
Based upon these, “White Cards” are filled and
“Observation Reports” are prepared. White Cards and
Observations Reports are presented to the
management of reviewing facility to address observations in a time bound manner. Entire review
process is based on identification of “Facts”. These facts are compared with and linked to a set of
“Performance Objectives” in each functional and cross functional area. The review team uses the
“Performance Objectives & Criteria (PO&C)” document in each area as the basis for the review.

23
 
Review Preparation

Preparation for review is very important for Corporate Review or Internal Review or Self-
Assessment. The first step in preparation for review is to identify the scope of the review. This can be
known by referring the Performance Objective and Criteria for Safety Management System. It will
provide a good idea for planning of observations, investigations and interviews etc. For each
Performance Objective, Criteria are made to evaluate the facility activities to meet the Performance
Objective. Criteria are not quantitative. Those cannot be used as a check list. Reviewer’s practical
experience and knowledge is utilized to make an objective assessment for an effective review. The
experience of other review team members from different units is shared for best results.

Before reaching the site, the review team members themselves be prepared for the review. Once a
person is identified as the team member for Corporate Review or Internal Review or Self-Assessment,
it is necessary to prepare himself for carrying out the review. The team member may collect various
data about the plant, which will help them to focus review in assigned functional area.

For reviewing industrial and fire safety areas, the reviewer must be thorough about Factories Act,
Atomic Energy Factory Rules, Codes and Standards pertaining to Safety and Fire Protection etc.
Following are the examples of the document of organizations that a reviewer can refer to for gathering
the information:

1. Industrial & Fire Safety Section Organization including that of Fire Services.
2. Monthly, Quarterly and Annual Industrial & Fire Safety Reports
3. Accident Statistics and Accident Investigation Reports of:
a. Near Miss Accidents
b. First Aid injuries
c. Non-Reportable Accidents
d. Reportable Accidents
e. Dangerous Occurrences
4. Statistics of fire incidents and investigation reports of fire incidents.
5. Reports on previous Corporate Review or Internal Review or Self-Assessment and
compliance to the observations
6. Reports on Regulatory Inspection and compliance to the findings
7. Minutes of Safety committees (Sectional & Apex) meetings
8. Trend of performance indicators related to Fire Safety and Industrial Safety
9. Communicate with the Counterpart and obtain additional information on surveillance plan,
weekly plan etc.
Preparation after reaching the review site:

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It is to be recognised that the time available for review is limited and therefore it is important that the
reviewers have their review programmes and targets well defined. Reviewers can also manage this
from the counter parts of the functional areas. All reviewers may prepare themselves well for
achieving high quality review. The review will start with the plant Inspection. This is a walk around
and thorough visual inspection of all the installations. Job Observations shall be planned as per the
pre-determined plan. The job list can be made available from which the observer can select the jobs.
Interviews with line managers also shall be conducted which will give more clarity regarding the real
conditions of specific work area.

Performance Monitoring

Performance Monitoring will always take into account some parameters to grade the safety
performance. These parameters are classified as Leading and Lagging Indicators. The details and
difference between this two terms are explained below:

How to measure the effectiveness of review programme:

The normal practice of measuring the effectiveness of safety

review is based on the observable behaviour and countable
attributes. The performance standards shall be critically
examined. Individual Safety Performance Objectives are
identified and examined for the effectiveness.

The usual tools to monitor the safety performance are activity

based. In modern safety management systems, the
enhancement of safety performance grip with the monitoring
of leading and lagging indicators. Goal based monitoring is used for this purpose. Performance
measured will be always a complex combination of- result produced, behaviour displayed, activity
performed and the development in given time. The regular methods such as Frequency Rate, Severity
Rate, Safety Index, Man-days Lost, Number of reportable Injuries, Number of fatalities, Number of
Fire Incidents etc. are some good examples for performance monitors.

In last some years, Industrial communities worldwide started to adopt more effective steps than the
old accident statistic theories. Instead of or along with above said parameters, industries started to
monitor some parameters like Hazard Identification and Rectification Systems, Human Performance
Tools, Safety Culture Assessment, Near Miss Reporting, Trending of Safety Related Deficiencies,
Training and Coaching, Use of Audio Visual Aids, Use of Safety Interlocks and Engineered features,
Vision Zero for Safety etc. These parameters are known as leading indicators for Safety Performance.
There is a drastic positive shift in performance of companies when monitoring leading indicators.

25
 
Lagging Indicators
Lagging indicators are traditional safety matrix used to indicate features towards compliance with
safety legislations. These are the base numbers that evaluate the overall safety performance of the
company. Lagging indicators indicate the number of workers injured or hurt and the man-days lost.
But it does not indicate the efforts taken by the company management for accident prevention. Instead
of, they provide some projected ideas about more bad will happen. Lagging indicators are usually
called Reactive in Nature. These are obviously based on actual figures. It measures the real values in
numbers which help to quantify the benefits or losses. Lagging indicators are usually output oriented.
Those parameters are easy to monitor but hard to influence.
Examples for laggingindicators:
 Number of Reportable Injuries
 Frequency Rate and Severity Rate
 Number of Fire Incidents
 Number of Fatal Accidents
Leading indicators
Leading Indicators measure a future event used to drive and measure activities carried out to prevent
and control incidents and injuries. They are focussed on future safety performance and continuous
improvement. The steps taken by managements for accident prevention and control will be accounted
here. It gives a positive impact on the industrial climate and culture. So they are called proactive in
nature. These report the effective participation of employees and what employees are carrying out on
regular basis to prevent accidents and injuries.
Examples for leadingindicators are:

 Use of Human Performance Tools

 Safety culture assessment
 Trainings and Seminars
 Near Miss Reporting, Safety Related Deficiency Trending
 Design Modifications for safety
 Safety Incentive Scheme

Fig.: Safety Review Process

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Standard of Performance: Principle and Effective Techniques

The Safety Principles are very essential for continual improvement of any organization. A
strong safety culture with strong programs of personal safety, accident and injury prevention, wellness
promotion, and compliance with applicable health, safety and environment laws &regulations will
help to strengthen the safety performance. There are many principles available for elevating safety
standards of any organization.

Performance objectives for Safety shall be integrated with the employee’s performance plan. Some
examples are listed below. Always the objectives shall be measurable and achievable. The leader shall
take initiative to adhere with strategic plan as he will be the role model for all other employees.

Examples for Safety Performance Objectives:

 Individual Knowledge level

 Communication Skills
 Use of Procedures and Permits
 Interpersonal Skills
 Accountability
 End User Satisfaction
Evaluation of Safety Performance Objectives:

The periodic evaluation of Safety Performance

Objectives is very important, as the entire strategy
itself may slow down with time. The regular
industrial life may cause abrasion and decay of safety system. Workers may use short cuts and many
jumper usage may take place. Another issue is the need of change in approach at the different phases
of operation. As the workers get experienced, their level of understanding will change. So the systems
also shall be re organised as per the evaluation.

Failing to evaluate a safety system’s effectiveness is asking for trouble. It not only undermines the
safety system but also hurts the ability to control risk. Poor measurement is a key reason why safety
isn’t a priority at many organizations. Tactically, measuring a system’s effectiveness provides critical
information on how well a system operates, identifies areas for remedial action, generates feedback,
and builds motivation. More importantly, it provides a solid basis for continual improvement.

By adopting effective strategies and Performance evaluation methodologies, the organization will
reach at new heights. It helps to cut down the down time and enables more effective use of resources.
Another major improvement is the better inter personal relationship between the workers, line
management and top management. The working environment will be more pleasant and organization
status will move towards excellence.

27
 
The systematic and well planned management activities are always have a solid review system. This
will support the Safety Management System for being more effective. Identification and critical
evaluation of Safety Performance Objectives are the key factors for developing a highly effective
Safety Management System. The performance evaluation by using longstanding lagging indicators are
now changed with relatively new approach with leading indicators. The effective review and robust
evaluation process are instrumental for continual improvement.

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 CASE STUDIES

1. Fatal Accident occurred due to H2S exposure

(Failure of Quality Assurance– Management for safety)

Background:

H2S is used as carrier gas for isotopic exchange of deuterium in water and its further enrichment to
produce nuclear grade heavy water. Considering the large quantities of the hazardous gas handled in
plants, turnaround of these plants are taken in every two years for detailed in service inspection and
thereby assessment of fitness of the process equipment for further service life.

At the start of the turnaround of a plant, H2S from process towers is transferred to the storage tanks in
process called rundown, by using knockout drum, compressors, coolers and chillers.

Brief description of the incident:

During such rundown process for one of the exchange units, the drain line of the knock out drum
failed leading to release of H2S gas into the atmosphere around the area. During the process two
compressors along with the knockout drum on suction side and two coolers and chillers on discharge
side were in service. Operating crew consisting of one supervisor and three operators were engaged in
the rundown activity. The crew received a call from Control Room that one of the H2S monitors
installed in the compressor area had activated and got reset within a few seconds. Meanwhile a beacon
hooter installed in nearby area also got actuated in the field. Two operators including the deceased,
went to compressor area to perform leak survey and were carrying their breathing air (BA) sets. While
returning back from the field the operators heard a loud sound from the compressor side. One of the
operator slightly away from the compressor was able to wear his BA set however the deceased who
was near to the compressor was not able to wear his BA set and collapsed after walking some
distance. The supervisor and other operator present in the operator room, rushed to the site and
isolated the knockout drum (whose drain nozzle failed and released H2S gas). A rescue team was also
called immediately. Fire crew which reached the spot started water spray to dilute the H2S
concentration. The deceased was rushed to Occupational Health Centre at plant site and then to
Colony Hospital, but could not be revived.

What went wrong?

The incident was thoroughly reviewed to find out exact root cause of the incident and to take
corrective actions accordingly. Based on the review of the incident it was concluded that ‘failure of
Quality Assurance System to identify the lapses in planning, procurement, repair and maintenance of
the equipment handling hazardous chemicals’ lead to the fatal accident. Salient observations of the
review are as follows:

29
 
1. Multi-tier review mechanism at plant site was ineffective.
2. Hazardous area entry procedure especially w.r.t donning of BA set was not followed while
carrying out the leak survey on the day of incident.
3. Operation of plant with constrained conditions i.e. faulty compressor (from which intermittent
H2S leak was evident and was not rectified) contributed to the accident.
4. Lapses at human and organizational levels which reflect poor safety culture at plant.

Recommendations:

After detailed review of the incident, it was noted that lapses committed during procurement of
bottom dish led to failure of drain nozzle resulting in loss of containment of H2S gas is only direct
cause of the event. It was recommended to review the safety management system (including human &
organizational aspects, leadership for safety aspects etc.) to identify the latent weaknesses and address
them appropriately.

This incident highlights the glaring failure of management responsible to ensure safety of plant
personnel through implementation of quality assurance aspects related to the process equipment (new/
repaired), which remain unnoticed even after application of layers of approvals.

Actions taken by management responsible for the facility:

Management constituted committees to review the safety management system and to identify the
latent causes that led to the accident. Based on the recommendations of review committees, the
management at plant site and headquarters has initiated corrective measures based on the
recommendation of various committees who have reviewed the incidents and safety management
system of the plant.

30
 
2. Explosion and Fire at British Petroleum Texas City Refinery
(Failure of Leadership for safety)

Background:

Refinery of British Petroleum (BP) located near Texas City (normally referred as BP Texas City
Refinery) was the third largest oil refinery in the United States. Prior to 1999, Amoco owned the
refinery. BP took over operation of the plant after merger with Amoco in 1999.

On March 23, 2005, the refinery suffered one of the worst industrial disasters in the recent US history.
Explosion and fire killed 15 personnel and injured another 180 and resulted in financial loss to the
tune of $1.5 billion. Houses were damaged as far away as three-quarters of a mile from the refinery.

The incident occurred during the startup of isomerization (ISOM) unit when a raffinate splitter tower
was overfilled; pressure relief devices opened, resulting in a flammable liquid geyser from a
blowdown stack that was not equipped with a flare. The release of flammable liquids led to an
explosion and fire. All of the fatalities occurred in or near office trailers located close to the
blowdown drum. As emergency measures, a shelter-in-place order was issued that required 43, 000
people to remain indoors.

Brief description of the incident:

On the morning of March 25, 2005, the raffinate splitter tower in the refinery’s ISOM unit was
restarted after a maintenance outage. During the startup, operations personnel pumped flammable
liquid hydrocarbon into the tower for over three hours without any liquid being removed, which was
contrary to startup procedure instructions. Critical alarms and control instrumentation installed on the
tower for liquid level indication, gave false indications that failed to alert the operators about high
liquid level in tower. Consequently, unknown to the operations crew, the 170 foot tall tower was
overfilled and liquid overflowed into the overhead pipe at the top of the tower.

The overhead pipe ran down the side of the tower to pressure relief valves located 148 feet below. As
the pipe filled with liquid, the pressure at the bottom rose rapidly from about 21 psi to 64 psi. Three
pressure relief valves opened for six minutes, discharging a large quantity of flammable liquid to a
blowdown drum with a vent stack open to atmosphere. The overfilled blowdown drum and stack led
to a geyser-like release out of the 113 foot tall stack. This blowdown system was originally installed
in 1950s and was having unsafe design. It had never been connected to a flare system to safety contain
liquids and combust flammable vapors released from the process.

The released volatile liquid evaporated as it fell to the ground and formed a flammable vapor cloud.
From the investigation of the it was concluded that most likely source of ignition for the vapor cloud
was backfire from an idling diesel pickup truck located about 25 feet from the blowdown drum. The

31
 
15 employee killed in the explosion were contract workers working in and around temporary trailers
that had been previously sited by BP as close as 121 feet from the blowdown drum. Schematic
diagram of the system is given below

Figure 1: Raffinate section of the ISOM

Review of the incident:

The incident was initially reviewed by Chemical Safety and Hazard Investigation Board (CSB) of
United States. The final report of the investigation was issued in March 2007. During the
investigation, CSB issued an urgent safety recommendation to the BP Group Executive Board of
Directors that it convene an independent panel of experts to examine BP’s corporate safety
management system, safety culture and oversight of the North American refineries. BP accepted the
recommendation and commissioned the BP U.S. Refineries Independent Safety Review Panel, chaired
by former Secretary of State James baker, III (Baker Panel). The scope of the Baker Panel’s work did
not include determining the root cause of the Texas City ISOM incident. Baker Panel issued its report
in January 2007.
What went wrong?

1) After the detailed investigation of this refinery incident, CSB noted following findings:

Key Technical Findings:

A. Irrespective of the startup procedure, the level control valve on the raffinate splitter tower,
which was provided to send liquid from tower to storage, was kept closed. That led to
flooding of the tower.
B. Tower level indicator was faulty and redundant high level alarm did not activate.

32
 
 C. No display of material balance flowing in and out of the tower, on the control panel, to alert
operator about dangerously high level.
D. There was lack of supervisory oversight and technically trained personnel during the startup.
E. Supervisors and operators poorly communicated critical information regarding the startup
during the shift turnover; BP did not have a shift turnover communication requirement for its
operation staff.
F. ISOM operators were likely fatigued from working 12-hour shifts for 29 or more consecutive
days.
G. Operator training programme was inadequate, training staff was significantly depleted and
simulators were unavailable to operators practice handling abnormal situations.
H. Outdated and ineffective procedures did not address recurring operational problems during
startup, leading operators to believe that procedures could be altered or did not have to be
followed during the startup process.
I. The process unit was started despite previously reported malfunctions of tower level
indicating instruments.
J. The size of blowdown drum was insufficient to contain the liquid sent to it by pressure relief
valves.
K. Neither Amoco nor BP replaced blowdown drums and atmospheric stacks, even though a
series of incidents warned that this equipment is unsafe.
L. Occupied trailers were too close to a process handling highly hazardous material.
M. In years prior to the incident, eight serious releases of flammable material from ISOM
blowdown stack had occurred and most ISOM startups experienced high liquid levels in
splitter tower. No incident was investigated.

Key organizational findings:

i. Cost-cutting, failure to invest and production pressure impaired process safety

performance.
ii. The BP Board of Directors did not provide effective oversight of BP’s safety culture and
major accident prevention programmes.
iii. Reliance on low personal injury rate at Texas City as a safety indicator failed to provide a
true picture of process safety performance and the health of safety culture.
iv. Deficiencies in BP’s mechanical integrity program resulted in the ‘run to failure’ of
process equipment.
v. A ‘check the box’ mentality was prevalent at the Unit, where personnel completed
paperwork and checked off safety policy and procedural requirements even when those
requirements had not been met.
vi. The facility lacked reporting and learning culture.

33
 
 vii. Safety campaigns, goals and rewards focused on improving personal safety metrics and
worker behavior rather than on process safety and management safety systems.
viii. Response of BP managers to identified deep-seated safety problems was typically ‘too
little, too late’.
ix. Facility did not effectively assess changes involving people, policies or the organization
that could impact process safety.
2) As per the scope defined while its formation, the Baker Panel focused on process safety than
personal safety i.e. deficiencies relating to corporate safety culture, process safety management
systems & performance evaluation, corrective action and corporate oversight. The panel findings
are listed below:
 Corporate safety culture
a) Process safety leadership - BP has not provided effective process safety leadership and
has not adequately established process safety as a core value across all its five U.S.
refineries.
b) Employee empowerment –BP has not established a positive, trusting and open
environment with effective communication between management and workforce.
c) Resources and positioning of process safety capabilities – BP had not always ensured that
it identified and provided the resources required for strong process safety performance at
its U.S. refineries. Also the personnel at U.S. refineries were overloaded due to numerous
initiatives mandated by corporate management.
d) Incorporation of process safety into management decision-making –BP did not effectively
incorporate process safety into management decision-making. Even though,
accountability was a core concept in BP’s management framework for driving desired
conduct, BP had not demonstrated that it effectively held executive management and line
managers and supervisors, both at corporate level and at refinery level, accountable for
process safety performance at its five U.S. refineries.
e) Process safety culture at BP’s U.S. refineries – BP had not instilled a common, unifying
process safety culture among its U.S. refineries. Although the five refineries did not share
a unified process safety culture, each exhibits similar weaknesses like lack of operating
discipline, toleration of serious deviations from safe operating procedures and apparent
complacency toward serious process safety risks.
 Process Safety Management Systems
i) Process risk assessment and analysis – While all BP’s U.S. refineries had active programs
to analyze process hazards, the system as a whole did not ensure adequate identification
and rigorous analysis of those hazards. It was also indicated that the extent and recurring
nature of the deficiency was not isolated but systemic.

34
 
 ii) Compliance with internal process safety standards –Though BP had internal standards
and programs for managing process risks, the corporate safety management system did
not ensure timely compliance with the same at U.S. refineries. This finding relates to
several areas addressed by BP internal standards: rupture disks under relief valves,
equipment inspections, critical alarms and emergency shut-down devices, area electrical
classification and near-miss investigations.
iii) Implementation of external good engineering practices – BP’s corporate safety
management system did not ensure timely implementation of external good practices that
support and could improve process safety performance.
iv) Process safety knowledge and competence – BP’s system for ensuring an appropriate
level of process safety awareness, knowledge and competence in the organization relating
to its five U.S. refineries had not been effective in a number of respects such as, level of
process safety knowledge or competency required at different organization levels was not
defined, lack of such knowledge and competency in the staff and over-reliance on BP’s
computer based training.
v) Effectiveness of BP’s corporate process safety management system –BP’s corporate
process safety management system did not effectively translate corporate expectations
into measurable criteria for management of process risk or define the appropriate role of
qualitative and quantitative risk management criteria.
 Performance evaluation, corrective action and corporate oversight
1. Measuring safety performance – BP primarily used injury rates to measure process safety
performance at its U.S. refineries before this accident. It did not understand or accept
what this data indicated about the risk of a major accident or the overall performance of
its process safety management systems. As a result, its corporate safety management
system for its U.S. refineries did not effectively measure and monitor process safety
performance.
2. Incident and near miss investigations – BP had not instituted effective root cause analysis
procedures to identify systematic casual factors that may contribute to future accidents.
The Panel also believed that BP’s process safety management likely resulted in
underreporting of incidents and near misses.
3. Process safety audits – Based on the findings about auditor qualifications, audit scope,
reliance on internal auditors and the limited review of audit findings, the Panel found that
BP has not implemented an effective process safety audit system for its U.S. refineries.
Panel also concerned that the principal focus of the audits was on compliance and
verifying management systems to satisfy legal requirements.
4. Timely correction of identified process safety deficiencies – The Panel pointed that BP
sometimes failed to address promptly and track to completion of process safety

35
 
 deficiencies identified during hazard assessments, audits, inspections and incident
investigations. The Panel could find repeat audit findings especially apparent with
overdue mechanical integrity inspection and testing and failure in follow through after
these reviews.
5. Corporate oversight – Panel’s examination indicated that BP’s executive management
either did not receive refinery-specific information that suggested process safety
deficiencies at some of the U.S. refineries or did not effectively respond to the
information that it did receive. Panel believed that BP’s process safety management
system was not effective in evaluating whether the steps that BP took were actually
improving the company’s process safety performance. It found that neither BP’s
executive management nor its refining line management had ensured the implementation
of an integrated, comprehensive and effective process safety management system.

Actions taken by management responsible for the facility:

The Panel’s recommendations were based on findings developed during 2001. Since, March 2005,
after the incident took place, BP had undertaken many measures that could impact process safety
performance at five U.S refineries.

36
 
3. Fatal Incidentdue to electrocution

(Failure of safety management system)

Background:

A new electrical cable laying and connection work was planned to provide electric supply to one of
the units in a factory. The work contract was awarded to a licensed electrical contractor. As a part of
the contract, the work of lifting and termination of high voltage power supply cable at the Factory Bus
side was planned to be executed on the day of incident. In order to perform the assigned job, existing
power to 11kV switchyard of the factory from the State Power
Distribution Company (SPDC) substation had to be
disconnected. The work could have been safely done by
isolating the 11kV feeder through the available 11kV circuit
breaker (SF6 type) under the control of the factory. However,
the said breaker as well as the Air Break Switch (ABS) on the
line were not functional for more than six months at the time of
incident. Similarly the ABS on the dipole under the control of
SPDC were also not working. Hence, positive isolation of
factory switchyard was resorted by removal of Horn Gap Fuses
(HGFs) under the jurisdiction of SPDC. Contractor supervisor was telephonically informed about the
disconnection of power supply by a factory employee present at SPDC substation. Prior to start of the
work, contractor supervisor ensured no power in the line using discharge rod. Thereafter, the deceased
was instructed to remove the horn gap fuses (at height of around 14 feet on dipole structure) to carry
the cable work. The victim climbed the structure without wearing PPEs and removed first horn gap
fuse (HGF). While removing 2nd HGF he received an electric shock and fell on the ground and
received head injury. Medical examination of deceased indicated death due to electrocution.

Review of the accident:

The accident was reviewed in detail through a multi-tier review process to identify the root cause &
latent causes of the incident and to take corrective actions accordingly.

What went wrong?

a) The in-built safety systems i.e. air break switch (ABS) and circuit breaker (CB) on the SPDC line
at factory end were not functional since last six months. Similarly the ABS on the dipole under
the control of SPDC were not functional. Hence positive isolation of electric line could not be
provided. The facility did not object to the wrong procedure being followed for isolating power
supply. The removal of HGFs was not under the scope of the issued permit.

37
 
b) The electrical isolation was taken verbally without following any protocol or written procedure as
per relevant rules. Also the procedure followed and equipment used for isolation of electric
supply was not in accordance with the relevant rules.
c) Instead of waiting for SPDC personnel to arrive and carry out necessary work w.r.t maintenance
of non-functions ABS including isolation, the contractor in haste asked the deceased to remove
HGFs located in factory premises but under the control of SPDC.
d) The contractor supervisor did not have license/ trade certificate from state electrical inspectorate
for working on 11kV systems. Further the supervisor did not enforce the use of protective gears
by the worker while carrying out work at height on high voltage electrical system.
e) There was no supervision from the factory management at work site.
f) It was noted that deficiencies in the safety work permit system, height pass system etc. were
highlighted in the inspections and other reviews in the past. However factory management had not
initiated appropriate corrective actions.
g) There were no efforts made to establish root cause of the accident and urgent corrective actions
accordingly.
h) It was further noted that multiple sequential deviations/ violations comprised direct causes of the
fatal accident. It was concluded that the event was a result of failure of various safety
management systems factors such as effective supervision, implementation of safety procedures,
compliance to regulatory procedures & recommendations, involvement of senior management for
ensuring safety etc. It was stressed on the practice of self-regulation at factory to identify and
rectify the deficiencies in safety management systems.

Actions taken by management responsible for the facility:

Senior management of the factory hadinitiated actions to address all the observations made during
review of this event and to rectify shortcomings in the safety management systems.

38
 
References

1. The Factories Act, 1948

2. Atomic Energy Factories Rules, 1996
3. IAEA Safety Standards on Leadership and Management for Safety (General Safety Requirements
No. GSR Part 2), International Atomic Energy Agency, Vienna, 2016
4. Hellenic Republic, Ministry of Transport & Communications, Air Accident Investigation &
Aviation Safety Board (AAIASB), Aircraft Accident Report on Helios Airways Flight HCY522
Boeing 737-31S at Grammatiko, Hellas on 14 August 2005, 11/2006
5. Trevor Kletz, What Went Wrong? Case Histories of Process Plant Disasters, Fourth edition, 1999
6. Investigation Report of Refinery Explosion and Fire (BP Texas City Refinery) by U.S. Chemical
Safety and Hazard Investigation Board, Report No. 2005-04-I-TX, March 2007
7. The Report of the BP U.S. Refineries Independent Safety Review Panel, January 2007

39
 
40
 Part-B:
Challenges in medical examinations

Contributors:
Dr Hemant Haldavnekar, BARC
Dr Ajay Dubey, KKNPP
Dr Arindam Chatterjee, VECC
Dr Amrita Misri, Member OHSC
Dr Diptendu Das, AERB
Shri S. R. Bhave, Member OHSC
Mrs. Pammy Goswami, AERB

41
 CONTENTS
Sr. Title Page No.
No.
1.0 Introduction 43
2.0 Statutory Provisions 45
3.0 Duties of Certifying Surgeons 47
4.0 Guidelines for Medical Examination of Occupational Workers 48
4.1 Statutes under Atomic Energy (Factories) Rules, 1996 48
4.2 Statutes under Atomic Energy (Radiation Protection) Rules, 2004 53
5.0 Types of Medical Examinations 54
5.1 Pre-Employment Medical Examination 54
5.2 Pre-Placement Medical Examination 54
5.3 Periodic Medical Examination 55
5.4 Specific Medical Examination 55
5.4.A Medical Examination Of Crane & Forklift Operators
5.4.B Medical Examination Of Drivers
5.4.C Medical Examination Of Firemen
5.4.D Medical Examination Of CISF Personnel
5.4.E Medical Examination Of Contract Workers
5.5 Job Specific Guidelines for Certain Categories of Employees
6.0 Challenges in Medical Examination 59
6.1 Logistic Challenges 59
6.2 Administrative Challenges 60
6.3 Decisional Challenges 61
7.0 Conclusion 62

42
 1.0 INTRODUCTION
Large population throughout the world is employed today in various industries. It is of
paramount importance that the management of the industries takes care of the working
conditions so that it should not adversely affect the health conditions of the workers. At the
same time the workers are also required to follow the stipulated guidelines/ Standard
Operating Procedures and all statutory regulations laid down by the regulators / other
statutory bodies. It is essential to monitor the health of the workers periodically; right from
their joining and throughout their service.
There are some probable hazards in every industry. The hazards are physical, chemical,
biological, psychological, etc. Mainly the physical hazard includes noise, vibrations,
temperature, pressure, illumination, radiation, etc. The chemical hazards are corrosive, poison
or toxic, fire, explosion, pollution and occupational diseases and poisoning caused by them.
There are also biological hazards due to bacteria and molds from materials. Social and
psychological hazards are due to habits, customs, behaviors and attitudes.
In industry, it is a team work where engineers, doctors, hygienists, psychologists, workers
and managements contribute collectively towards the wellness of the person at work.
Occupational health includes all factors relating to work and working conditions, methods
and environment that may cause diseases, injuries or deviation from health including
maladjustments to work. It implies not only health protection but also health promotion for
improving the health & working capacity of the worker, preventive measures against
diseases, improvement of nutrition and general mental health.
It is often seen that the evaluation of occupational diseases and injuries is difficult due to
limited availability of reliable information, mainly due to limitations in the diagnosis and
reporting of occupational diseases. The health status of workforce has direct impact on
national economies.
Safety includes health & hygiene, which emphasizes that safety is not only loss prevention
but it also, includes workers wellness. Industrial hygiene studies physical & chemical
hazards, environmental factors and stresses associated with work, their effects on man,
measurement of these factors, training, experience and prescribe control method to reduce
their ill effects.
The concept of occupational health is well established long back and it may be noted that Dr
Bernardino Ramazzini, the Head of “Medicine” at the University of Modena, in 1682 focused
on workers' health problems in a systematic and scholarly way. He visited workplaces,
observed workers' activities, and discussed their illnesses with them. He systematically
collected the data regarding diseases of workers & their work environment & correlated with
the cause in working environment. Primarily on the basis of his work, Ramazzini is called
“the father of occupational medicine.”
In the Department of Atomic Energy, the concept of occupational health was envisaged since
its inception. Dr Homi J Bhabha promoted occupational health and had sent two medical
professionals from Bhabha Atomic Research Centre; Dr M. L Gadgil and Dr N U Gulvady
for post-graduation in occupational health to United States of America.

43
Atomic Energy Regulatory Board (AERB) promotes Occupational health in entire DAE
under different committees on occupational health. In order to streamline the procedures in
1993 a committee was formed known as Occupational Health Advisory Committee (OHAC)
which was reconstituted in 1999 as Advisory Committee on Occupational Health (ACOH).
At present there is Occupational Health & Safety Committee (OHSC) which is reviews
implementation of statutory regulations stipulated in Atomic Energy (Factories) Rules, 1996
[AE(F)R] and Atomic Energy Radiation Protection Rules 2004 [AE (RPR)].
OHSC compiles and analyses the occupational health statistics of the various DAE units, and
can request for additional data and recommends corrective measures, if any as good
occupational health practice / statutory requirements.

44
 2.0 STATUTORY PROVISIONS
Workers’ health has been of interest of physicians in India for almost half a century and the
Indian Association of Occupational Health was founded in the 1940 in the steel city of
Jamshedpur. Occupational safety and health practice started off with injuries and accident
reporting and prevention.
Like many developing countries, India has gone through a long process of industrialization
and ‘The Factories Act, 1948’ amended in 1987; is the main legislation governing safety,
health and welfare of persons employed in factories. Provisions of the Factories Act related to
medical examinations are as follows:
 “Hazardous process” that causes material
impairment to the health or pollution of the
general environment, is defined in Section 2 (cb)
of the Factories Act, 1948.
 General duties of the Occupier and Manufacturer
to ensure health & safety at work of all workers
are defined in Section 7A & 7B respectively of
the Factories Act, 1948 (FA, 1948).
 Precautions against dangerous fumes, gases,
vapour, dust etc. and in confined spaces like tank, chamber, pit, and pipe are
prescribed in section 36 of FA, 1948.
 Section 41-F prescribes the permissible limits of exposure of chemicals and toxic
substances which are further enlisted in the second schedule of FA, 1948.
 Section 41-H prescribes the duty of occupier to remove imminent danger to life or
health.
 Section 87A prescribes power to prohibit employment an account of serious hazards.
 Section 89 prescribes notice of occupational diseases and is given in third Schedule of
FA, 1948 where in 29 notifiable diseases are enlisted.
 Section 91A describes provision for safety and occupational health surveys.
The Factories Act, 1948 is a central enactment and is enforced by the State Government,
which also has the power of framing rules under the provision of sections available in the
Factories Act, 1948.
Atomic Energy Regulatory Board (AERB) is the enforcement authority for all DAE units
except BARC facilities. In exercise of the powers conferred by Section 27 of the Atomic
Energy Act, 1962 (33 of 1962), and all other powers enabling him in this behalf, the
President constituted an Atomic Energy Regulatory Board (AERB) to carry out certain
regulatory and safety functions envisaged under Section 16, 17 and 23 of the Act. Section 23
empowers the Regulatory Body with administration of Factories Act 1948.
Atomic Energy (Factories) rules 1996 provide safety provisions for dangerous operations
which might cause occupational diseases.
Provision for optimum working conditions / facilities / limits; for dust and fume, ventilation
and temperature, disposal of waste and effluents, lighting, drinking water, latrines & urinals,

45
spittoons, cleanliness, washing facilities, machine guarding, first-aid, canteen, dining hall,
crèche, etc. are also included for the health protection of workers.

46
 3.0 DUTIES OF CERTIFYING SURGEON
As per Rule 7 of Atomic Energy (Factories) Rules, 1996, the duties of certifying surgeons are
enlisted below:
(1) The Certifying Surgeon shall visit the factory for the purpose of examination of all
persons employed in processes covered by rule 88 of these rules at such intervals
prescribed under the same rules and the Schedules attached thereto, such units, factories
within the local limits assigned to
him.
(2) The Certifying Surgeon shall, upon
request by the Competent Authority,
carry out such examination and
furnish such report as it may indicate,
for any factory or class or description
of factories where cases of illness
have occurred which, it is reasonable
to believe, are due to the inherently
hazardous nature of the manufacturing process carried on/ or attributable to other
conditions of work prevailing therein, or by reason of any change in the manufacturing
process carried on/ or in the substances used therein, or by reason of the adoption of any
new manufacturing process, there is a likelihood of injury to the health of the workers
employed in that manufacturing process.
(3) During such visits the Certifying Surgeon shall examine the persons employed in such
processes and shall record the results of his examination in Form 1 and place it in a
medical file which shall be kept by the Manager and produced to the Certifying Surgeon
at each visit.
(4) If the Certifying Surgeon finds as a result of his examination that any person employed in
such process is no longer fit for medical reasons to work in that process, he shall suspend
such person from working in that process for such time as he may think fit and no person
after suspension shall be employed in that process without the written certificate of
fitness by the Certifying Surgeon in Form 1A and the same shall be placed in the medical
file.
(5) The Manager of the factory shall afford to the certifying surgeon all facilities to inspect
any process in which any person is employed or is likely to be employed.
(6) The Manager of the factory shall provide for the purpose of any medical examination
which the Certifying Surgeon wishes to conduct at the factory (for his exclusive use on
the occasion of an examination) a room which shall be properly maintained, adequately
ventilated and lighted and furnished with a screen, a table (with writing materials), chairs
and other furniture necessary for a medical examination room.
Further specific requirement of medical examination of workers involved in various
dangerous operations are elaborated in various schedules under Rule 88 of Atomic Energy
(Factories) Rules, 1996.

47
 4.0 GUIDELINES FOR MEDICAL EXAMINATION OF OCCUPATIONAL
WORKERS
The details of medical examinations as prescribed under the statutes namely the Atomic
Energy (Factories) Rules, 1996, the Atomic Energy (Radiation Protection) Rules, 2004 are as
follows:
4.1 Statutes under Atomic Energy
(Factories) Rules, 1996:
a) Rule 55: Examination of eye-sight of
certain worker
Applicability: Workers employed to
operate a crane, locomotive or forklift
truck, or to give signals to a crane or
locomotive operator.
Medical Examination: Eye-sight and
colour vision to be examined and the
worker to be declared fit by a qualified Ophthalmologist to work whether with or
without use of corrective glasses.
Periodicity: At least once in every period of 12 months up to the age of 45 years and
once in every period of six months beyond that age. Record of examination or re-
examination to be maintained in Form-I.
b) Rule 71: Annual Medical Examination
Applicability: The food handlers in canteen is the sensitive group of population that
can be a focus for spread of various infectious agents (e.g. Salmonella typhi / S.
paratyphietc) to the industry employees and hence has to be medically examined
even when asymptomatic.
Medical Examination: Medical examination for fitness to be carried out by the
factory medical officer or the Certifying Surgeon include:
a) A comprehensive general physical examination. (E.g. nails, skin for any fungal
infection etc.)
b) Routine blood examination;
c) Routine and bacteriological testing of faeces and urine for dysentery and
typhoid, and
d) Any other examination including X-ray as may be considered necessary by the
factory medical officer or the Certifying Surgeon.
Any person, who in the opinion of the factory medical officer or the Certifying
Surgeon is unsuitable for employment on account of possible risk to the health of
others, shall not be employed as canteen staff.

48
 Periodicity: Annually.
c) Rule 88: Dangerous Manufacturing Processes or operations:
Schedule I: Electroplating
Applicability : Every worker employed in the electrolytic processes defined as
electrolytic plating or oxidation of metal articles by the use of an electrolyte
containing acids, bases, or salts of metals such as chromium, nickel, cadmium, zinc,
copper, silver, gold etc.
Medical Examination: To be conducted by a Certifying Surgeon and shall include
X–ray of the chest and –
a) in case of chromium plating, examination for nasal septum perforation and test
for chromium in urine;
b) in case of nickel plating, test for nickel in urine; and
c) in case of cadmium plating, test for cadmium in urine and alpha-2
microglobulin in urine.
Periodicity:
i) Before first employment;
ii) Re-examination shall be carried out at least once in every year. In case of the
workers employed in cadmium, chromium and nickel plating process, re-
examination shall be carried out once in every six months. This shall exclude
chest X-ray which shall not be required normally to be carried out earlier than
once in 3 years.
Schedule II: Chemicals and Chemical Works
Applicability: Workers employed in the following
processes covered in Appendix “A” to this schedule
including manufacture; manipulation or recovery of:
a) a number of specified metals and their salts,
alloy, oxides etc.,
i) Ammonia and its salts etc.
ii) Specified acids,
iii) Cyanogen compounds,
iv) Phosphorous compounds
v) Chlorine,
b) Hydrogen sulphide,
c) Chlor-alkali process,
d) Coal tar products,
e) Nitro compounds,
f) explosives, and
g) a number of organic compounds

49
to be medically examined by a Medical Officer / Certifying Surgeon.
Medical Examination: A general type medical examination is prescribed.
Periodicity:
i) Before employment, to ascertain physical suitability of the person to do the
particular job;
ii) Once in a period of six months, to ascertain the health status of the worker.
Schedule III: Manipulation of stone or any other material containing free silica
Applicability : Workers employed in manipulation i.e. crushing breaking, chipping,
dressing grinding, sieving, mixing, grading or handling of stone or any other solid
material containing more than 5% by weight of free silica.
Medical Examination: To be conducted by a Certifying surgeon and shall include
pulmonary function tests and chest X-ray.
Periodicity:
i) Within 15 days of first employment. Worker shall not be allowed to work after
15 days of his first employment unless certified fit for such employment by
the Certifying Surgeon.
ii) Re-examination shall be carried out at least once in every 12 months except
chest X-ray which shall be once in 3 years.
Schedule IV: Grinding or glazing of metals and processes incidental thereto:
Applicability: Workers employed in grinding i.e. abrasion, by aid of mechanical
power, of metal, by means of a grindstone or abrasive wheel or glazing of metal i.e.
abrading, polishing or finishing by attaching or applying any abrading or polishing
substance to any wheel, buff, mop or similar appliance.
Medical Examination: To be conducted by a certifying Surgeon and shall include
pulmonary function tests and in suspected cases, chest X-ray.
Periodicity:
i) within 15 days of first employment, worker shall not be allowed to work after
15 days of his first employment unless certified fit for such employment by
the Certifying Surgeon.
ii) Re-examination by the Certifying Surgeon at least once in every 12 months.
For re-examination, PFT & X-ray on discretion of Certifying Surgeon.
Schedule VI: Foundry- Production of iron or steel or non-ferrous castings and
processes incidental thereto:
Applicability : Workers employed in foundry work i.e. production of iron or steel
castings (excluding production of steel in the form of ingots or the production of steel
in the production of pig iron) or non-ferrous castings (excluding smelting &
manufacture of lead or melting & casting of lead or lead based alloy for production of
ingots, billets, slabs etc.) and incidental processes, namely the preparation and mixing

50
of materials used in the foundry process, the preparation of moulds and cores,
knockout operations and dressing or fettling operations.
Medical Examination: To be conducted by a Certifying Surgeon and shall include
pulmonary function tests and chest X-ray.
Periodicity:
i) within 15 days of first employment. Worker shall not be allowed to work after
15 days of his first employment unless certified fit for such employment by
the Certifying Surgeon.
ii) Re-examination by the Certifying Surgeon at least once in every 12 months, as
above, except chest X-ray which will be once in 3 years.
Schedule VIII: Beryllium Operations:
Applicability: Workers employed in work on Beryl ore,
Beryllium and its compounds.
Medical Examination:
i) Comprehensive pre-placement history and
physical examination for all workers to be
carried out including chest X-ray, baseline
pulmonary function tests, namely, forced vital
capacity (FVC) and forced respiratory volume at
1 second (FEV 1.0), Liver function tests and a baseline weight is also recorded
.
ii) Re-examination of each worker as follows:
a) Spirometry, including FVC and FEV 1.0;
b) Medical history questionnaire including presence and degree of
respiratory symptoms i.e. breathlessness, cough, sputum production, and
wheezing;
c) Chest X-ray PA view
d) Check for Atopic dermatitis
Periodicity:
a) Pre-placement;
b) Re-examination annually
Medical surveillance of the worker shall be continued upto 20 yrs. from the cessation
of work or his death whichever is earlier. Competent Authority, Inspector and
Medical Inspector shall have access to medical records, which shall be maintained for
at least 20 years.
In addition to the above, the AERB’s Advisory Committee on Occupational health
(ACOH) had recommended that employees exposed to Beryllium should also have
test for Microalbuminuria and Liver function tests.

51
Schedule X: Finishing Abrasive propelled by Compressed Air or Steam:
Applicability: Workers employed in any of the processes like cleaning, smoothening,
roughening etc. of articles by using as an abrasive a jet of sand, metal shot, or grit or
other material, propelled by Compressed Air or Steam.
No women shall be employed or permitted to work at any operation of sand blasting.
Medical Examination: To be conducted by a Certifying Surgeon and shall include
pulmonary function tests and chest X-ray.
Periodicity:
i) within 15 days of first employment. Worker shall not be allowed to work after
15 days of his first employment unless certified fit for such employment by
the Certifying Surgeon.
ii) Re-examination by the Certifying Surgeon at least once in every 12 months, as
above, except chest X-ray which will be once in 3 years.
Schedule XI: Operations involving High Noise Level
(90 dBA or above):
Applicability: Workers exposed to continuous and / or
impulsive / impact noise exceeding permissible levels.
Medical Examination: Auditory examination to be
conducted by a Certifying Surgeon including
determination of auditory thresholds for pure tones of
125, 250, 500 ,1000, 2000, 4000, 8000 Hz.
However, keeping in view the window period for the
hearing loss, the AERB’s Advisory Committee on
Occupational Health (ACOH) had recommended the following:
“If the workers are exposed to 85 dBA and above and assigned the regular work at
that area (Job specific) irrespective of the use of personal protective equipment and
time of exposure, during the course of their employment, should be examined
annually for audiometry.”
Periodicity:
a) Within 14 days of first employment
b) Re-examination at least once in every 12 months.
Schedule XIII: Handling of radioactive substances:
Every person who, in the opinion of Competent Authority, is occupationally exposed
to radiation shall be subjected to medical examination prior to the commencement of
the work in the radiation area. Medical Examination should include X-ray
examination of the chest, all general laboratory investigations such as the examination
of blood and excreta and examination of the skin, hands, finger, finger-nails and eyes.

52
4.2 Statutes under Atomic Energy (Radiation Protection) Rules, 2004:
Every person, who is occupationally exposed to radiation and who, in the opinion of
the Competent Authority, should be subject to radiation surveillance shall be
medically examined prior to commencement of radiation work.
Rule 19: Periodic Medical Examination of Radiation Workers
Applicability:
i) Radiation Worker: a person who is occupationally exposed to Radiation.
ii) Classified Radiation Workers: Workers, so designated by the employer, who
are likely to receive an effective dose in excess of 3/10th (Thirteenth) of the
Average Annual dose limits notified by the Competent Authority (i.e. in
excess of 06 msv). He shall forthwith inform those employees that they have
been so designated.
As a good Occupational Health Practice, it was decided by ACOH, AERB that
periodicity of Medical Examination of the Classified Radiation Worker should be
once in a year. Radiation workers who receive dose below 6 mSv annually may be
examined on the criteria of age and health grounds. Based on the morbidity/ mortality
data and health risk involved for age related conventional diseases, it is recommended
that those above 45 years of age should be medically examined once in a period of
three years and those  45 years of age should be examined once in a period of five
years
Medical Examination:
i) X-ray examination of the chest;
ii) All general laboratory investigations such as the examination of blood and
excreta;
iii) Special investigations such as examination of the skin, hands, finger, finger-
nails and eyes.
Periodicity:
a) For classified Radiation Workers – At least once in three years
b) For other Radiation Workers – At least once in Five years

53
 5.0 TYPES OF MEDICAL EXAMINATIONS
5.1 Pre-Employment Medical Examination
Pre-Employment Medical examinations is a
comprehensive medical examination comprises of
medical tests and Physical health status assessment
which ensures that the person is fit to do the
required job. It is in general, a medical checkup
before employment and also provides a baseline
data for future comparison.
Pre-employment medical examination usually
includes the following components:
 Height, weight, body mass index (BMI)
 Cardiovascular examination (heart check, blood pressure, pulse)
 Full musculoskeletal examination including comprehensive range of movement
 Central nervous system examination
 Examination for hernias and other abdominal abnormalities
 Urinalysis for diabetes or kidney / bladder disorders
 Respiratory examination
 Assessment of Vision including colour blindness
5.1.2 Other specific pre-employment medical examination requirements may include:
Audiometry (hearing test)
Spirometry (lung function test)
Titmus Vision Testing
5.2 Pre-Placement Medical Examination
A pre-placement medical examination is undertaken by an occupational health service
at the request of an employer as part of the risk assessment process and only after a
job offer has been made. It is basically an assessment of fitness and medical
suitability for the role made by an occupational health service.
5.2.1 Purposes of pre-placement evaluations
i) To determine if the applicant has a health condition that may be aggravated by the
workplace.
ii) To determine if the applicant has a health condition that may place the safety or
health of others at risk.
The primary objective of the pre-placement evaluation is to ensure that employees are
medically fit to perform the essential functions of the job.

54
 The second objective is to determine whether the employee has a medical condition
that may place the health and safety of others at risk. This is critically important with
certain jobs, such as operating machinery or driving for example, the people with
unstable epilepsy or insulin-dependent diabetes are not permitted to drive vehicle. The
rationale is that if these conditions are not properly controlled, they could place others
at risk. Circumstances may allow persons with these medical conditions to perform
other job duties.
5.3 Periodic Medical Examination
Periodic medical examination is conducted to assess
the continuing fitness of the worker for his intended
work and also to observe for any deviation from his /
her baseline health data.
This medical examination is carried out for
employees, who have no medical complaints and it is
different than the traditional diagnostic examination.
These include not only the detection of incipient
disease, but also the evaluation of the adjustment of
the individual to his environment and an assessment
of his personal hygiene. It should be concluded by a discussion of what has been
found, and by positive, persuasive advice and education which will lead to better
health.
The system of periodic medical examinations is a traditional component of
prophylactic medical examination of workers. The introduction of the Regulations
makes it possible to broaden the scope and elevate the quality of prophylaxis among
workers, thus to contribute to periodic examinations as part of the overall system of
preventive measures. The most important aspect of periodic medical examinations lies
in early diagnosis of occupational diseases & adoption of uniform medical
programmes for its subsequent prevention.
5.4 Specific Medical Examinations
Details of medical examinations of certain workers are given as follows:
A. Medical Examination of Crane & Forklift Operators
A crane operator’s medical fitness and the specific requirements of the machine are
critical and a holistic approach to the individual operator is essential. For example
different levels of fitness and ability are required for mobile cranes, crawler and tower
crane.
The examination will incorporate:
 A comprehensive physical examination to assure optimal health
 Additional testing as necessary, including:
a) Depth perception & 3 D vision

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 b) Routine Lab blood test
c) Examination for any condition or disease that could interfere with an
ability to complete the job safely
B. Medical Examination of Drivers
The Medical Examination of Drivers is primarily to assess the severity, progression,
treatment or effects of a medical condition, if any, in regards to a driver's fitness to
drive. The medical examination of drivers includes:
 Full medical examination: including urine test, BMI (Body Mass Index), blood
pressure and head to toe examination.
 Visual Screening remains the keystone – including near, far, colour and depth
perception
 Lung function test.
 Ear examination to detect any abnormalities
C. Medical Examination of Firemen
Firemen are exposed to extremes of Physical,
Mental and Environmental stresses which
increases their risks to cardiac, musculoskeletal
and behavioral health problems. The medical
examination of Firemen includes:
 Full medical examination: including urine
test, BMI (Body Mass Index), blood
pressure and head to toe examination.
 Eye exam: vision specifications exist in
which aided eye sight must be 6/9 for both
eyes and no worse than 6/36 for unaided.
 Lung function test.
 Chest X-ray: an x-ray is required of the chest to ensure the upper body skeletal
structure is healthy.
 Ear examination to detect any abnormalities
D. Medical Examination of CISF Personnel
CISF personnel have to be examined medically to ascertain their fitness under a
specific medical examination known by the name of “Medical examination under
SHAPE category”. SHAPE is an acronym for Psychology (S), Hearing (H),
Appendages (A), Physical (P) and Eyesight (E). State of health of a person is
indicated by granting him grading 1 to 5 against these factors. Any one of medical
category less than SHAPE-1 will have limitations upon nature of duties assignable to
him/her.

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 E. Medical Examination of Contract Workers
In the modern era, the industries are engaging
various agencies to carry out their specific and
general work like: civil, mechanical, canteen,
HR, medical etc. These agencies in turn engage
contract work force to carry out these jobs. It is
the prime responsibility of employer to assess
the medical fitness of these contract workers on
the same lines as is done for the regular workers.
At times due to shortage of regular work force,
the principal employer may allow the contractor
to get the medical examination of the workers done by any qualified doctor. The
periodicity of medical examination of contract workers is same as applicable to
regular workers in respective job category.
5.5 Job Specific Guidelines for Certain Categories of employees
In addition to general examination, following investigations / tests are recommended
to detect presence of abnormalities and also to provide baseline data.
A. Workers in Other areas
i) H2S based Heavy Water Plants
Check intactness of tympanic membranes
 Perforation of tympanic Membrane to be recorded. (condition is not a
disqualification)
ii) Work in Protective suits and at High Temperatures
 Cardio-vascular examination,
 Pulmonary Function Tests,
 Excretion Function Tests
B. Security
 Body Mass Index -*BMI= Wt. in kg / height in meters squared),
Recommended BMI* is 19-25 for young adults and 28 for middle age.
 Hearing should be normal
Following will be the disqualification criteria for security personnel
 One eyed vision
 Myopia over -4.00D &Hypermetropia over + 4.00D
 Seizure Disorders
 Complete color blindness
C. Firemen
 In presence of HT & abnormal ECG refer to Physician.
 Varicose veins – refer to specialist
 Hernia /Hydrocele - fit after surgery

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 General medical fitness requirement for Firemen is as follows:
 Normal Hearing
 Candidate should qualify in physical endurance test like running 100
meters with 64 Kgs weight in one minute, climbing rope and/or vertical
pipe to a height of at-least three meters from the ground. (P.E. Tests to be
conducted by Industrial Safety Section).
 Physical Standard - Height & weight 165 cms., 50 Kg Respectively
 Body Mass Index* (*BMI = wt. in kg / height in meters squared) -
Recommended BMI* should be between 19 and 25 for young adults and
28 for middle age.
 Chest  81 cm normal, + 5 cm expanded, No deformity.
 Visual - 6/6 without glasses,
Following will be the disqualification criteria for Firemen;
o Uncontrolled Hypertension and / or IHD
o Seizure Disorders, EEG if indicated
o Night & color blindness
o One-eyed vision
o Bilateral nystagmus and Positive Romberg Sign.
D. Crane operators, riggers, fork-lift operators and drivers
Requirement
 Binocular 3-D (Stereoscopic) vision
 Field of vision should be normal
 Normal hearing
Disqualification
o Nystagmus - for drivers.
o One-eyed vision
o Seizure Disorders
E. Stipendiary Trainees
Requirement
Physical Standards Height 160 cms., Weight 45.5 Kgs (Relaxable by unit
head).
Disqualification
Complete color blindness in some fields/trades.
F. Special assignment for working at height –height Pass
Requirement

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  In presence of HT & abnormal ECG – Refer to Physician.
 Physical Ability Tests (6) (Annexure – VII of AERB/SG/IS-4) - Walking
freely over a 6" narrow horizontal bar at 1 foot height. Walking freely over a
horizontal bar at 9 ft. height wearing a safety belt. (Obesity hinders mobility
and markedly obese are unfit for climbing ladders etc.). To be tested by
industrial safety section.
 Tests for labyrinthine functions and for sense of position
Disqualification
o Postural Hypotension
o Cardio-vascular - Uncontrolled Hypertension and / or IHD
o Bilateral nystagmus and Romberg sign positive
o Seizure Disorders, EEG if indicated
The Guidelines for pre-employment medical examination and fitness for special assignments
(AERB/SG/IS-4) should be referred for further details.
6.0 CHALLENGES IN MEDICAL EXAMINATION AND APPROACH TO
OVERCOME THE CHALLENGES
6.1 Logistic Challenges
 These challenges may be categorized as
under:
A. Inadequacy of Manpower
B. Inadequacy of Material
C. Inadequacy of Machine/ infrastructure
 Non-availability of occupational health physician / specialist empowered to
comment on the report – example inadequate staffing; certifying surgeon, nursing
/ ophthalmologist / ENT specialist/ radiologist, one person doing multiple jobs
hence is not able to devote time for medical examination.
 Non availability of medical equipment (Pulmonary Function test machine /
Audiometer/ x ray machine / ECG machine etc.)
 Inadequate infrastructure to carry out the comprehensive medical examination of
the workers.
6.1.1 Approach to overcome logistic challenges
A. Available medical manpower can be sent for short term courses in Occupational
Health like 7/14 day training programs in Central Labour Institute (CLI) to have
the basic knowledge in this field.
B. Management should make all possible efforts in setting basic facilities for
conducting medical examination.
C. In order to comply with the statutory requirements, cost benefit analysis shall be
carried out in establishing appropriate infrastructure for Occupational Health

59
 Centre. Accordingly a decision can be taken of establishing in-house
infrastructure or out sourcing the services e.g. Audiometry examination,
spirometry etc.
6.2 Administrative Challenges
These challenges are broadly classified as
follows:
a. In certain cases there is a mismatch in
number of workers notified by the
concerned agencies of different categories
viz.; classified radiation workers, other
radiation workers, etc.
b. Interpretation of the statutes related to the
medical examination of workers under
different categories (Classified radiation / other radiation workers / workers
exposed to high noise area) e.g. most of the DAE units are conducting medical
examination for classified radiation workers every year whereas as per Atomic
Energy (Radiation Protection) Rules, 2004 classified radiation workers have to be
examined at least once in 3 yrs. This, at times, creates mismatch in compiling,
comparing and analyzing data of various DAE units.
c. Audiometry examination for workers exposed to more than 85 dBA is being done
as good occupational health practice in all DAE units. However due to various set
points of permissible noise levels to conduct audiometry by various agencies
(OSHA- 85 dBA for 8 hrs. exposures & for every increase of 3dBA the time
exposure is halved, Factories Act 1948 - 90 dBA for 8 hrs. exposures and for
every increase of 5 dBA the time exposure is halved), it becomes difficult to
compare the DAE statistics on audiometry with the national & international
averages.
d. In majority of DAE facilities canteen services are outsourced, Contract documents
do not have well defined checklist for health surveillance based on statutory
requirement and penalty option also is not in place.
e. Non-reporting of employee for the periodic medical examination as per the
schedule leading to not able to complete 100% medical examination in that
particular year.
6.2.1 Approach to overcome administrative challenges
A. This can be effectively overcome with a
sound inter-sectional coordination between
the various management offices (HPU/
O&M/HR /IS &F) and the occupational
health physician, responsible to conduct
medical examination.
B. Different units can conduct the medical
examination as per the periodicity

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 mentioned in statutes and recommendations of ACOH, presently OHSC. However
the reporting of the medical examination to AERB should be as per the AERB’s
requirements.
C. Audiometry can be carried out uniformly by all DAE units for the workers
exposed to noise level in excess of 85 dBA irrespective of time of exposure and
PPEs used. However the audiometry examination should be limited for the
workers who have been assigned the work in noisy area.
D. Various provisions in this regard can be made in the tender document of canteen
services for better industrial hygiene.
E. The management should ensure completion of 100% medical examination
preferably by identifying a coordinator who can ensure that employees report for
medical examination as per schedule.
6.3 Decisional Challenge
In certain cases, where the candidate is offered the job under specific quota e.g.
Person with Disability (PWD), the interpretation of disability certificate produced by
the candidate has to be interpreted carefully. At times the candidate produces the
certificate from different agencies where it is very difficult to verify. In these cases
the decision making becomes difficult at unit level.
Approach to overcome decisional challenges
It is recommended to send all these cases to the appropriate medical authority of the
district e.g. Medical college / district hospitals, where the unit is located.

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 7.0 CONCLUSION
DAE gives top priority to the health of their employees and have a well-established
Occupational Health centers in all its units. All the units are not only conducting the medical
examinations of their employees as per the laid down statutes but also exceeding the
minimum requirements as a good occupational health practice. However, there is always a
scope for improvement on continuous basis. This monograph brings a comprehensive
discussion on different medical examinations and various issues that pose a challenge to the
certifying surgeons and the solutions to overcome them.

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35th DAE Safety Occupational Health Professionals’ Meet Monograph

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