Case Studies on Industrial Accidents -2

8/12/2019 Case Studies on Industrial Accidents -2

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COMPILED BY

OFFICE OF THE ADDITIONAL DIRECTOR, INDUSTRIAL SAFETY & HEALTH,

PUNE


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Preface

We know that many stories of accidents, near-misses, and accidents waiting to happen go untold

According to Henrichs Theory of Accidents, for every one reportable accidentthere are 29 non-reportable

accidents and 300 first aid cases. On analysis for the causes of accidents, he further states that cause are- 88

% accident due to unsafe act, 8 % accidents due to unsafe working conditions, 2 % each due to physica

deficiency and natural disaster. Thus, unsafe act and unsafe working conditions are the main causes of the

industrial accidents. As much as the next years promise to be exciting for the industry, they also pose a

great challenge to the industry to maintain workplace safety and health. We must address this perception

and change the reality. While workers are at work place, it is important that they do not risk life and limb. It

is crucial that these workers go home safely after work.

This compilation of case studies on fatalities and serious accidents in the industries is initiated and put

together by the Office of The Additional Directorate Industrial Safety & Health, Pune. This booklet depicts

how the accidents occurred and provides valuable learning points on how they may have been prevented

This booklet of case studies offers insights to all in the industry on how these tragic accidents occurred, so

that we may glean important, lifesaving lessons from the experience. In learning from our past mistakes

we can and must prevent these mishaps from happening again. Together with your help, we can transform

the factory into safe and healthy workplaces for our workers.

Some human errors appear to be completely random. However, most errors are not random but are

system induced or systemic errors caused by the unsafe system of work. The book will use case studies to

demonstrate how and why they have occurred and what could have been done to reduce their likelihood o

occurrence or the severity of their consequences. However, the objective of the book is not simply to

reproduce case studies of systemic errors that have led to serious accidents. Rather, it is intended to

identify common features in the accidents and the way they are investigated, so that lessons may be

learned to prevent similar accidents in the future. There is another aspect of blame, which needs to be

considered. In the immediate aftermath of a serious accident there is a natural tendency, especially by the

management, quickly to suggest a cause by quite o ften the words it is believed the accident was a result of

workers error are heard. The accident investigation does not accept human error as inevitable but goes on

to reveal the underlying reasons. Organizations of the industries should look too closely at the system

faults which caused the accidents. Further accidents of a similar nature will occur because the underlying

causes have not been corrected. Apart from the human cost of future accidents in terms of loss of life, injury

and trauma, the long term cost to the organization in loss of production, customers and reputation will far

exceed the cost of correcting a faulty system.

It is crucial both to the prevention of major accidents with multiple fatalities which make the headlines, as

well as to the host of minor accidents leading to injury and disability, which rarely make the headlines, but

still cause untold human suffering.

Accidents could occur due to various reasons. It is not possible to cover case studies on all the types of

causes. However efforts have been made to cover cases studies based on commonly used machines,

processes, activities. They cover a variety of issues, ranging from accidents at Engineering Industries to


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chemical industries. The cases studies include accidents on the power press machines- Mechanical, Electro

pneumatic, Hydraulic, machines like-pressure die casting machine, bagasse bale braking machines, lathe

machines, etc. The case studies are based on the causes like non provisions of guards, lack of maintenance,

unsafe system of maintenance work, unsafe material handling, unsafe working at height, unsafe working in

confined space, unsafe method of pneumatic testing of coils of heat exchangers. It also covers the

incidences like collapse of cement silos, sliding gate, boiler chimney, explosion of the reaction vessel, curing

oven etc.

The book comprises a wide range of case studies from various industries in order to show how systemic

errors have in the past led to catastrophic accidents. The use of these case studies also enables the more

technical subject matter in the book to be better understood. In order to change the future, the lessons of

history need to be brought to bear on the present. This is why the book draws so heavily on what has

happened in the past in the hope that some of the terrible accidents referred to in the case studies may

never be repeated.

The case studies in this booklet are presented in a typical manner. It provides you the information about

how the accident occurred, what were the observations made by the investigating officer, what went wrong

and also suggests the remedial measures.

Through a series of case studies and the lessons drawn from them, you will:

* Probe the methods of failure by which most industrial accidents occur,

* Investigate common components of accidents,

* Explore a common-sense strategy for systematic industrial operations,

* Determine the purpose of operating limits and the safe operating envelope,

* Review how alert, well-trained operators are developed,

* Examine the importance of investigating abnormal events,

* Realize the worth of continuing training,

* Analyze a case study in implementing the systematic approach.

The intention is that the reader can use the book to select an appropriate accident analysis methodology to

suit their analysis needs, and then use the practical guidance and case study examples provided to see how

the method works and then apply the method effectively. These factual cases studies are investigated by

the officers of Directorate of Industrial Safety & Health. The success of this booklet will rely on every safety

professional if they study each case thoroughly and take effort to prevent the accidents and not to create

another case study in future.

I express my sincere gratitude to the officers and staff of my office who directly or indirectly helped in

compiling this book.

Thank you!

M.N.Gadappa

Additional Director

Industrial Safety & Health, Pune


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INDEX

SR.NO. A CASE STUDY ON COMPILED BY PAGE NO

1. Electro pneumatic Power Press Machine Shri.R.P.Khadamkar 01

2. Mechanical Power Press Machine Shri.A.B.Pawar 03

3. Hydraulic Power Press Machine Shri.V.M.Yadav 054. Power Press Machine- Unsafe system of work during

maintenance work

Shri.R.P.Khadamkar 07

5. Pressure Die Casting Machine Shri.R.D.Kichamabare 10

6. Rotary Vacuum Dryer Shri.J.B.Kumbhar 12

7. Bagasse bale breaking machine Shri.R.D.Kichamabare 14

8. Lathe Machine-Non use of tight fitting clothing Shri.R.P.Khadamkar 16

9. Lathe Machine-Unsafe system of work during maintenance

work

Shri.S.G.Giri 18

10. Material Handling-Use of improper lifting mechanism Shri.N.A.Deshmukh 20

11. Unsafe Material Handling Shri.S.G.Phadatare 23

12. Unsafe Material Handling in a Sugar Factory Shri.R.B.Lakhe 25

13. Working at height-Falling through fragile roof Shri.S.G.Giri 27

14. Falling from a Platform without Railing Shri.Y.P.Patange 29

15. Working in Confined Space-In a vessel at a Chemical

industry

Shri.J.B.Kumbhar 31

16. Working in Confined Space-In a tank at a Engineering

Industry


17. Working in Confined Space -In a tank at Edible oil Industry Shri.R.D.Kichamabare 36

18. Falling in quenching tank containing hot water Shri.T.M.Kambale 38

19. Heat Exchanger-Unsafe system of work during pneumatic

testing


20. Extrusion Machine-Use of a kerosene burner near the

trough containing a highly flammable solvent-toluene

Shri.A.B.Pawar 45

21. Explosion of the condenser coil Shri.P.V.Adkar 47

22. Chemical Industry-Unsafe system of work while handling Di

Methyl di Sulphide.

Shri.V.M.Yadav 48

23. Explosion of the Reaction Vessel Shri.P.V.Adkar 51

24. Minor Fire causing tragedy Shri.P.V.Adkar 53

25. Explosion in the curing oven Shri.P.V.Adkar 55

26. Collapse of cement silo at Ready Mix Concrete plant Shri.V.M.Yadav 56

27. Collapse of sliding gate of the shed of the factory Shri.R.P.Khadamkar 60

28. Prevention of fall of Boiler Chimney Shri.P.V.Adkar 63

29. Driving Fork Lift Shri.N.A.Deshmukh 65

30. Explosion due to Ammonia gas leakage in a cold room. Shri.V.M.Yadav 66

31. Chlorine Gas Leakage-Successful Disaster Management Shri.V.A.More 69


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A Case Study On 1

1.SERIOUS ACCIDENT OCCURRED WHILE WORKING ON ELECTROPNEUMATIC

POWER PRESS MACHINE

Compiled By

R.P.Khadamkar

Deputy Director


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A serious accident had occurred to a worker while working on the Power Press Machine in the factorypremises.

ABOUT THE ACCIDENT:

The factory is involved in the manufacturing of

the various press components required for theautomobile industries. The manufacturingprocess for the job Piller Side Wall involves

various operations on C.R. sheets like-drawing,

trimming, restriking, piercing etc. The drawing

operation is carried out on the 400 T powerpress.

The said power press was having loading side,

from where the job was loaded for drawing

operation and unloading side from where the job

prepared, was taken out. On each side of the

machine i.e, loading and unloading side, therewas a push button station. Thus there were total

two no. of push button stations. Each push

button station was having two push buttons.

When all push buttons were pressed, the strokeof the power press machine was getting

operated.

The injured worker was employed through the

contractor as Power Press Operators. On the day

of incidence, the injured worker along with a

co-worker was entrusted with the work on 400 T

Power Press machine in the factory premises for

carrying out the drawing operation of the job

Piller Side Wall. Accordingly they started thesaid machine. For carrying out the said job, the

work involved was as under. The co-worker was

working on loading side of the machine and the

injured worker was working on unloading sideof the machine. The co-worker was loading the

job on the die of the machine through the

opening in the punch and die of the machine by

hands from loading side. Then both of them

were operating the push buttons of therespective stations provided to them. With this

the punch was coming down and the job was

getting pressed between punch and die of the

machine and punch was going back to T.D.C

(Top Dead Centre). After drawing operation, the

injured worker was removing the job by handsfrom the die of the machine and keeping near

the machine. They prepared about 700 no. o

jobs in the above said manner. While the injured

worker was removing the next prepared jobfrom the die of the machine, the punch of the

machine suddenly came down, while his righ

hand was still on the die. As a result, his right

hand was caught and crushed between the punch

and die of the machine. The accident resulted inthe amputation of his right hand at level of mid

forearm.

OBSERVATIONS:

It was a Power Press Machine of capacity 400TThe main motor is of 3 phase, 440V, 60 H.P.

1440 RPM. The upper die fixed to ram forms

the punch and the bottom die is fixed to the

table i.e. bed. The size of punch and the die top

was about 1600 mm x 930 mm. The maximum

POWER

PRESSM/C


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distance between the punch and die was about400 mm, when the punch was at TDC. Thedistance of the die top from the ground level

was about 820 mm. The front and rear opening

of the machine was of size of about 2840 mm x1050 mm. The left side and right side opening

of the machine was of size about 800 mm x

1400 mm. On each side of the machine i.e.

loading and unloading side, a push buttonstation was provided. Each push button station

was having two push buttons. The loading side

and unloading side and right, left side openingsof the machine are not found provided with a

photo sensitive guard or any other guard for

preventing access to the punch and die, while

the machine is in motion.For carrying out the drawing operation

of job on the power press machine, a job is to be

kept on the die of the machine from the loadingside through the rear opening with hands. When

the stroke of the machine operates, the punch

comes down and the job gets pressed betweenthe punch and die of the machine. As a result,

drawing operation of the job takes place. Thus

due to design, location, function, reciprocating

action of the punch, the portion between punchand die is dangerous zone and constitutes the

dangerous part of the machine, when the punch

is descending.

WHAT WENT WRONG: 2

The accident had occurred, while the injured

worker was removing the next prepared jobfrom the die of the machine. The punch of themachine suddenly came down, while his right

hand was still on the die. As a result, his right

hand was caught and crushed between the punch

and die of the machine. He was seriouslyinjured. Thus, there was access to the dangerous

parts of the machine, while the machine was in

motion. The above said dangerous part of themachine ought to have been securely fenced by

providing an interlocking photo sensitive

safeguard to prevent access for any part of body

to it from all sides of the machine, while themachine is in motion and also the safeguard for

securely fencing of the above said dangerous

part ought to have been constantly maintained toprevent access to the dangerous part, for each

worker working on the machine. But the front

opening (unloading side), the rear opening(loading side) and side openings of the machine

were not provided with any safeguard for

preventing access to the above said dangerous

part of the machine, while the machine was inmotion.

REMEDIAL MEASURES:

i) The dangerous zone between punch and die ofpower press machine shall be securely fenced

from all sides by interlocking safeguard and

prevent access of any part of body and thesafeguard shall constantly maintained and kept

in position while the punch is in motion.

DANGEROUS

ZONE DANGEROUS ZONE

ACCESSIBLE FROM

REAR SIDE


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A Case Study On 3

2.SERIOUS ACCIDENT OCCURRED WHILE WORKING ON MECHANICAL POWER PRESS M/C

Compiled By

A.B.Pawar

Deputy Director


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A serious accident had occurred to a worker while working on the Power Press Machine in the factorypremises.

ABOUT INCIDENCE:

The factory is involved in the manufacturing of

the various press components required for

automobiles. The manufacturing processinvolved various operations on s.s. sheet like,

blanking, forming, etc. The injured worker was

employed as a helper. On the day of incidence,

he was entrusted with the work on 150 T PowerPress Machine for carrying out the forming

operation. Accordingly he started the said 150T

Power Press M/C. For carrying out the said job,

the work involved was as under. He waskeeping the piece of s.s. sheet on the die of the

machine through the front opening of the power

press machine by his right hand. Then he wasoperating the stroke of the machine by pressing

the foot pedal switch provided at the front sideof the machine. With this the punch was coming

down and the s.s. sheet was getting pressed

between punch and die of the machine and

punch was going back to T.D.C. (Top DeadCentre). He was taking out the prepared job by

his left hand through the front opening. Then he

was again keeping another s.s. sheet for next job

and the process was repeated.

While he was keeping next job on thedie of the machine through the front opening

the foot pedal switch got pressed by his foot

unknowingly and the stroke of the machine got

operated. With this the punch of the machinecame down and his right hand was caught and

crushed between the punch and die of the

machine. He was seriously injured. The accidenhas resulted in the amputation of the two

phalanges of the fore finger and middle fingerand part of the first phalange of the ring finger

of his right hand.

OBSERVATIONS:

I

It was 150T mechanical Power Press machineThe punch was fixed to ram and the die was

fixed to the bottom table. The size of table was

about 600 mm length x 730 mm breadth. The

die was cylindrical having size of about 200 mm

dia x 140 mm height. The maximum distance

between the punch and die was about 120 mmwhen the punch was at TDC. The machine is

provided with the foot pedal switch at heigh

170 mm from the ground level.

For carrying out the operation for job on the

power press machine, a job was to be kept on

POWER

PRESSM/C

DANGEROUS

ZONE


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For carrying out the operation for job on thepower press machine, a job was to be kept on

the die of the machine through the front opening

with hands. When operator presses the footpedal switch, the stroke of the machine operates.

As a result the punch comes down and the job

gets pressed between the punch and the die of

the machine, to form the required shape and

size. Then the punch goes up to the T.D.C. (TopDead Centre) and the prepared job is removed

from the die of the machine through the frontopening by hands.

Thus due to design, location, function,

reciprocating action of the punch, the portionbetween punch and die is the dangerous zone

and constitutes the dangerous part of the

machine, when the punch is descending.

WHAT WENT WRONG?

4

The accident had occurred, while the saidworker was keeping the next job on die of the

machine by right hand. The stroke of the

machine got operated, while his right hand wasbetween the punch and the die of the machine.

Thus there was access to the dangerous part of

the machine, while the machine was in motion

The above said dangerous part of the machine

ought to have been securely fenced by providinginterlocking safeguard of substantia

construction to prevent access for any part ofbody to it, while the machine is in motion. But

the above said dangerous part of the machine

was not securely fenced by providing with anysafeguard to prevent access to it, while the

machine was in motion.

REMEDIAL MEASURES:The dangerous zone between punch and die of

power press machine shall be securely fencedby interlocking safeguard and prevent access of

any part of body and the safeguard shalconstantly maintained and kept in position while

the punch is in motion.

NO SECURE

FENCING TO

DANGEROUS

PART


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A Case Study On 5

3.SERIOUS ACCIDENT OCCURRED WHILE WORKING ON HYDRAULIC POWER PRESS M/C

Compiled By

V.M. Yadav

Deputy Director


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A serious accident occurred to a worker, while working on the hydraulic power press machine in thefactory premises.

HISTORY:

The factory was involved in the manufacturing

of wheels required for cars, heavy motorvehicles. In the plant there were rim line, disc

line and assembly line. The rims were

manufactured on the rim line and the discs were

manufactured on the disc line. The rims were

fed one by one to the inlet conveyor of thehydraulic power press machine in the assembly

line. The discs were kept on the rim at the inlet

conveyor manually. Then the rim with disc was

fed to the hydraulic power press machine by

inlet roller conveyor. The hydraulic power pressmachine was operated to press rim and disc

together to form a wheel.

ABOUT THE ACCIDENT:The injured worker was employed through the

contractor and was working as an Operator. On

the day of incidence, the injured worker alongwith other worker was entrusted with the work

on assembly line for manufacturing of wheels.

Accordingly they started the 30 T Hydraulic

Power Press Machine in the assembly line. The

Hydraulic Power Press Machine was havingparts like-a ram, a fixture, die tool, contro

system etc. A fixture was fixed to the ram

provided at the bottom to form a punch, while a

tool was fixed at the top to form a die. The

punch was hydraulically operated. An inleconveyor was provided at the left side for

feeding rim and disc to the press machine. An

outlet conveyor was provided at the right side o

the press machine. For carrying out the said job

the work involved was as under. A rim from therim line was fed to the inlet conveyor of the

press machine. The injured worker was keeping

a disc received from the disc line, on the rim

manually. Then other worker was operating the

machine from control panel to push rim alongwith disc on the fixture inside the hydraulic

power press machine. Then he was operating the

press machine from the control panel. With this

the rim along with the disc was moving upwards

by the ram of the machine and the rim and discwere getting pressed in between the tool (die)

and the ram (punch) to form the wheel. The ram

along with wheel was moving downwards

again. The wheel was then fed to the nex

station for welding operation, by outletconveyor. The process was being repeated for

the next job again. They prepared about 300

such jobs in the above said manner. For next

job, the rim along with disc was pushed on the

fixture inside the hydraulic power pressmachine. But, the injured worker felt that the

disc was not properly located on the rim. So, he

put his right hand on the disc through the fron

opening of the machine to check and to confirm

it. By that time the other worker, who wasunaware about this, operated the hydraulic

power press machine from the control panel

With this, the ram (punch) along with the rim

DANGEROUS

ZONE

HYDRAULIC POWER

PRESS MACHINE


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power press machine from the control panel.With this, the ram (punch) along with the rim

and the disc moved upward and the right hand

of the worker was caught and crushed betweenthe die tool and the job (disc on the rim). The

accident resulted into the amputation of two

phalanges of first finger and amputation of the

middle finger, ring finger and little finger of his

right hand completely.

OBSERVATIONS:It was 30 T Hydraulic Press machine. The tool

of size 400 mm diameter fixed to the upper

portion formed the die and the fixture fixed tothe ram formed the punch. The rim together

with the disc formed the job wheel. The size of

the wheel was about 400 mm diameter x 160

mm height. The height of the fixture fitted to theram was about 1300 mm from the floor level.

The height of the disc of the wheel from thefloor was about 1460 mm. The distance between

the wheel top (disc) and the upper die tool wasabout 150 mm. The size of the front opening

was about 550 mm x 700 mm. The ram was

operated by the hydraulic pressure of about 100bars. For carrying out the said operation on

the 30 T hydraulic power press machine, a rim

and disc were to be kept on the fixture fixed tothe ram of the machine. The worker had to

check whether the disc is located properly on

the rim. When the auto cycle was started, thepunch along with the rim and disc moved upand the job (the rim and disc) got pressed

between the punch and die tool to form a wheel.

Thus due to design, location, function,reciprocating action of the punch, the portion

between punch (ram) and die (tool) was

dangerous zone and constituted the dangerousparts of the machine, when the machine was in

motion.

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WHAT WENT WRONG:

The accident to the worker, while he waschecking alignment of the disc on the rim bykeeping his right hand inside the job wheel and

tool die of the machine. Thus there was access

to the dangerous part of the machine, while themachine was in motion. The above said

dangerous part of the machine ought to have

been securely fenced by providing interlockingsafeguard of substantial construction to prevent

access for any part of body to it, while the

machine was in motion. But the above said

dangerous part of the machine was not securelyfenced by providing with safeguard to prevent

access to it.

REMEDIAL MEASURES SUGGESTED:The dangerous parts of hydraulic power press

machine shall be securely fenced by an

interlocking safeguard to prevent access for anypart of body to it, while the machine is in

motion.

NO

PHOTOSENSITIVE

GUARD


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A Case Study On 7

4.A FATAL ACCIDENT WHILE REMOVING CLUTCH ASSEMBLY OF POWER PRESS M/C

DURING MAINTENECE

Compiled By

R.P.Khadamkar

Deputy Director


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A fatal accident had occurred due to unsafe system of work, lack of training, lack of instructions,

while carrying out maintenance of the 150 T Power Press Machine in the factory.

CONSTRUCTION OF CLUTCH:

The manufacturing process in a factoryinvolved use of an electro pneumatically

clutch operated

150 T Power Press Machine.The machine had main parts like ram, bottomtable, power transmission system, electro

pneumatic friction clutch and brake unit,

pneumatic control system, electric controlpanel etc. The clutch was air operated and

mechanically interlocked brake unit. When

clutch was engaged, the brake disengaged andwhen clutch was disengaged, the brake got

applied automatically. The construction of the

electro pneumatic friction clutch and brake

unit was as follows. The clutch assembly wasmounted on the shaft and consisted a cylinder,

piston, inner disc, outer disc, brake facingplate, clutch facing plate and brake holding

plate etc. The inner disc along with hub was

mounted on the shaft close to the flywheel.The inner disc was provided with 18 no. of

guides located in circular position. High

tension springs were placed on each guide.The piston and cylinder were mounted on the

shaft and fitted to a hub by using 8 no. of allen

bolts, such that the springs got compressed

between the back of piston and inner disc. Theclutch facing plate was mounted close to the

inner disc and brake facing plate was mounted

close to the outer disc. When stroke of themachine was operated, the piston moves

forward by air pressure against the spring

tension causing brake to release and clutch toengage. At the end of stroke the air pressure

releases and the piston comes back to its

original position due to spring tension. Thusunder normal condition, when the clutch was

disengaged, the springs remain in compressed

state. A brake holding plate was fitted after theclutch and brake unit. The check nuts are

provided outside the brake holding plate at the

end of the shaft.

ABOUT THE ACCIDENT:

POWER PRESS M/C

CLUTCH ASSEMBLY


18/84

8

incidence taking place, a problem of stroke

slipping on the said Power Press Machine wasreported. On examination, the Maintenance

contractor found that the gap between the

clutch facing plates increased due to wear and

tear of liners (brake, clutch facing segments).As per his instructions, the brake/clutch facing

plate were removed and sent for replacing theliners. On the day of incidence, it was decidedto carry out maintenance of the clutch

assembly of the 150 T Power Press Machine

so as to keep the clutch assembly ready,before the brake/clutch facing plate was

received back. The Maintenance Supervisor

told the deceased worker to help him in

carrying out the maintenance work. Heinitially removed air supply line, rotor seal

and solenoid valve. He brought a table near

the machine and removed the check nuts ofthe clutch assembly by standing on the table.Then he removed one allen bolt out of 8 no. of

allen bolts of the clutch assembly. Before he

opened the second bolt, he went to themaintenance office for attending the phone

call. By that time, the deceased worker

climbed up the table for removing the allenbolts.

While opening the allen bolt, the clutchassembly got dissembled and the cylinder,

piston came out speedily and hit against his

chest and he fell down from the table. He was

seriously injured and died on the spot.

OBSERVATIONS:

The clutch assembly included a cylinder,piston, inner disc, outer disc, brake facing

plate, clutch facing plate and brake holdingplate etc. The cylinder and piston were of cast

iron and weight about 40 Kg each. Out of 8

no. of allen bolts (size M16 x 66.6 mm

length), 6 no. of bolts are found in brokencondition. Out of 18 no. of high tension

springs (size 42.9 mm O.D. x 29 mm I.D. x96.8 mm length), 4 no. of springs are found

broken and one spring damaged. The cylinderpiston, springs, allen bolts are found lying on

the floor. Under normal condition, when the

clutch is disengaged, the springs remain incompressed state and hold the cylinder and

piston close together by spring tension.

WHAT WENT WRONG?

The brake and clutch facing segments (liners)got worn out and the gap between the clutchfacing plate increased due to excessive use of

the machine. As the machine was continued to

use with the excessive gap, out of 8 no. ofallen bolts, 6 no. of the allen bolts broke

which remained inside the assembly. After

removing one allen bolt, the deceased workerwas removing the coincidently the remaining

allen bolt. As soon as he removed the allen

bolt, the spring tension released suddenly

With this, the clutch assembly got dissembledand the cylinder, piston of the clutch assembly

came out speedily and hit against the chest of

the said worker. As a result he was seriously

injured and succumbed to injuries.

It is revealed that-

i)Before opening the clutch assembly, tensionof the H.T. springs was not released by using a

puller or any other tension releasing

BROKEN

ALLEN BOLTS

BROKEN

SPRINGS

CYLINDER PISTON


19/84

arrangement and it was not ensured thattension of the spring was released.

ii)At the time of accident the clutch assembly

was being dismantled on the machine itself

without removing it from the shaft.iii)The machine was not maintained by timely

replacing the clutch, brake facing, without

allowing the gap between facings and discs toincrease excessively. The machine was

continued to use with the excessive gap,

causing 6 no. of the allen bolts to break. Thusthe systems of work were not safe.

iv)The precautionary notice showing

information and instructions in respect of

9

dismantling of the clutch were not displayednear the machine. Also training about safe

system of dismantling the clutch was not

given to the workers to ensure safety.

REMEDIAL MEASURES SUGGESTED:

i) While carrying out dismantling of theclutch, tension of the springs shall be released

by using puller and it shall be ensured that the

springs are in normal state.ii)Only trained workers shall be required and

allowed to carry out such type of work.


20/84

A Case Study On 10

5. SERIOUS ACCIDENT WHILE WORKING ON PRESSURE DIE CASTING MACHINE

By

R.D.Kichambare

Former Joint Director

Industrial Safety & Health

----------------------------------------------------------------------------------------------------------------------------

Accident Type: Caught Between

Type of Industry: Engineering

Size of work Crew: 4/600

Work Site Inspection Conducted: Yes

Designated competent Person on Site: No

Employer Safety and Health Programme: No

Training and Education for Employees: No

Craft/Type of Deceased Employee: Unskilled

Age and Sex: 19, Male

Time on the Job: A month

Time on the Task: 6 Hrs

Description of the Accident:

In a factory involved in manufacturingAluminum castings for automobile industry, a

worker working on one of the several Pressure

Die Casting Machines (PDCM), was crushed todeath. In the said factory there were several

PCDMs. One of them was of 800 MT capacity.

The cylinder heads were manufactured on this

machine. The machine had two large platens of

size about one square meter, carrying molds onit. One on them was mounted on the tail stock, a

reciprocating die carrier of the machine and the

other was mounted on head stock of themachine, a stationary die holder of the machine.

There was an interlocked guard on the machine

consisting of two cages made out of wire mesh.

One of the cages was a fixed one fencing themoving parts of the tailstock of the machine.

The other was a reciprocating telescopic type.

The process involved, inserting loose cores in to the die on th

tail stock,

spray the dies with a special kind of oifor easy removal of the castings,

insert a loose sleeve on the die mounteon the headstock of the machine,

pouring a molten aluminum metal inthe hopper of the injection cylinder o

the machine,

pull the reciprocating telescopic guarto cover the open space into which th

die holding reciprocating tailstocwould move to close the dies, and s

the machine ready for injection,

operate two interlock switches ( pusbuttons )on the body of the machin

and actuate the injection operation,


21/84

11The operation of two switches would actuate thetail stock of the machine to move forward to

close the dies and the molten metal would then

get injected automatically in the die cavities.

After the injection of the molten was complete,following was the sequence of the operation of

the machine.

The reciprocating tailstock of themachine would automatically traverse

back into its earlier position,

Open the reciprocating guard on themachine manually,

Remove the castings from the machine,remove the loose cores from the

castings, and keep them into trolley for

further machining operations,

set the machine for the next cycle,The cycle for the described sequence of

operations was of about 3 minutes. The closingof dies would take hardly 5 seconds, after the

guard was set in its place. Four workers wereinvolved into the manufacturing of the

Aluminum Castings in the manner prescribed

above. Three of them were on one side of themachine on which a control panel was installed,

on the pillar of the headstock of the machine

and another worker, a forth one was required towork on the opposite side of the machine. One

of the three workers was the main machine

operator. His job was to spray the oil mist on thedies when they were ready for closing andinjection, pour the molten metal into the

injection cylinder of the machine, operated two

interlock switches on the machine, to actuate the

closing of the molds, followed by injection. Thesecond would put the loose cores into the die

cavities, and the third worker would help

transfer the casting into the trolley, after it wastaken out. The job of worker on the opposite

side of the machine was to keep the loose sleeve

on the die, mounted on the headstock of themachine.On the fateful day, the sliding portion of the

interlocking guard (front gate) was not

functional, and the machine was being operated

without using the front gate of the guard. Itresulted in dies closing even before the sliding

portion of the interlocking guard was pulled

over to cover the opening into which the

tailstock-die would move. The activity ofmanufacture had been going on this fashion for

over two hours, with proper coordination

amongst all four workers. At one stage, whenthe main machine operator was about to actuate

the two interlock switches on the control panel

the forth worker on the other side of themachine noticed that the loose sleeve he had

kept on the die mounted on the head stock had

moved little away from its position. Hetherefore, leaned into the opening between the

dies, and tried to set it right into its position

However meantime, unaware of what the

worker on the side of the machine was doingthe main machine operator pushed the two

switches on the control panel of the machine

for closing dies for injection. As the tailstock

moved forward to close the dies for injection,the worker on the other side of the machine

who was leaning into the opening between the

dies to set the loose sleeve right into its positionwas caught with his upper portion of his body

between the moving tailstock and the headstock

of the Pressure Die Casting Machine, and wascrushed to death on the spot.

Accident Prevention Measures:

An electrical interlock arrangement shalbe provided so that the molds cannot beclosed unless front safety gate is fully

closed and on opening the front safety

gate, the molds would stopautomatically,

A hydraulic safety shall be incorporatedwith the front safety gate such that it wil

prevent the tailstock mold plate forwardon opening of the front safety gate,

The interlock arrangement so providedshall be maintained in effective working

condition.


22/84

12

A Case Study On

6. SERIOUS ACCIDENT WHILE WORKING ON A ROTARY VACUUM DRIER.

Compiled By

J.B.Kumbhar

Deputy Director


------------------------------------------------------------------------------------------------------------------------------

Serious accident took place in bulk drug manufacturing factory. One of the supervisor having

qualificationB.Sc. & Diploma in Industrial Safety, and employed as Production Officer met with an

serious accident while he was working on Rotary Vacuum Drier (here after called as drier).

ABOUT THE ACCIDENT: --

On the date of accident, the work of draining out

Sodium Salicylate slurry from the drier was in

progress and two workers were working in this

area. At about 6.30 pm, it was noticed by twoworkers working on drier that Sodium Salicylate

slurry in the drier had become thick and due to

this drain valve was choked up. They tried to

dilute slurry by circulating steam through drain

valve jacket but it was of no use. So, these two

workers requested IP to remove this choke up

by showering water in side the drier. So, IP

went on the drier platform and started

showering water in side the drier through its top

opening with the help of inch plastic pipe. At

that time, his right hand thumb came in contact

with the rotating blades (plates) of the stirrer

and it was caught & pulled in the gap between

the blades and the inner surface of the drier

body. This resulted in the on the spot

amputation of his right hand palm up to wrist.

He immediately rushed down to the ground

floor and requested other two workers to call for

vehicle. He then ran up to 100 m towards the

office. From there he was taken to local

hospital. He was given first aid and as per the

advice of local Dr., he was shifted to orthopedic

specialist for further treatment. His amputed

right hand palm was brought to hospital by

another vehicle at about 11 pm. It was checked

by Doctors and after examining the amputed

palm, it was concluded by doctors that it was

not possible to in plant the amputed part of his

right hand. This accident has resulted in to

amputation of right hand palm up to wrist.

OBSERVATIONS:- The said drier on which

the IP met with an accident is located in Sodium

Salicylate department. This drier is on the

platform and there is one centrifuge on the

ground floor adjacent to the platform. There is

1005 x 195 mm opening provided on the top of

this drier. Height of this top surface of this

opening from the working platform floor is 940

mm. There is one stirrer (shaft) fitted in side this

drier and it is connected to 10 HP,(1440 rpm )

electric motor through reduction gear box. Onthis stirrer, blades (metallic plates) are fitted

alternatively. The minimum gap between the

inner surface of the drier body and the outer

diameter of stirrer plates is 5 mm. These stirrer

plates rotate in clockwise direction and its rpm

is 7. Depth of the rotating stirrer blades from the

top surface of the top opening is 150 mm. Body

of this drier is a jacketed vessel for circulation

of steam. On the bottom side of this drier, there

is one 4 inch drain valve. This drain valve is

also provided with arrangement for circulating

steam around it. One hose pipe is connected to

this drain valve and the other end of this hose

pipe is connected to centrifuge. This drier is

used to remove excess water from the Sodium

Salicylate solution. For this, Sodium Salicylate

solution is charged in to this drier by pipe line

and it is heated by circulating steam through the


23/84

jackets and simultaneously stirring/blending is

done. Then the slurry of the Sodium Salicylate

is drained out in to centrifuge through drain

valve by gravity.

WHAT WENT WRONG:- On this stirrer,

blades (metallic plates) are fitted alternatively

inside the drier body.. The minimum gap

between the inner surface of the drier body and

the outer diameter of stirrer plates is 5 mm.

These stirrer plates rotate in clockwise direction

with 7 rpm. Depth of the rotating stirrer blades

from the top surface of the top opening is 150

mm. It was essential to provide suitable inter

13

locking arrangement to the top lid of the drier so

that the drier will not start when the lid is open

However, during inquiry with the IP, it was

revealed that there was no lid provided to the

top opening of the drier, when he met with an

accident.

REMEDIAL MEASURES: In order to avoid

such type of accidents in future, it was

recommended to provide suitable interlocking

arrangement to the top lid of the drier so that the

drier will not start when the top lid is open and

it will stop automatically if the top lid is opened

when stirrer is in motion.


24/84

A Case Study On 14

7. A Worker Gets Ripped to Death

By

R.D.Kichambare

Former Joint Director

Industrial Safety & Health

------------------------------------------------------------------------------------------------------------------------------In a Sugar Factory, a worker got ripped to death while working on Bagasse Bale Breaking Machine.

Background:A bagasse is, a left over sugar cane body, after

juice is totally extracted from it, in the process

of Manufacture of Sugar. The bagasse, is thus aby-product of Sugar Factories. Every year,

several tonnes of bagasse is generated in Sugar

Factories. The storage of bagasse in loose form

is a great problem for the factories. It is

therefore, compacted into bales, on BagasseBaling Machines, while it is still moist.

Normally, the bales are of 1'x1'x1' ( one cubicfeet )size. After the bails are compacted on

Baling Machines, they are bound by steel cross

wires, in order that the bales do not easily open.These bales are stacked in pyramid form, in

open in the Sugar factory compound, to be used

as a Boiler fuel, for the next Sugar Cane

crushing season of the factory.For using the bagasse from these bales as a fuel

for boiler, it becomes necessary to remove thesteel wires on the bales and break the bales intoloose bagasse, in order

to ensure the efficient combustion of the

bagasse. This is done on Bagasse Bale Breaking

Machines.The Bagasse Bale Breaking Machine consist of

two closely held spiked rollers, revolving in

opposite direction, housed in a open hopper.The rollers are driven by a electric motor. The

rotary motion from motor is transmitted to the

spiked rollers by the pulleys and belt drives.The bale breaking operation is carried out byfeeding wire bound bales on to the spiked

rollers, in the hopper of the Bagasse Bale

Breaking Machine. The spiked rollers, revolvingin opposite direction, hold back the entangled

steel wires, bound around the bagasse bales. It

further tears the bound bagasse bales into loosebagasse. The loose bagasse falls on to the

running conveyer at the bottom of the Bagasse

Bale Breaking Machine, and the loose bagasse

is carried to the boiler, to be used as a fuel.

The steel wires which are held back, getentangled on the revolving spiked rollers. These

wires need to be removed frequently to allow

the Bagasse Bale Breaking Machine, to work

efficiently for breaking the bagasse bales into

loose bagasse. The operators of the BagasseBale Breaking Machine, were required to

remove the steel wires removed from the balesand entangled in the spiked rollers.

The operators were allowed to remove it by

sitting over the accumulated heap of the bagasseto the level of the hopper, around the Bagasse

Bale Breaking Machine, by using their legs to

remove the entangled wires.

Brief Description of the Accident:

On the day of the accident, as the operator wassitting on the edge of the hopper, and was busyin removing the steel wires of the bagasse bales

entangled on the spiked rollers, by his

legs, his legs was caught in the gathering in

spiked rollers, and the operators was pulled intothe hopper. With the result, both of his legs

were entangled in the spiked rollers, and his legs

got ripped into pieces.As the alarm was raised by the injured operator

the workers working around, immediately cut

off the electric supply to the Bagasse BaleBreaking Machine, and tried to rescue theinjured worker. The body of the worker had to

be removed by dismantling the spiked rollers of

the Bagasse Bale Breaking Machine. Howeverby the time the injured worker was rescued, he

had bled profusely through the rip injuries on

his legs, and succumbed to them.


25/84

Accident Prevention Recommendations:

i) The steel wires used for binding the Bagasse

Bales, should be removed, before the bales are

fed for being broken into the Bagasse BaleBreaking Machine,

ii) A long chute, preventing the access of the

workers to the spiked rollers, with a closed but

15

interlocked hopper, should be provided on the

Bagasse Bale Breaking Machine, in order to

ensure that the access of the worker is preventedto the dangerous revolving gathering in spiked

rollers, while they are breaking and opening the

bagasse bales.


26/84

A Case Study On 16

8 .SEROUS ACCIDENT ON A LATHE M/C DUE TO UNSAFE SYSTEM OF WORK

Compiled By

R.P.Khadamkar

Deputy Director


------------------------------------------------------------------------------------------------------------------------------

The serious accident to a female worker occurred, while working on the lathe machine in the factorypremises.

ABOUT THE ACCIDENT:

The factory is involved in the machining of the

components required for the manufacturing of

the automobile components like gears, cross

bars etc. The raw material is received in theform of forged jobs of gears, cross bars from the

forging factories. The machining process on the

cross bars involved operations like facing ofcross bars on the lathe machines and making

holes of required size in the cross bars by usingdrill machines.

The injured worker was working as a helper. On

the day of incidence, the injured worker was

entrusted with the work of facing operation ofthe job-cross bars on the lathe machine.

Accordingly, she started the lathe machine. The

lathe machine was an electrical power driven

machine and having parts like head stock fitted

with chuck, tail stock, tool post, lead screw,power transmission system and an electric

motor. The operation on the lathe machine was

as follows. The job is held in the chuck and a

tool is fitted to the tool post. When the machinewas started, the power from the electrical motor

is transmitted to the chuck and also to the

carriage through the transmission system. The

lead screw was having square threads and

provided at a height about 600 mm from the

floor. When the machine was started the job

along with the chuck started rotating and thefacing operation was carried out by using the

tool fitted in the tool post. The lead screw also

got rotated by a power transmission system

while the machine was in motion. She carried

out the facing operation of about 30 jobs-crossbars on the lathe machine. While she was

carrying out the facing operation for the next job

on the lathe machine, the loose end of her sar

i.e. padar got entangled with the rotating leadscrew. As a result she fell and hairs of her head

also got entangled with the rotating lead screw

The supervisor rushed to the lathe machine and

stopped the machine and removed her. She was

seriously injured. The hairs along with the skinof her head got detached from the skull. The

accident has resulted in the serious head injury

to her. Also part of the lobe of her left ear got

amputated.

OBSERVATIONS:

The lathe machine was of 3-phase, 415 V, 1440

R.P.M., 3.0 H.P. an electrical power driven

machine. The overall size of the machine was

about 2400 mm L x 500 mm B x 1200 mm H

LATHE M/C

LEAD SCREW TO WHICH

HAIRS OF WORKER GOT

ENTANGLED


27/84

The lead screw was of 40 mm dia x 2400 mmlength and was having square thread on its

throughout its length. It was located at the

operator side at a height about 600 mm from the

floor. The power from the motor wastransmitted to the lead screw through the belt,

pulley, gear train. The lead screw rotated at a

speed about 30 R.P.M.

WHAT WENT WORNG:

It is revealed that- The lathe machine washaving moving parts like-chuck, lead screw,

carriage and parts of transmission system. The

serious accident to the worker had occurred, as

the loose end of her clothing i.e. padar of sarigot entangled with the lead screw of the lathe

machine, which was in motion. As a result, she

fell down and hairs of her head got entangled

with the moving parts i.e. lead screw. She wasseriously injured.

i)The injured worker ought to have been

provided with the apron or tight fitting clothingto prevent loose clothing getting entangled with

the any moving parts of the lathe machine.

17

ii)Also, the injured worker ought to have beenprovided with cap/ helmet on her head (with

hairs tied in a bun) to prevent the hairs of her

head getting entangled with the any moving

parts of the lathe machine.But she was not provided with such or any other

type of the personnel protective equipments

when she was required to work on the lathemachine. Thus the systems of work in the

factory were not safe and involved risk to the

health and safety of the injured worker workingon the lathe machine.

REMEDIAL MEASURES SUGGESTED:

i)No female workers shall be required / allowedon such type of machine, unless she has been

provided with the apron/ tight fitting clothing

and its use is ensured.

ii) No female workers shall be required /allowed on such type of machine, unless the

hairs of her head are tied in a bun and she has

been provided with the cap to prevent hairscoming out.


28/84

A Case Study On 18

9. SERIOUS ACCIDENT ON LATHE M/C DUE TO UNSAFE SYSTEM OF WORK.

Compiled By

S.G.Giri

Assistant Director


------------------------------------------------------------------------------------------------------------------------------

A serious accident occurred to a worker, while working on the lathe machine in the factory premises.

HISTORY:

The factory was involved in the manufacturing

of domestic pressure cookers. The processinvolved cutting, pressing, turning operations by

using the machines like power press machines,

lathe machine. The lathe machine was electrical

power driven machine. The power from the

main motor was transmitted to the chuckthrough the V- belt pulleys. A Forward/Reverse

switch having lever was provided at the front

side of the machine for starting the lathe

machine. For adjustment and setting of themachine, V-belts were required to be removed.

After carrying out of the alignment of slider and

setting of the machine, the belts were fixed

again on the pulleys.

ABOUT THE ACCIDENT:

The injured worker was working as LatheMachine Operators. On the day of incidence, the

injured worker along with other worker wasentrusted with the work of the trimming of

pressure cooker lids on the lathe machines.

After the lunch, the operation for small lid was

to be carried out. Hence it was necessary tocarry out slider alignment and setting of the

lathe machine. For carrying out the work, thebelts from the main pulleys were to be removed

The injured worker called the other worker and

asked to help in the setting work. The other

worker was working on the front side and the

injured worker was working at the rear side othe lathe. At that time, while the injured worker

was trying to remove belt from the pulley byrotating the main pulley of the machine by lef

hand, the switch of the machine got operated bythe body of the other worker, unknowingly. As a

result, the motor and pulley started rotating inreverse mode and left hand thumb of the worker

got caught in and crushed in the intake nip

formed between the belt and the third pulleyThe accident resulted in the amputation of his

left hand thumb.

OBSERVATIONS:The lathe machine was electrical power driven

The overall size of the machine was about 2370

mm L x 1000 mm B x 1100 mm H. The driving

pulley of size 100 mm dia was mounted on the

motor shaft. The driven pulley of size 400 mmdia was mounted on the shaft, on which six

pulleys of different sizes were mounted. The

LATHE M/C

BELT PULLEY IN WHICH

THUMB CAUGHT


29/84

19

power from driving pulley is transmitted to thedriven pulley through a V-belt. The 3

rd pulley

was of size 180 mm dia, from which power was

transmitted to another set of driven pulleys. The

extreme right pulley was coupled to the slider

driving pulley through a V-belt. A Forward/Reverse switch was provided at the front side

of the machine, at a height of about 800 mmfrom the ground floor. When the lever of the

switch was turned to left position, the motor

rotated in clockwise direction and when it was

turned to right position, the motor rotated inanticlockwise direction. When the motor was

started, the power was transmitted to the set of

pulleys. The speed of first set of pulleys andhence 3

rd pulley was about 360 R.P.M. The

height of the 3rd pulley was about 1000 mmfrom the ground floor. When the motor rotated

in anticlockwise direction, the portion betweenthe V-belt and the 3

rdpulley formed intake nip.

A main ICTP switch was installed on the wall

near the machine, from where an electric supplywas provided to the Forward / Reverse switch.

WHAT WENT WRONG:

i)Before starting the said work, the electric fuses

of the main ICTP switch of the lathe machine No.2

ought to have been removed and kept in the

custody of the responsible person to prevent

starting of the lathe machine by anyone

unknowingly. But fuses were not removed and

not kept in possession of responsible person

Thus the systems of work were not safe and

involved risk to the health and safety of workers

at work.

ii)Also, while carrying out the said work, there

was no supervision for ensuring that the said

work should be carried out safely.

REMEDIAL MEASURES:

i)Before starting such type of the work, the

electric fuses of the main switch shall beremoved and kept in the custody of the

responsible person to prevent starting of themachine by anyone unknowingly.ii)Such type of work shall be carried out the

under the supervision of the responsible person

to ensure that the said work should be carried

out safely.

LEAVER OF

FORWARD /

REVERSE SWITCH

ICTP SWTICH

FROM WHICH

FUSES WERE NOT


30/84

A Case Study On 20

10. A FATAL ACCIDENT DUE TO IMPROPER LIFTING MECHANISM

Compiled By

N.A.Deshmukh

Assistant Director


------------------------------------------------------------------------------------------------------------------------------

A fatal accident had occurred, while handling a load body for loading it into the truck.

ABOUT ACCIDENT:

The premises was involved in the

manufacturing of load bodies required fortransport vehicles. The process involves the

fabrication of bodies and painting. Then the

load bodies were loaded on a truck with the

help of a monorail crane at dispatch section inthe factory.

The deceased was working as a

Supervisor. On the day of incidence, the

deceased along with four other workers

resumed their duties in third shift. Onresuming duties, they went to the dispatch

section to carry out the work as usual. The

work involved was as under. After fabrication

and painting the load bodies were brought to

the dispatch section. They fitted accessories tothe load bodies and carried out the touch up

painting of the load bodies. Then the truck

was brought to the delivery end of the

dispatch section. The deceased with the helpof other worker was loading the load body on

the truck. The process of loading the load

body into the truck was as follows-

The load body, which was ready for

dispatch was kept on the ground at the

delivery end of the section. The truck was

parked in reverse direction with its carrier

towards the delivery end. The monorail crane

was brought at the delivery end in the dispatchsection. A lifting tackle having two ends

provided with brackets with holes at each end

was hanged into the hook of the crane. Then

two polyester webbing slings were put into the

each hole of the lifting tackle in such way thattwo loops were formed at each end of the

lifting tackle. The load body was providedwith J hooks welded to both sides. Two

loops of sling were being inserted into two J

hooks of one side of the load body and theother two loops of the sling into two J hooks

at the opposite side of the load body. Then, the

load body was being lifted with the help of the

monorail crane. Then the orientation of theload body was made proper by turning it

horizontally manually in hanging condition, so

that it could be properly fitted to the fixture

provided at the carrier of the truck. Afterfitting a load body on a carrier, the loops of

the slings were being removed and the load

body was being dispatched. Then the

procedure was repeated for the next load

body. In this manner they loaded about 7 noof load bodies till 1.30 A.M.

At about 1.30 A.M., there was tea time so alof them, except the deceased went for tea at

LOAD BODY

LOAD BODY

HIT


31/84

the open space near delivery end of thedispatch section. But the deceased, a

Supervisor waited there for loading the next

load body. He hanged the load body to thewebbing slings inserted in the lifting tackle in

the above said manner and lifted it with the

help of the monorail crane to a height about

2.5 metre. He kept the load body in hanging

condition with the crane and he was going tocall the truck driver to bring the truck at the

delivery end for loading. While passingbeneath the hanged load body, when he turned

the load body by hands for making its

orientation proper, the sling slipped from theJ hook (driver side) of the load body. As a

result, the load body got tilted due to

unbalance and swirled clockwise and hit

against the head of the deceased. The workerslifted the load body by crane and removed

him. He was seriously injured and wasimmediately shifted to the Hospital, where he

was declared dead.

OBSERVATIONS:

The load body was fabricated by using them.s. sheet, angles, channels etc. The overall

size of the load body was about 5100 mm L x

2150 mm B x 2200 mm H and weight was

about 810 Kg. The load body was providedwith 8 no. of the J hooks along the

lengthwise to its both sides ( Driver andCleaner). The J hook was made of m.s. rod

of 12 mm dia and is of size 18 mm radius x 90mm length. The J hooks were fixed to the

load body by welded joints. The J hook and

mud guard at drivers side of the load bodywere found in damaged condition. The

polyester webbing slings were of having

capacity 1 T each. Each sling was of size 6000

mm length x 50 mm width x 12 mm thick and

21

was having loop of size 410 mm length aboth ends. The lifting tackle was of m.s. and

having size 2280 mm length and was provided

with bracket with circular hole of dia 60 mmat each end. The monorail crane provided was

of capacity 1T. The crane was having

electrical power driven hoist and long travel.

WHAT WENT WRONG:

It was revealed that-The fatal accident

occurred, while handling the load body forloading it to the truck. The deceased was

required to turn the load body in hanging

condition, so as to make its orientation proper

and to fit it on the carrier of the truck. Whilehandling the load body with the crane, the

loop of the polyester sling came out of the

open end of the J hook. As a result the loadbody swirled due to unbalance and hit against

his head causing fatal accident.

The lifting mechanism including thecrane, lifting tackle, polyester webbing sling

J hooks on the load body were being used

for handling the load bodies and loading it tothe truck for further transport of load bodies

The load of the body is transmitted to everyparts of the lifting mechanism.

The load body ought to have been providedwith round hooks and the webbing slings

ought to have been provided with the hooks at

ends having spring loaded positive locking

arrangement to prevent the sling coming outof the hooks of the load body, while lifting or

in lifted condition. But the lifting mechanism

i.e.J hooks, webbing slings without having

J HOOK

WITHOUT


32/84

any type of locking arrangement wereprovided and used for handling the load

bodies, which caused the fatal accident to the

said worker.

22

Thus the arrangements in the factory inconnection with the handling, transport of

heavy articles like load bodies were not safe

and involved risk to the health and safety ofworkers at work.

REMEDIAL MEASURES:

i) The lifting mechanism having round hooks

and webbing slings with hooks havingpositive locking arrangement shall be

provided and used to prevent the sling comingout of the hooks of the load body, while lifting

or in lifted condition.

LIFTIN

G


33/84

A Case Study On 23

11.A FATAL ACCIDENT AT A FACTORY MANUFACTURING-ERW AND CEW STEEL TUBES

Compiled By

S G Phadtare

Deputy DirectorIndustrial Safety & Health, Pune

------------------------------------------------------------------------------------------------------------------------------

A fatal accident that took place at 16:45 pm with worker age 27 years, employed through a contractor

MANUFACTURING PROCESS:Manufacturing of S.S. E R W (electric

Resistance welding) tubes is being carried on in

this factory. The steel role (coil) received at

factory is slit on slitting machine into the coils

of required width, depends upon the diameter of

tube to be manufactured. Then these slit coilsare loaded on trolley and brought to the tube

mill section. Then individual coil is lifted by

EOT crane and stored near tube mill machine.Single coil is lifted by a local crane and loaded

on support of mill machine and locked by

locking plates. The operator who brings the slit

coils to mill machine ,also load the coil on

support of mill machine, with the help of fixedcrane near mill machine. Open end of coil is

taken to further process of formation of tube by

ERW process. Loading of coil on support ofmill machine and locking it as per the

photographs attached no.1 to 5

ABOUT THE ACCIDENT:On the date of accident, the crane operator

oined duties in second shift. According to him

his duty was to bring slit coil from trolley tomill machine by EOT crane, then load the coil

on slit loader of mill machine by a local crane (2

ton capacity) and lock the coil with locking

plates. After joining duties he brought 4 slitcoils by EOT crane (7.5 ton) to mill machine no.1. Out of these 4 coils, he loaded one coil on

machine and started the tube formation process.Each coil is weighing appx.1.35ton

At 16.45pm, to load the second coil on machine(position of both coils is shown in photograph

no 6), operator removed the locking plates and

was loading coil on slit loader, the coil dashed

against the foundation of mill machine .Due to

which the chain holding the coil slacken, the

coil was unbalanced and one end of chain came

out of hook as spring loaded locking

mechanism was not working.(photo no.7) Thecoil fell on one side, on the deceased worker

who was doing cleaning work near the

machine.(Photo no.8). He was pressed belowthe coil. Immediately the crane operator, with

the help of EOT crane, lifted the slit coil and

injured worker was taken out. He was put in

ambulance and taken to hospital where he was

declared dead.

WHAT WENT WRONG:

After verifying the locking system of hook, itwas observed that the spring loaded locking

system, which prevents the chain coming out oopening of hook, is not working. As such after

dashing the coil to the machine foundation

chain was slacken and easily came out of hook

and the coil fell on one side on deceased. The

said crane was got examined by a competenperson declared under Factories Act 1948. He

was again asked to carry out the examination o

the said crane and give his observations

Accordingly he had given his observationswhich supports the cause of accident.

REMEDIAL MEASURES:It shall be confirmed that the spring loaded

locking system, which prevents the chain

coming out of opening of hook, shall beworking.


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24


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A Case Study On 25

12.SERIOUS ACCIDENT DURING MATERIAL HANDLING DUE TO UNSAFE SYSTEM OF WORK

Compiled By

R.B.Lakhe

Deputy Director


In one factory worker met an serious accident, while loading the M. S. Plates on the platform of the

truck, sustaining serious head injury which proved fatal. This accident occurred due to adoption ounsafe system of work.

ABOUT ACCIDENT:

On the day of accident, the deceased worker,had attended the duty at 8.30 am as usual along

with three coworkers And the work of loading

the M S plates (size 5m.x 1.25m. x 6mm ) in

the truck was being carried on in the stored yard

of the factory.In store yard of the factory, there are various

types of material such as M S bars, angles,

channels, pipes including M S Plates and on thesaid day the work of loading of m s plates was

to be completed, which was started with the

help of JCB loader for lifting the plates,

employing four workers.

The system and arrangement of loading the M Splates in the truck was as follows.

The plate which was to be loaded in the truck

was being made holes lengthwise at a distanceof one meter from both the ends of the plate by

gas cutter. Then the wire rope ( 5/ 8 ) withDshackle was bolted in both the holes and the

plate was lifted vertically by JCB ( power-76hp. ) 6 inch above the height of platform of the

truck (4 ft.) and was being dropped on theplatform which was falling horizontally with

huge sound on the platform with most of the

portion outside the platform of the truck in

imbalance position Then the four workers were

used to push the plate inside, on the platform soas to load it completely on the platform.

It is marked that, the JCB which is used

specifically for digging purpose was used for

lifting and loading the heavy plates resultinginto the said fatal accident.

On the day of accident, the deceased worker,

along with his coworkers started the work of

loading at 9 am. and completed the loading of

one M S plate till 9.30 am. under thesupervision of Supervisor Shri S Y Pansare. As

there were total 12 Plates the supervisor

thought that loading may consume more time iplates are loaded one by one and therefore

second time two plates were taken at a time

which were made holes by gas cutter and wire

rope with Dshackle was bolted to both the plates

and was lifted vertically by the hand (bucket) oJCB and dropped on the platform of the truck

The plates fell horizontally on the platform in

such a way that most of the portion ( 75 %) wasoutside the platform. Immediately after falling

the plates, the deceased worker who was

standing there itself, started loading the plates

along with three coworkers by pushing the said

plates inside, on the platform and while doingso, the plates which were in imbalance position

due to maximum portion outside, fell on the

body of the workers. However the othercoworkers escaped miraculously and the plates

fell on the back of the deceased sustainingserious head and neck injury. The other workers

nearby rush to the spot. However the deceasedworker was profusely bleeding. He was

immediately taken to Hospital. However Doctorexamined and declared him dead.

SPOT ANALYSIS :

The spot examination, work system of loading

the plates , working of JCB, Position of liftingplates, position of truck platform , working

position of the deceased worker etc. revealed the

details which are as follows-

1) Machine / Mechanism : JCB Loader

2) Make : BEML Ltd.

3) Bucket Capacity of lifting soil : 1 cu m.

4) Power : 76HP

5) Operating height : 5.8 m.6) Size of wire rope with D shackle : 5/8 inch


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7)Dimension of M S plate : 5m x 1.25m x 6mm8)Weight of one Plate : 300 kg

9)Size of loading platform of truck: 5.3 x 2.4 m.

10)Distance of loading platform from groundlevel: 4 ft.

11) Position of plates while lifting : Vertical

12)Position of plates after dropping on platform:

Horizontal

13)Portion of plates outside platform afterfalling : 75 %

14)Plates lifted at a time : 2 No.15)System of loading plates: Improper and

Dangerous

16)Arrangement for handling of plates : Unsafeand Risky

WHAT WENT WRONG:

The lifting of heavy M S plates by JCB loader isitself very dangerous act since it is not meant for

lifting plates but for the use of digging the soil.Further for loading the plates after falling in

imbalance position on the platform of the truck,the workers should not have allowed to push it

inside , on the platform of the truck unless stable

position of the plates was ensured which wasnot done and resulted into the said fatal

accident.

26

Secondly, the arrangement used in connectionwith handling that is lifting the plates was done

by JCB loader which is at all not meant for the

said purpose.The Management should have provided and

carried out the said work of lifting and loading

by making the arrangement of suitable crane to

ensure the health and safety of the workers at

work and further by adopting the proper systemof work that are safe and without the risk to

health, which could have prevented the saidaccident.

REMEDIAL MEASURES :1)The suitable crane with adequate lifting

capacity shall be provided for lifting / handling

the heavy M S plates.

2) The plates shall not be lifted vertically anddropped down from the distance which is

dangerous to cause accident.3) The proper system of lifting and loading

shall be adopted to ensure safety and absence ofrisk to the health of the workers.

4) The workers shall be well acquainted and

properly trained to carry out the loading ofheavy plates.

5) Protective wears like safety shoes, helmet

hand gloves shall be provided to the workers


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Case Study On 213. FALLING THROUGH THE FRAGILE ROOF

Compiled By

S.G.Giri

Assistant Director


--------------------------------------------------------------------------------------------------------------------------An accident to a worker had occurred while walking on the A.C.Sheet roofing of the building in factory premises.

HISTRORY:

The factory was involved in the bottling of

foreign liquor. There was an old administrativebuilding having A.C.sheet roofing, inside the

factory premises. The cabins inside the building

were having false ceiling. The false ceiling was

at height of about 3150 mm from floor and

above it was the A.C.sheet roofing at height2500 mm. A staircase is provided for going to

the terrace and roof. From terrace, one could

reach the A.C. sheet roofing by crossing theparapet wall.

ABOUT THE INCIDENCE:

As it was the beginning of rainy season, it was

decided to check and repair the leakages in roof

of the administration building. The gaps

between the A.C.Sheets, J-hooks, cause therainwater to leak through the roof of the

building. So, the Factory Manager called the

injured worker and asked them to assist him in

the said work. They climbed up the roof of theadministration building by using a staircase

provided from outside to check and assess the

actual work to be carried out for rectification of

the leakages. Then they stepped on theA.C.sheet roof of the administration building

and started observing the roof for leakages.

completing the observation of one portion, th

were moving forward to check next portionthe roof. In this manner they moved about

metre distance on the roof. While mov

further, the injured worker slipped. In

attempt of balancing, when he held

A.C.sheet of the roof by hands, it gave a wdue to load of his body and he fell through

roof on the ceiling of the cabin, which w

about 2500 mm below the roof. As a result, ceiling of the cabin broke and he further f

through a height about 3150 mm. Thus he

through a total height of about 5.65 metre a

was injured. The accident resulted into

fracture of his spine.

OBSERVATIONS:

The administration building was of size of ab

25 m length x 15 m breadth. The roofing was

the Asbestos Cement sheet (A.C.sheet). T

minimum height of roof (truss level) from fl

was about 5.0 m and maximum height of ro(ridge) was about 8.0 m from the floor. The ro

structure was consisting of trusses and purli


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The A.C. sheets were fixed to the purlins of theroof structure by 'J' hooks and nuts. For

checking and observing the roofs,worker was

required to pass over the A.C. sheet roof to a

distance about 12 m. The cabin beneath thebroken A.C.sheet is having a metallic grid with

panels of heat resistant material like asbestos

fixed in it.

WHAT WENT WRONG:

The roofing of the administration building wasof the Asbestos Cement sheet (A.C.sheet),

which was a fragile material. The injured

worker was required and allowed to pass over

the A.C.sheet roof for carrying out theobservation of roof for assessment of work.

When, he slipped and held the A.C.sheet, it gave

way and he fell through the height of about 5.65

m and the accident occurred. It is furtherrevealed that-The injured worker was required

and allowed to stand, pass over the A.C.sheet

roof, without providing him any suitableladders, duck ladders, crawling boards.

REMEDIAL MEASURES:Whenever the person / workers are required to

stand, passed over and carry out any work on

the A.C.sheet roof, or roof of the fragile

material, through which they were liable to fall,

i)They shall be provided with suitable andsufficient ladders, duck ladders, crawling

boards and

28ii) A safety net shall be provided beneath the

fragile roof, while carrying out the work at roof.

iii)A permit to work on the fragile roof, by a

responsible person of the factory.


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A Case Study On 29

14. FATAL ACCIDENT WHILE WORKING ON A PAPER MACHINE.

Compiled By

Y.P.Patange

Assistant Director


------------------------------------------------------------------------------------------------------------------------------

Fatal accident to one worker took place in paper manufacturing factory, while he was working on papermachine.

ABOUT THE ACCIDENT:-The deceased worker was working in this

factory through contractor, since last 5 years.

On the date of accident he had reported on dutyat 8 am to work in first ship. There was no

electric supply from MSEB from 3.30 am to

8.20 am. After the supply was received, the

paper machine was started. At about 8.40 am,

the deceased worker had climbed on theplatform near the MG cylinder to remove the

chock up of the water shower pipe. After

reaching on the platform, he had requested co-

worker to operate the water shower valvelocated on the ground floor. Accordingly, the

co-worker operated the valve and then went to

control panel which is located at about 15 feet

away from the spot of accident. The deceased

then started the work of removing chock up byhammering on the outer surface of the water

shower pipe. While doing so, he probably losthis balance and fell on the moving felt and was

trapped in 200 mm gap between the felt roll and

the suction box. There is no eye witness to thisincidence. Co-worker, working nearby, noticed

that there is fold on the felt cloth, near the

suction box. He suspected that the deceased

worker might have fallen on the moving felt. So,he immediately stopped the paper machine and

rushed to the platform along with two other

workers. On reaching there on the platform,

they noticed that the deceased worker wastrapped on the felt and injured. He was found

lying in unconscious condition, in the 200 mm

gap between the felt roll and the suction box.

Seeing this, they realized that it was essential to

cut the felt for removing him from there.Accordingly, the felt was cut and he was

removed from the felt and shifted to hospital

where he was declared dead.

OBERVATIONS: The paper machine is used

for making paper by recycling waste paper. At

the centre of this machine, there is machine

glaze cylinder/drier (here after called as MGcylinder). Below this MG cylinder, there is 400

mm X 1980 mm long touch roller. Next to this

touch roll, there is felt roll, one guide roll

stretcher roll, felt roll, suction box/vacuum box

and two washing rolls. One 1980 mm wide fel(belt) is passing over from these rolls. This felt

passes between two washing rolls to touch rol

below the MG cylinder. From there, it passes

below the felt roll and then from the bottom othe guide roll to the stretcher rolls. It passes to

from the bottom of the next felt roll and then to

the suction box. From suction box it reaches the

washing rolls. In this way it keeps on moving

continuously.There are three platforms at 3050 mm heigh

from the ground level, provided on three sidesof the machine and are extending from MG

cylinder to washing cylinders. Pipe railings are

provided on the outer side of these threeplatforms. On the inner side of these platforms

there are moving parts of the machine, like

rotating washing rolls, felt roll, stretcher roll

moving felt, etc. However, there is norailings/fencing provided on inner side of these

three platforms, so as to avoid access of the

worker to these moving parts of the paper

machine.There is 200 mm gap between the felt roll and

the suction box and height of the felt roll and

suction box from the platform level is about 300

mm. Adjacent to this felt roll there is one 25

mm pipe water shower which extends from theground level to the top of felt roll vertically

From there, it passes horizontally over the felt

and extends up to the other end of the felt


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30Height of this shower pipe from the platformlevel is 500 mm.

Workers are required to go to these platforms

for adjusting the felt rolls, removing chock up of

water shower, changing felts, greasing ofbearings etc. They do this work by standing on

these platforms.

This machine is power operated machine fittedwith two 50 HP electric motors. Power of these

motors is transmitted to rolls through belt

pulleys fitted on common shaft, then to gear boxand from gear box to MG cylinder through

sprocket and bevel gears. It was revealed that

normally speed of the felt is about 30 m/min.

WHAT WENT WRONG:-

There are three platforms at 3050 mm height

from the ground level, provided on three sidesof the paper machine. Two platforms are

extending from MG cylinder to washing

cylinders and are on either sides of the moving

felt. There is 200 mm gap between the felt rolland the suction box and height of the fel

Documents

Case Studies on Industrial Accidents -2