Learning Lessons

from
Baghjan#5 Disaster Recovery
Operations
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27th May 2020 will be remembered as a black day for all Oil
Indians so far disaster is concern and also the day from
which we started learning, fighting sever disaster crisis.

LEARNING LESSONSFROM BAGHJAN#5 DISASTER RECOVERY OPERATION SAROJ MISTRY

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It was about 01:20PM on 9th June 2020. I was about to reach Baghjan#5 disaster site with a
Bolero Vehicle. I was alone except Bolero driver.
Suddenly we observed people are shouting and running out from the disaster location and
signalling to the vehicle to back. I anticipated the reason and told driver to turn immediately.
Due to tension driver could not see the condition of the place and while turning one wheel
were got stuck in the dry drain.
Everybody is running to save themselves, I got stuck there and were trying hard to push the
vehicle from back to free the wheel from the drain. People with their minimum belonging,
some also with her little child were running and trying to escape from the area to a safe place.
My tension was at its peak. Shouting for help, but nobody was in a mood to even notice me.
At last I saw a company vehicle with some security personal coming out from, the disaster
site. I stopped them and asked for help and with their help my vehicle got freed. In the
meantime a group of 8 to10 people gathered there with bamboo and stick in their hand
shouting against our company and started hitting on my vehicle. I was with full company
dress, safety shoes etc. They did not allow the vehicle to move. I was in deep fear. Could not
think what to do or not. Sitting inside the vehicle with driver in the front seat, I stared to take
off my company cloth from by body to hide my identification as company employee. In the
mean time I heard two big hit one after another on the front glass screen of my vehicle. It
broken in pieces and pieces of glass came like bullet towards me also. I was totally frightened.
All of a sudden I saw two Fire tender came from Baghjan OCS side which saved us (myself
and the Driver). As the fire tender would not be able to move towards the disaster site until
our vehicle is released to move out. One leader short of man from the crowd stopped others
to do more damage to the vehicle as well as probably us also and asked us in ordering voice
to start the vehicle and leave the place immediately.
We started immediately and didn’t stop till we reach Baghjan Police station (Thana).
Somehow I manage to get little bit normal, but still frightened condition and send HOD
Electrical the message that I am safe at exactly 01:48PM.
This was the worst situation I encountered in my entire 37 Yrs. professional career with a
most valuable learning.
- Never move alone to any disaster site, when you are a team member for
providing services to the fire fighting and rescue team so that you do not feel
helpless at the time anticipated danger and fear.
I was MSO-Engineering Mine when the disaster happened and was about to return back to
my parent department, i.e. Electrical Engineering Department.
I joined back to Electrical department on 8th June 2020 during this disaster at a time when
the condition of the disaster site very grim with huge area surrounding the well (especially
towards the wind direction) turned into very critical hazardous condition and the
atmosphere filled with mixture of hydrocarbon and air. All the statutory precautions were
in place for any activity there. Immediately after my join, HOD advised me to take the
responsibility of Station team leader as well as Overall in-charge for backup services.
My first job was to take the clear picture of the Disaster site on every safety aspects and also
my physical presence at the site to view and feel the emergency and hence on the very next
day i.e. 9th June, 2020 I made a programme to visit the site.
After the fire in Baghjan#5 well and the above incident, I could not properly sleep that day.
All time I felt some short of discomfort. Very next day got the message of misfortune of our
two brave firefighters. Sadness feelings, remained for days. Though I will not be able to
LEARNING LESSONSFROM BAGHJAN#5 DISASTER RECOVERY OPERATION SAROJ MISTRY
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comment on the entire happenings of the disaster site, my second valuable learning from the
incident was...
- While electrical services similar type of disaster first job is to find the escape
route to save own self in case of emergency.
We had our SOP for all electrical activities in Hazardous atmosphere, however type of this
disaster was new to us and we felt necessity for revision of the SOP related site condition,
hence we made that. We also trained our people working the disaster site, whenever we
identified a new hazard as well as any instructions from safety personals also. To follow and
maintain statutory guideline for all electrical equipment and systems some time we felt
necessary to have readymade panels or power switching device etc. with all safety features
as per CEA guideline.
- Learning is to have reserve stock sufficient Nos. of such switching devices or
portable panels, which can be used during emergency situation and disaster.
Time to time we visited site to check or audit safety aspect of all electrical works and give
safety instruction and proper electrical works following CEA / DGMS guidelines. At the same
time during emergency activity at the time of disaster we do not get chance to follow all
guideline such as permit to work, lockout-tagout (LOTO) etc. as per CEA / DGMS guideline.
- Learning is that, it is required to discuss at higher level to take up the matter
and discuss with the statutory bodies so that without affecting safety features
on personal and System safety, whether we can relax some statuary
requirement during emergency to reduce loss of life or property.
This disaster was associated with a large Nos. of evacuated family, hence no of relief camps
were established by HR and PA department. Essential requirements like Water and
electricity were arranged by Electrical and Field Engineering Department. Electrical
Engineering Department do never keep ready stock of such huge stock of wiring and other
electrical materials and do not have sufficient manpower also. Hence we required to manage
the same with lots of, hard work and dedication so that all are went smooth without any
major complaint. We obtained full support from management for approval of emergency
procurement. However, it was not easy to deal with. Learning in this regards to deal this
issue smoothly are…
- We need to keep some buffer stock of all such items to provide support at the
initial stage and at the same time arrangement for outsource all such
requirement.
- All safety and statutory regulation related issues to be dealt from electrical
department only, and hence all backup materials like DB’s with RCCB / RCBO
and earthling system is to be kept separately as ready stock for the purpose.
9th September 2020 was the worst day for electrical engineering department during the
entire operation. Each member of our department were deeply saddened to hear the news
of fatal accident of one of our beloved colleague, an excellent engineer while working at the
disaster site. Without explaining more about the incident all major learning for future
activity to avoid similar mature of incidents are…
- Never use mobile or any communication device for confirmation of Electrical
Power switching issues.
- Always try to keep your cool during any job related to Electrical Power.

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- Do not get influenced by requirements or orders from other people who are not
an electrical knowledgeable personal and not a team member of your working
group.
- Always do any electrical activity on the assessment according to what you learn
and also if you have confidence and know the system fully.
- Do not bypass electrical safety guideline.
- Do not be complacent on any issue related to safety (electrical or others)
- Wait for a moment, take a deep breath and think twice for all jobs deals with
electrical power.
- 30mA RCBO may not be able to save your life if you are not alert enough to do
the job in a safe manner.
- All employee works in electrical system must be trained with Lifesaving
technique, artificial breathing technique and shock treatment chart.
- It is you only who can save your life, PPE and other gadgets is the last resort.
- Finally for providing any electrical services required for disaster site similar to
Baghjan it is always better to send two Engineer together to the site to get better
decision making at any critical condition.
We took lots of corrective measures to boost the morale of our men, who were engaged for
providing electrical services at the disaster site.
- We made two engineers together mandatory for site after that till end of the entire
operation.
- Fresh safety talks is delivered to for all engineers and every sections related to
Baghjan disaster site.
- SOP for Electrical Engineering Department is revised with inclusion of new critical
activities related to disaster site and other areas of Electrical Works.
- We did frequent safety inspection at the disaster site and took necessary steps to
ensure safe working environment at the disaster site.
For any disaster of similar kind, major role were to play by the Engineering Services Group,
except expert job related to well head.
Disaster Management Plan for Engineering Services Group were prepared in 2018 when I
was Mines Safety Officer of Engineering Mine. However, providing services to fight the
disaster of this kind might not be orderly at the time of actual execution and during the
process we learned a lot also, find lots of new effective ways to get the result faster pace with
optimum resources.
Here I will put my view limited to the activities of Electrical Engineering Department.
Though we had our disaster management plan related to entire Engineering Service Group,
we did not have fully equipped backup inventory. Hence we had to face lots of limitations
and hurdle to get all backup materials and services in shortest time. Emergency procurement
channel were established, and we also got benefitted from that channel to procure some
emergency requirement. However, items related to technical and statutory requirement for
hazardous area are not available from the local market. So we had to wait for getting the
material. Which delayed our action and increases the downtime.
Here I want to mention about working environment and workplace condition related
electrical crew members, who were present at the disaster site 7×24 for the entire period of
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operations since 27th May 2020. Energy, efforts, alertness, emergency response and the
dedication of all shift members in every shift were commendable. However, the area
surrounding the well head upto about 100 meter were not conducive for normal work. And
in this area we were lagging behind the optimum requirement for mental and motivational
support for safe working environment to get better result in faster pace. If we could have
arrange separate crew hut with basic facility, we would be able to have avoid various
complicacies and issues time to time.
As an overall in charge for backup support services and station leader I had the opportunity
to analyse various issues, which could be make more orderly with some changes of
preparedness concept, style or process to get better result with optimum effort. Learnings
in this matter, basically from the electrical engineering services point of views are…
- Skid mounted Crew hut for electrical services personals with basic facilities is
very much essential at the disaster site.
- This crew hut shall be equipped with first line emergency items as indicated in
the Disaster management plan which is already reviewed and finalized
considering all issues learned from Baghjan.
- A team of disaster management Crew will be given responsibility to check the
working condition of each items monthly basis and process for replacement if
become unusable through emergency procurement channel.
- Emergency response team is to take part in various II / III tire Mock drill
operation.
- Communication Nos. of all members is to be updated time to time and updated
emergency response plan is to be display in every department level safety
meeting.
- At least to sets of Walkie-Talkie to be procured to use during disaster.
- Apart from Disaster Management Plan for Engineering Services Group our
department also should have Disaster Management Plan for Electrical
Engineering Department Separately.
- All working personal works in hazardous areas should be made fully aware
about the hazard and danger associated in their working areas and should be
encouraged not to by-pass or violate any safety guidelines.
Disaster Management Plan for Electrical Engineering Department is also made ready and
circulated to all.
I had conducted Nos. of safety talks with all Employees and Engineers Engaged at Baghjan
disaster site. Brief summery reports with learning points from the safety talk with all
working personnel engaged for Electrical Services at Baghjan are as below…
- Training on Basic Electrical safety conducted in two batches on : 24th & 25th
September 2020 at the Conference Hall of Electrical Engineering Department
- No of participates were
 24th September 2020 : 19 Nos
 25th September 2020 : 13 Nos.
Discussion points were
 Danger of electrical operation and maintenance and Do(s) and Don’t(s) on
Electrical safety aspects.
 Safety Precautions to avoid Electrical Shock.
 Communication procedure during Electrical work
 Probable reasons for electrocutions and their safety aspect for prevention.
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 Different Hazards on Electrical Works in the field and Safe practices.

 Safety procedure on Electrical shutdown and re-energization.
 Handling of Testing and measuring instruments
 Body and Neutral Earthing
 Maintenance of portable Electrical equipment.
 Coping with work related stress.
 Behavioural based safety.
All participants were involved in the discussion on each points. All queries form the
participants were addressed.
Apart from existing safety practices some new suggestion also came from the participants
and clarified as listed below:
a) Insurance for all working personnel deployed for Baghjan Duty.
b) Bunk House for Electrical General / Shift people
c) Avoid forcing to enter inside the plinth area for electrical job
d) Switches at all power points / lights at long distance.
e) Additional Safety Shoe (total 2 Nos) for Baghjan duty work persons.
All points listed above were also new lessons for improvement.
Conclusion:
If we practice more it will make us more perfect. As we gain experience the consequences
will starts to influence our behaviour and we learn to be more perfect to tackle crisis more
orderly and systematic. And that is why probably it is unreasonable to expect everything to
be orderly, sensible, and appropriate during disaster management. We do have an orderly
planed disaster management action plan. However, various factors can reduce our ability to
provide perfect electrical services for the team works for Disaster recovery at hostile
environmental conditions as it was experienced at Baghjan#5. During Baghjan disaster
recovery operation, one of the major learning for me was the significance and importance
review and culture of emergency preparedness. We lost three valuable life, which is
irrecoverable. The consequences of all misfortunes definitely taught to avoid all mistake
involved and we will be able to identify all such potential problems. This will guide all
departments involved in the disaster recovery operation, to review their responsibilities
continually in a brief but comprehensive manner and allows practice of disaster
preparedness without implementing an entire disaster drill.
All the above-mentioned learning will definitely reduce loss during disaster. But sometimes
human behaviour leads to follow shortcut method. Human behaviour is the observable act.
The observable act generally controlled by activator, which occur prior to behaviour and
directs us to act. and consequence, which motivate us. Learnings from the disaster is a result
from the consequence. But all benefit of learnings will not be able to stop losses. Sometimes
the shortcut leads to major accident or disaster which is the act of activator of individual.
In my opinion, to block any shortcut activity on any critical operation there must be check
by an expert, who is not a member of the operation team, so that responsibility and
accountability can be fixed in documented form. This will enable to take final call according
to safe operating procedure for that particular operation and chances of major accident or
disaster due to human error will be avoided.

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LEARNING LESSONSFROM BAGHJAN#5 DISASTER RECOVERY OPERATION SAROJ MISTRY