FATAL ACCIDENT AT AN REFINERY

Brief of the Incident:

• Construction activities for 23 nos. of trestle foundations for OSBL Pipe Rack for Catalytic Reforming unit (CRU) project
was in full swing by contractor, out of which 13 nos. are on road no. 11 towards north side of lndmax unit and the rest
10 nos. on the dyke walls towards north side of tank nos. TK-13 & 15. JSA for the job was done by a multidisciplinary
team and all safety precautions were clearly mentioned for safe execution of the job.
• Construction of 04 nos. out of 13 of trestle foundations along the road no. 11 was completed and 8 nos. foundations
works out of 10 viz., excavation, cage preparation etc. were in progress at the dyke wall area of tank farm T-13 & 15.
• The incident occurred at trestle foundation pit (TR-13C) of dimension of 6.2 mtrs. length, 6.2 mtrs. breadth and 6 mtrs.
deep (depth 4 mtrs. from top of tank dyke) at OM&S tank farm area near TK-13 & TK-15.
• In the above-mentioned pit, excavation, PCC, bottom reinforcement of foundation and vertical reinforcement for
pedestal were completed.
• Concern on inadequate shoring at the south side of main CRU project site was raised to the contractor and accordingly
jobs were stopped on 08.06.2023. Agency was advised to provide adequate sloping and shoring at all excavation sites
under CRU project prior to resumption of any construction activities.
• There was rainfall of around 30 mm on the night of 09.06.2023 & light drizzle in the morning of 10.06.2023 leading to
some scouring of earth from the sides of the excavation pit.
• On the day of incident, clearance was issued to the contractor at 1004 hrs. for composite confined space entry & hot
work permit. The contractor mobilized resources to carry out shoring towards east side of the pit TR-13C. Shoring
towards the west side of the pit, using metallic shuttering planks and pipes, was carried out previously.
• On the day of incident, it was informed by the supervisor that five contract workers went inside the excavated pit for
removing the scoured earth prior to repair of shoring towards east side of the foundation when suddenly soil from
earthen dyke collapsed on the workers.
• Three workers managed to escape from the pit. However, two workers, got trapped inside the pit.
• Immediately, emergency call was raised at 1200 hrs. and the workers were rescued and sent to hospital. After
administering treatment, they were later shifted to Apollo Hospital for further treatment, where one of the workers
succumbed to the injuries.

Major gaps/ lapses:

Root cause of incident:
Non-compliance w.r.t:
• Shoring was not adequate and
• Excavation without proper shoring and strutting/ shuttering. Steep vertical
strong to hold the soil cave-in/
excavation was done for depth of about 4 mtrs.
collapse of soil. Presence of water
• Entry into confined space without adhering to the basic protocols like
due to rain on previous night and
maintaining in-out register/ watcher etc.
drizzling in the morning on the day
• Non-availability of proper approach from nearby road to the job site and
of incident had weakened the
rescue.
stability of the soil and resulted in
• Lack of supervision.
collapse of soil into the pit leading
to entrapment of 02 nos. of • Work was executed just after the rain which stopped at around 0900 hrs.
workers. Rainwater ingress in the soil created pressure on the shoring and it got
collapsed due to water in the pit and porous nature of soil.

Lessons learnt:
• Compliance of work permit system as per OISD-STD-105 and Job
Safety Analysis (JSA) recommendation to be ensured before start
and during execution of work.
• JSA is to be reassessed in case of change in site conditions due to
weather/ rain, etc. to reinforce with additional precautions for
strengthening the existing shoring and its adequacy should be
checked.
• A rescue plan/ resources and proper approach to job site to be
ensured before start of job.
• Excavation should be done as per clause no. 6.1 of OISD-GDN-192
by providing shoring and strutting and maintaining angle of repose
for ensuring the structural stability of the pit.
• Supervision at site of excavation to be strengthened. Dedicated Incident Location
supervisors to be deployed. Collapsed soil (East side)

Detail Incident Investigation Report can be accessed thru CO-HSE website under Accidents/ incidents tab.