HIPO (July’23)

Sn Date Location Incident brief ABC

GR
1 04-Jul-2023 WTP Minor fire after short circuit of LT cable B
2 05-Jul-2023 SRU H2S exposure during maintenance of Control Valve B
BR
3 16-Jul-2023 QC Lab Smoke from oven during VR testing B
HR
4 17-Jul-2023 OHCU Naphtha spillage during online clamping C
BGR
5 07-Jul-2023 TT Loading Weld leak in LPG unloading line at loading gantry B
6 28-Jul-2023 Township Domestic LPG delivery in e-Rickshaw A
PR
7 10-Jul-2023 Off-site Tilting of loaded tractor trolley during reversing B
8 27-Jul-2023 HCU Minor fire at inlet flange of Breach lock exchanger B
9 30-Jul-2023 HGU-76 Hydrogen leakage from Idle compressor B
PNC
10 25-Jul-2023
02/18/2024 CMU Incorrect termination of power cable to rotary feeder A
 HIPO (July’23)
Sn Date Location Incident brief ABC
PNC
11 18-Jul-2023 CT-3 Damage of Cooling Tower Fan Blade in operation B
DR
12 21-Jul-2023 CRU Minor hydrocarbon leakage from the reactor outlet flange B
13 24-Jul-2023 DM Plant Wheel of butterfly valve detached and fall on ground from height. B
MR
14 26-Jul-2023 AVU Fall of metallic object from height B
15 26-July-2023 SS# 51 Battery got ruptured while in charging condition B
CPCL
16 07-Jul-2023 DM Plant HCL fumes from dosing pump discharge diaphragm valve B
17 05-Jul-2023 OHCU EOT Crane movement switch stuck in ON position A
PDR
18 27-Jul-2023 HCDS H2 leak from 2nd stage suction LP tapping of strainer PDT A
19 26-Jul-2023 Off-site Pick up vehicle collided with Fire Hydrant post A
20 29-Jul-2023 BOOT-3 HYVA toppled while unloading WMM A
02/18/2024
GR
 GR
Place of
Incident WTP, Intake, Pressure Filter / WTP
Date & Time 04-Jul-2023 13:30 Hrs.
 Power to Gopal Nagar CISF Colony was being supplied from Sector I SS Feeder
No 2C Section II.
 Power interruption in the CISF colony was observed due to failure of feeding
cable, on checking, the LT cable was found punctured at multiple locations.
 To restore the power supply of Gopal Nagar CISF Colony, a 35 Sq mm Armored
Aluminum LT cable was laid temporarily from WTP Substation to CISF colony
Description feeder.
of Incident  As cable was laid temporarily on ground some external damage took place
and there might have water ingression through the damaged portion during
rain which led to short circuiting of the cable.
 Fire & Safety personnel used a DCP Fire extinguisher to put out the fire on the
affected cable.
 Power cable was isolated and disconnected fromboth ends.
 GR
Short circuit in the temporary laid cable which was damaged externally. The cable
was laid just over the ground to meet job urgency in CISF colony. The permanent
Root Cause of the cable fault was detected at multiple location and identification of these locations
incident are getting delayed as most of the cable was passing through difficult terrain.

Medium Term:
 Temporary laid cable to be replaced with permanent cable, complying with
standard cable laying procedures.
 Cable route markers to be provided at prominent locations to ensure safety and
easy identification.
Long Term:
Recommendations/  Complete health assessment including sizing assessment of all interconnecting
Status cables to be carried out in township area to avoid outage of existing cables.
 Based on the assessment, cable procurement action to be taken in time bound
manner to replace the old and under size cables.
 Cable laying with proper route marking including laying through HDD at road
crossing or inaccessible area for safety and easy identification.
GR
 GR
Place of
Incident SRU: KOD downstream Control valve (51B-LC-0201)
Date & Time 05-Jul-2023 16:00 Hrs.
 Level build-up observed in the DCU ATU KOD (51B-V-07) and level controller
51BLC-0201 opened on AUTO mode.
 Even after 100 % opening of the level controller, KOD level didn’t come down.
Panel Operator informed Field Operator for opening of bypass of control valve
(51BLC-0201) as level is not coming down after control valve opening 100%.
 Field Operator opened the 51BLC-0201 controller bypass and level came
Description down. Job was given to IM for checking the DCU ATU sour gas KOD level
of Incident control valve (51BLC-0201) suspected chokage issue.
 Field Operator isolated the control valve and handed over the control valve to
IM. LPD of control valve was opened and very small amount of off gas came
out of LPD.
 Further IM loosened the control valve bonnet and suddenly fuel gas came out
of control valve bonnet. H2S portable detector available with both PN
operator and IM technician started showing alarm.
 GR
Root Cause of the
SDV 51BXV0201 and upstream isolation valve of controller 51B LV 0201
were passing.
incident
Long Term:
Recommendations/  Upstream isolation valve of 51B LV 0201 to be replaced.
Status  LPD valve chokage issue to be rectified during opportunity shutdown.
 SDV 51BXV0201 passing issue to be rectified.
BR
 BR
Place of
Incident Heavy Oil testing room, QC Lab
Date & Time 16-Jul-2023 16:30 Hrs.
 AVR sample was collected from AVU unit and sent to the QC Lab to check the
density.
 In order to liquidize the VR for density measurement, the operator placed the
VR sample inside the oven.
Description
of Incident  During the heating of VR, smoke was observed from inside the oven.
 Immediately, the power of the oven was cut off and informed to F&S.
 To prevent backdraft/ flashover, F&S advised keeping the oven door closed
until the temperature returned to normal.
 BR
Root Cause of the
Heating of VR sample was started without cleaning of oil spilled on tray
inside the oven.
incident
Immediate:
Recommendations/  Ensure proper cleaning of tray inside the Oven after every use/ testing.
Status
 Before putting oil sample in the Oven for testing, check the condition of
tray for any oil spillage and clean it if any spillage is found.
 HR
Place of
Incident OHCU / OHCU-U91
Date & Time 17-Jul-2023 16:00 Hrs.
 As the CBD/ OWS drain is susceptible to CUI, insulation of the line was
removed for inspection as part of planned inspection on 11.07.23.
 Line found to be corroded in 8inch length, above the bottom isolation valve
and minor seepage was also observed during inspection.
Description  First isolation gate valve found to be passing, hence line couldn't be isolated.
of Incident Subsequently, leak was arrested by pipe clamp.
 On 17.07.23, it was planned to carryout online clamping of the leak.
 Upon PN clearance, online box clamp was positioned and during the course of
tightening , leak had increased, and naphtha spillage occurred.
 HR
Root Cause of the
Corrosion under insulation leading to leakage.
incident
Immediate: Leaked drain line that has been isolated is to be replaced
Medium Term: Line from 1st isolation to be kept bare& painted with
phenolic epoxy by providing a safety cage, as the line is usually not in
Recommendations/ operation.
Long Term: Online clamping of the corroded/ leaked sections to be done
Status after assessing and ensuring adequate thickness of line where clamp is to
be fixed
Specific: Clamping of externally corroded/ leaked lines to be done where
line has adequate thickness to hold the clamp.
BGR
BGR
 BGR
Place of
Incident OM&S / LPG TTL
Date & Time 07-Jul-2023 11:00 Hrs
 At 11:00 Hrs. on 07.07.2023, leak was observed near weld joint of the
downstream flange of isolation valve in LPG unloading line to Mounded
Bullets/ Horton Spheres at Bay No. 8.
Description
 Loading operation was immediately suspended at Bay No. 8.
of Incident  As a precautionary measure, leakage checking of other similar locations was
carried out and no leak was detected.
 Mech. Maint. informed for isolation of the leaked LPG unloading line.
 The said line was emptied out by flaring for maintenance/ replacement jobs.
 BGR
Root Cause of the
The failure is attributed to material defect/ defective flange supplied by
LSTK contractor during project stage.
incident
Immediate:
 100% witness & record of DP test of bevel ends of fittings by TPI/ Client
during procurement stage as per RHQ M&I approved QAP (Ref. RHQ-
M&I-MN-QAP-10 REV 00). Status: Will be ensured during next
Recommendations/ procurement. (Complied) .
Status  Thickness Gauging of LPG unloading lines to be checked. Status: No
thickness loss observed (Completed).
 Hydrotest of similar LPG unloading lines in other loading Bays to be
carried out to ensure integrity.
 Ensure DP test of bevel ends of fittings (Flange & Elbows) before welding
at site for critical services like LPG.
BGR
 BGR
Place of
Incident Township
Date & Time 28-Jul-2023 10:00 Hrs.
 Gas godown is located near BGR Township community hall which is used for
unloading of domestic LPG cylinders for further distribution.

 On 28.07.2023 at 10:0 hrs., it was observed that e-Rickshaw was carrying filled LPG
Description cylinders from LPG godown.
of Incident
 12 nos. LPG cylinders were haphazardly loaded on E-rickshaw for delivering to
INDANE customers residing outside BGR Township. E-rickshaw stopped immediately.
 BGR
Root Cause of the Lack of knowledge and Negligence of E-rickshaw driver and personnel at LPG
incident godown.
Immediate:
 Use of passenger vehicles including E-rickshaw for handling and transportation
of LPG cylinders to be prohibited. Status: Advisory letter vide reference
IOCL/BNGN1/Safety/RCCS/1 issued to RCCS Ltd. by AM (LPG-Sales), Bongaigaon
I LPG SA. Use of passenger vehicles including E-rickshaw banned by RCCS Ltd.
Recommendations/ For delivery of LPG cylinders-Complied.
Status  Personnel engaged in handling of LPG cylinders at LPG godown in BGR township
to be counselled. Status: Concerned personnel counselled-Complied.
 DGR security to be instructed to restrict transportation of LPG cylinders by E-
Rickshaw. Status: DGR Security instructed-Complied.
PR
 PR
Place of
Incident OFFSITE CRUDE TANK FARM AREA
Date & Time 10-Jul-2023 11:30 Hrs.
 Pipe rack footing work was in progress in offsite area on Road-B. After
completion of piling work, Permit & clearance was issued to M/s BGR for soil
filling in excavated pits. At around 1030 Hrs., rain started for half an hour. M/s
Description BGR started to work again at around 11:15 Hrs.
of Incident  At around 11:30 Hrs., the tractor trolley (HR 60L 6495) of M/s BGR was carrying
earth in its trolley of 5 x 7 for backfilling job.
 While reversing the tractor for dumping the earth, the trolley got tilted due to
uneven surface of the temporary road and toppled subsequently.
 Trolley was restored to its position in the presence of the project, PMC and F&S.
Approach road soil got loose after the rain which resulted in the tilting of the
Root Cause tractor trolley's left wheel. Failure of the driver & flagman in assessing the
condition of soil after rain.
 PR
Immediate:
Recommend
After rain, site conditions are to be reassessed before resuming work in
ations
excavated areas.
4-wheel tractor trolley to be used at excavation sites for better stability.
PR
 PR
Place of
Incident PRE UNITS / HCU
Date & Time 27-Jul-2023 10:00 Hrs.
 Unit was running normal @ 255 m3/hr t'put.
 At around 05:00 hrs. on 26th Jul’23, HCU got tripped due to total power and steam supply
failure.
 After getting power & steam clearance from P&U, unit start up activities was started at
around 10:00 Hrs.
 After following the start-up procedure, RGC was rolled and feed cut-in was done @ 09:30
Description hrs. on 27/07/2023.
of Incident  As a precautionary measure, Fire tender with crew was deployed near BLE before feed
cut-in. Steam rings around all flanges were charged.
 Suddenly after feed cut-in, HC leak observed from 75-EE-005A inlet flange which got
increased over the period of time.
 As a measure to control the leak, system pressure was reduced but leakage could not get
controlled. Water curtains were provided in downwind direction of leakage to avoid
spread of vapor.
 PR
 Situation was under observation. Suddenly nearby oil soaked insulation part
caught momentary fire which was immediately quenched by fire team.
 Even though measures were taken, leakage was not controlled. Decision was taken
to feed out. System was depressurized and handed over to M/M for gasket
replacement job after following handing over procedure.
 E05A Inlet flange gasket was replaced and unit was again taken under start-up on
30.07.2023.
Root Cause Thermal stress on the flange due to sharp variation in inlet/outlet flow.
Medium Term:
Stress analysis of the piping to be reviewed and necessary support modification as
Recommendatio per stress analysis report to be carried out.
ns
Long Term:
Possibility of gasket replacement to be explored which can withstand high
temperature as well as also withstand thermal shock cycles.
PR
 PR
Place of
Incident PRE UNITS / HGU-76/77
Date & Time 30-Jul-2023 15:00 Hrs.
 Plant was running normal. Compressor K -103A & K-203 was under running condition. K-
103B was in emergency standby condition.
 Hydrogen gas detectors alarm received by panel operator at around 15:00 Hrs.
 On instruction of panel operator, area EA along with SIC moved to the site to check the
condition of compressor area.
 During field visit, it was noticed that H2 was leaking with hissing sound from 76-K-103B
Description ( under stand by) discharge loader valve flange.
of Incident  Compressor was isolated and purged with nitrogen to stop the hydrogen leakage and
handed over to MM for rectification.
 The aluminum gasket of the discharge loader valve was replaced with new one and
uniform tightening of all the bolts was ensured. Subsequently, leak test was done and
after successful leak test compressor was handed over for operation.
 PR
After opening the discharge loader valve, the aluminum gasket was observed to be
Root Cause
over compressed from one point which might have led to minor leakage of the gas.
Immediate:
Recommendation The gasket has to be visually inspected before box up for checking of any dent or
s
uneven surface and only after checking & ensuring proper healthiness of the gasket
it should be used for box up. Uniform tightening of the flange has to be ensured.
PNC
 PNC
Place of
Incident CMU
Date & Time 25-Jul-2023 11:00 Hrs.
 CMU Commissioning activity of rotary calciner package was under progress.
 Power of all RAVs was normalized from MCC for checking of sequence logic of rotary
calciner.
Description
of Incident  Start command to RAV-2 was given from PLC.
 Motor stopped immediately from PLC. After giving command from PLC, motor of
RAV-3 starts rotating instead of RAV-2 in field.
 PNC
Root Cause of the Incorrect termination of power cable of RAV2 & RAV3 motor at MCC end.
incident
Immediate:
Recommendations/  Continuity checking for identification of power cable at both end to be done.
Status  Rechecking of cable terminations of motors to be done 100% of cases by PMC
and by IOCL prior to trial.
 PNC

Shaft condition after

Condition of fan blade Condition of gear and fan detach from gear box
 PNC
Place of Incident CPP-UTILITIES / COOLING TOWER
Date & Time 18-Jul-2023 08:00 Hrs.
• Plant was running normal and CT02 FAN 10 is in operation.
• Motor was stopped and condition of fan was checked by opening the entry
Description cover.
of Incident • Two no's of fan blade found damaged gearbox found dislocated partly from
the foundation.
• Three foundation bolts also found damaged.
• CT-02 FAN 10 discontinued from operation and taken for maintenance job.
1. Breaking of fan blades due to ageing.
2. The fan blades incurred damage resulting in an imbalance within the gear
Root Cause
box load. Also, the corrosive atmosphere compromises the integrity of
foundation bolt.
 PNC
Immediate:
1.Vibration switch checking and maintenance to be done for effectiveness.
2.Two vibration switch installed (one for alarm and other for tripping) for protection
of gearbox 1oo2 (one out of two) tripping to be implemented in each fan.
3.All Cooling Tower Fans blades life assessment to be done and integrity of
foundation to be confirmed.
Long Term:
Recommendations Vibration monitoring system to be installed in each fans with two vibration probes
one each for motor and gear box.
Specific Recommendations :
To have proper record of fan blade ageing and preventing such fan and gear box
damages due to fan blade ageing , methodology for fan blades replacement shall be
developed and implemented.
DR
 DR

Place of Incident CRU

Date & Time 21-Jul-2023 15:00 Hrs.
 CRU plant was running normal with Reformer throughput of 12.7 m3/hr with
inlet temperature of 4830c.

 At 1500 hrs., during the plant round, the area operator found the minor leakage
of hydrocarbon from the reactor outlet flange (05-RB003).
Description
of Incident  Instantaneously the message was conveyed to SIC & maintenance personnel was
informed to report at site.

 Immediately two steam hose was charged to dilute the leakage & avoid any
possible hazards . Gas test was done & Zero LEL was recorded at site.

 Steam charging continued at the leaky area. Steam lancer is provided at reactor
Inlet/Outlet flanges as a preventive measure.
 DR

Root Cause Gasket failure of the reactor (05-RB-003) outlet flange due to wear & tear.

 Continuous steam charging is to be maintained at the reactor outlet flange (05-RB-

003)- Complied.
Recommendatio
ns  Area to be monitored continuously under CCTV surveillance.- Complied
 05-RB-03 outlet flange to be opened in the upcoming shutdown and necessary
action is to be taken for rectification.- Job taken up in ongoing shutdown (Target:
Aug.’23)
DR
 DR
Place of
Incident DM Plant

Date & Time 24-Jul-2023 11:30 Hrs.

 A chain operated butterfly valve is located at height of approx. 4 M. on 6" line from
high pressure sand filter (HPSF-C) to stream-C SAC vessel.
 The butterfly valve is operated from ground with chain-wheel arrangement as per
operational requirement.
Description  On 24.07.2023 at 11:30 hrs., DM Plant operator was closing the valve by pulling its
of Incident chain as per routine practice.
 While he was pulling the chain, suddenly the wheel got detached from its spindle and
fell down at ground floor along with its operating chain in the close vicinity of the
operator.
 The defective wheel of the valve was rectified & operation continued.
 DR

Root Cause  Lock pin of the operating wheel got broken and wheel came out of its position
and fell down.
 Repair the damaged lock pin and rectify the valve to restore its normal operation.
– Complied
 Condition of chain also to be checked for its healthiness. – Complied
 Similar type of valves at height is also there at DM Plant area. Lock pin, chain
Recommendatio condition and the condition of the valve as a whole to be checked and its
ns healthiness to be ensured. – Complied
Long Term: Inspection of chain operated valves to be done on quarterly basis.
Complied
MR
 MR

Place of
Incident AVU
Date &
Time 26-Jul-2023 10:30 Hrs.
 Shutdown activities at different locations inside the plant area were in
progress.

Description  Various activities involving opening up box up activities were in progress.

of Incident
 While opening up of pipe flanges and manholes, nut bolts were found kept on
the grating platform at the same location.
 MR

Root Cause  Falling of bolts through grating platform gaps

 No arrangement for keeping of nut bolts
Immediate:
Recommendati  Incident should be shared among all working group doing similar activities
ons during toolbox talk meeting in shutdown/maintenance activity.

 Any loose items during maintenance must be stored in tray specially if it is

on porous platform i.e., grating.
MR

View of battery bank

 MR
Place of
Incident Substation No. 51, NPRU SS, Battery Bank
Date & Time 26-July-2023 20:00 Hrs.
 M/s HBL was awarded the job for load testing of the battery bank.
 Load test of battery bank was carried out on 25.07.2023.
 Battery bank of NPRU UPS-2 was under boost charging since 3:30PM on
26.07.2023.

Description  One of the battery (Ni-Cd battery) got ruptured while in boost charging condition.
of Incident  Immediately the battery bank was isolated.
 Upon checking, fumes were coming out from ruptured battery cell and
electrolyte was leaking from the ruptured battery cell. No further damage
occurred.
 MR

 12 nos. of battery cells were identified as faulty during PM checks were

replaced before load testing.
 Faulty battery cell which got ruptured couldn't be identified during checking
Description as the leak was in the rear side of the cell which was not visible due to its
of Incident position. During boost charging the faulty (leaky) cell got heated and
ruptured.
 The battery bank (make HBL) was manufactured in Aug’2012 and there is
frequent problem of leakages in battery bank of NPRU UPS-1 & 2.
 MR
Faulty battery cell got heated during boost charging. Reason for leakage of
battery is under examination by OEM. Report expected by 19.08.2023.
Root Cause Faulty battery cell could not be identified during earlier visual checking due to
its position.

Gaps and Lapses Report awaited from OEM.

if any
Immediate:
 Faulty cells of the battery banks to be identified and replaced.
 While Carrying out any Load test of battery bank, battery to be individually
checked by removing battery cell from its position wherever inaccessible and
Recommendations check thoroughly from all sides.
 OEM has been contacted for exact reason of battery cell leakage. Report
expected by 19.08.2023
Medium Term:
The design of the battery bank stand to be modified for better inspection of the
battery bank cells preferably by increasing the height of rear step of each tier.
 CPCL
EOT Crane movement switch (Pendent push button) stuck in ON position in OHCU
Compressor Shed (A2 HiPO category)

Pendent Push Emergency Stop

button which got Push button which
Incident Site stuck was activated
 CPCL
Place of Incident Ref-III OHCU MUG compressor shed
Date & Time 05.07.2023 at 1900 hours
 EOT crane in the MUG compressor shed was used for lifting the oil
drum from ground floor to first floor.
 Operator loaded the lube oil drum on paddle.
 Paddle was engaged in crane hook using slings.
Description of  It was lifted by using control panel and moved from east to west to
Incident place paddle on first floor platform.
 Operator was trying to keep oil drum down on 1st floor and observed
that EOT couldn’t be stopped as the pendent push button got stuck.
As a result, crane with lifted load was moving towards east direction.
 Operator actuated the Emergency stop push button and crane
stopped.
 CPCL

Root Cause  EOT stop push button got stuck.

Observations:
• EOT yearly test was done as per Rule 55A of Tamilnadu Factories Rules
1950 on 07.03.2023 by competent person. It was found satisfactory.
• SWL Main – 25 Tons / SWL Auxiliary – 3 Tons.
Observations & • Model and make – ARMSEL / 2003.
Recommendati Immediate Measures:
Adobe Acrobat
Document

ons / ATR  EOT control panel (Pendent push button) to be checked and repaired –
Attended.
 All other EOTs were checked for similar issues, if any - All found ok.
Long term:
 Yearly testing checklist shall be reviewed by Unit Manager and signed
jointly with Maintenance.
 CPCL
HCL fumes from dosing pump discharge diaphragm valve in DM Water plant (B3 HiPO
Category)

Diaphragm valve
leak

HCl Dosing
Pump
 CPCL
Place of Incident P&U-III DM plant -HCL dosing pump 123G11A

Date & Time 07.07.2023 at 08:00 hours

 HCL pump was running normal and dosing HCL to Resin regen section for
cation regeneration.
 DM plant Electrical maintenance technician was on his field rounds.
 He felt fumes in the DM plant and observed fumes coming out from HCL
dosing pump (30% conc.) discharge line.
 Immediately he informed to control room and switched off the pump from
Description of Incident substation.
 Meantime, people from surrounding area were also evacuated.
 Upon stopping the pump, HCL fumes subsided.
 Later, it was observed that the fumes were due to pump discharge
diaphragm valve leak.
 CPCL

Root Cause  External Corrosion due to proximity to Cooling Tower.

Immediate:
ATR /  Workers in the nearby area were immediately evacuated.
Recommendati  Valve was replaced.
ons Long term:
 Painting standard upgraded to “Painting 25” for facilities which are in close
proximity to CTs.
 PDR
Hydrogen leak from 2nd stage suction, LP tapping of strainer PDT
Leak from LP tapping of level transmitter of HHPS Vessel at VGO-HDT
 PDR
Place of Incident HCDS (Hydrogen Compression and Distribution System)

Date & Time 27-Jul-2023 19:10 Hrs.

 Hydrogen compressor, 56-K-01A & C were in normal operation in hydrogen
compression and distribution system (HCDS).
 During routine field visit Field JEA noticed unusual sound from HCDS compressor
C.
 He traced that unusual sound was coming from 2nd stage suction line and
subsequently found that hydrogen was leaking (45bar) from the upstream of
isolation valve(Stiffener to pipe weld joint) of LP tapping (3/4”) of strainer PDT-
1307.
Description of Incident  Immediately he informed to shift in-charge and other concern personnel.
 Immediately area was barricaded and nitrogen hose was provided as a
precautionary measures.
 Compressor C was isolated and changeover was done to compressor D.
 Positive Material Identification (PMI) was carried out for subject line and
stiffeners. Both were found to be in line with the Piping Material Specs (PMS).
 PDR
Due to inadequate support provided on PDT line and vibration in the system
Root Cause resulting in the formation of crack from the stiffener to pipe weld joint.

Immediate-
• Cracked line to be replaced with new one. (Complied)
ATR / • Vibration survey and stress analysis of lines connected to compressor to be
Recommendations conducted and necessary corrective action to be taken as per report.
• Adequate support system of impulse lines to be ensured.
 PDR

Pick up vehicle collided with Fire Hydrant post

 PDR
Place of Incident Road no 221 near 105 HSFO Tanks

Date & Time 26-Jul-2023 15:30 Hrs.

 M&I of HSFO Tank (105-TK-003) was being carried out by the agency M/s Jay
Gauri.
 Pick up vehicle(OR-21C-7516) of agency M/s Jay Gauri, engaged for transporting
manpower and resource to the tank site.
 On 26.07.2023 at about 15:30 hrs, empty pick-up vehicle was parked on road no
221 near HSFO tank (105-TK-003).
 Helper of same agency attempted to start the engine of pick-up vehicle,
resulting in the vehicle suddenly moving forward and colliding with nearby
Description of Incident hydrant post.
 The impact caused the vehicle to topple over into an open drain located in the
vicinity.
 No injury caused to helper or anyone. However, it caused damage to the vehicle
and the hydrant post.
 Immediately nearby personnel informed to fire station and all concerned
rushed to the site.
 Area was barricaded and later vehicle was shifted outside for repair and
maintenance.
 PDR
The vehicle was parked with the gear engaged and without applying the hand brake.
Root Cause The helper was not authorized to drive the vehicle, yet attempted to start and
operate it.
Immediate-
• Damaged hydrant post to be repaired. (Complied)
ATR / • Driver and helper to be suspended.
Recommendations • Penalty to be imposed on the agency M/s Jay Gauri for violating traffic safety
norms.
• Traffic safety awareness training to be conducted for all drivers/helpers to follow
safe driving practices.
 PDR
HYVA toppled while unloading WMM
 PDR
Place of Incident BOOT-3 Product area

Date & Time 29-Jul-2023 12:50 Hrs.

 Construction of Additional tankages by agency M/s B&R and composite work by
agency M/s Sopan were being carried out at BOOT-3 Product area.
 Dumper truck (HYVA) with Registration No. OD-09U-1277 of agency M/s Sopan,
loaded with Wet Mix Macadam (WMM) reached near new culvert of Alkylate
tank area.
 During the course of unloading of WMM by raising the hydraulic lifting jack, half
of the material was unloaded.
 For facilitating the unloading of remaining material, driver was slightly moved
Description of Incident the vehicle forward by turned the front tyre of the vehicle at the right side by
keeping the lifting jack in raised condition.
 Eccentric loading on the lifting jack of the vehicle and subsequently the hydraulic
jack failed.
 Resulting in toppling of the Vehicle.
 Immediately the area was barricaded and the toppled dumper truck was lifted
using hydra and crane. Then the dumper truck was sent outside for repair.
 PDR
Root Cause
 Breakage of hydraulic lifting jack due to wrong positioning of vehicle.
 Failure to assess the risk by the HYVA operator.
Immediate-
• HYVA operators to be trained on safe operation of the heavy vehicle.
ATR / Proper supervision required for material supplier’s vehicle during vehicle
Recommendations •
movement & loading/unloading activities.
• Penalty to be imposed on agency for lack of supervision.