Submitted By:

Abhishant Baishya

M.Tech HSE

UPES, Dehradun

CASE STUDY: MAJOR NEAR MISS/ACCIDENTS IN OIL TERMINALS

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Near Miss: A near miss is an unplanned event that did not result in injury, illness, or damage – but had the potential to do so.

Accident: An unfortunate incident that happens unexpectedly and unintentionally, typically resulting in damage or injury

NEAR MISS & ACCIDENT:

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1. IOC Oil Terminal , Jaipur ,2009

2. IOC Oil Terminal, Hazira ,2013

CASE STUDIES:

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JAIPUR OIL TERMINAL FIRE,2009

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The Jaipur Oil Terminal fire took place on 29 October,2009 at 7:30 PM at Indian Oil Corporation’s oil depot, at Sitapura Industrial area, Jaipur.

There were nearly 12 casualties and over 200 injuries.The blaze continued to rage out of control for 11 days.The incident occurred when petrol was being transferred from the

Indian Oil Corporation's oil depot to a pipeline. There were at least 40 IOC employees at the terminal, when it caught

fire with an explosion.

JAIPUR OIL TERMINAL FIRE,2009

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TRANSFER PUMP -1

MS TANK 401A

THE INCIDENT: SCHEMATIC LAYOUT

Standard Operating Sequence Likely Sequence

1. Ensure MOV and HOV are closed2. Reverse the position of Hammer Blind Valve3. Open the HOV4.Open MOV (initially inching operation to

establish no leakage from Hammer Blind Valve body)

1. MOV opened first.2. Hammer Blind Valve opened3. Leakage started.

MOV

HAMMER BLIND VALVE

HOV

11.86 M

NTS

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SOURCE OF MS LEAK

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MOV ON DISCHARGE LINE

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HAMMER BLIND AND HOV ON DISCHARGE LINE

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As Vapor Cloud spread in such a large area , the source of fire can be anything inside or outside the installation.

The Non flame proof electrical fittings in administration block located in the south western direction of the terminal or Spark during starting of the vehicle at the installation are probable cause of source of fire.

SOURCE OF IGNITION:

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THE INCIDENT – MAJOR TIMELINES

S. No. Activity Time(Hours)

1. Sealing of tank lines, valves etc. for PLT Before 17:50

2. Tank handing over by Pipelines to Marketing 17:50

3. Start of hammer blind reversal work After 17:50

4. Start of MS spillage 18:10

5. Rescue of Operation Officer 18:20-18:24

6. First communication outside the terminal 18:24

7. Sounding of siren After 18:30

8. Formation of vapor cloud across the terminal 18:10-19:30

9. Vapor Cloud Explosion 19:30

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Scenario 1:MOV was in open condition before the start of hammer blind reversal

job.Opened by someone anytime between the previous blinding operation.

Scenario 2:MOV opened accidentally when the blind was being reversed (due to

spurious signal or manually).

Amongst the two Scenarios, Scenarios-I, that the MOV was in open condition before the start of the hammer blind reversal job, appear to be more likely.

THE INCIDENT – POSSIBLE SCENARIOS

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Non-availability of one of the shift workman, who was supposed to be on duty.

Control room remaining unmanned due to above.Absence of specific written-down procedures for the works to be

undertaken and, therefore, reliance on practices.Opening of the HOV before completion of hammer blind reversal

operation.Not checking the MOV for its open/close status and not locking it in

Closed position. Not using proper protective equipment while attempting rescue work.

THE INCIDENT CONTRIBUTING FACTORS:

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Initiation of the critical activity after normal working hours, leading to delay in response to the situation.

Non-availability of second alternate emergency exit.

Proximity of industries, institutes, residential complexes etc. close to the boundary wall.

THE INCIDENT CONTRIBUTING FACTORS:

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FIRE AT IOC TERMINAL HAZIRA,GUJARAT 2012:

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The fire broke out at , about 12.30 pm in a diesel tank, at the IOC oil terminal on January 5, 2013 and was extinguished after 24 hours.

The fire reportedly started after a blast in tank no. 4, which contained nearly 55 lakh litres of diesel, during a welding work by three technicians to repair a leak.

Three persons were killed in the fire who were welders on contract.

THE ACCIDENT

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The “root cause” of the incident, according to the report, was the use of old, corroded plates to repair the floating roof of tank No. 4.

On December 31, 2012, within three months of re-commissioning of the tank, a leak in the roof pontoon was detected. This turned into petrol vapors that got ignited, leading to the explosion on January 5.

Seepage in pontoons emanated hydrocarbon vapors, which mixed with air and created hydrocarbon mixture in the pontoons. This mixture getting some source of ignition from acts of workers attempting to repair the seepage caused the explosion and fire.

CAUSE OF THE FIRE:

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The IOC facility at Hazira has nine tanks located nearby each other. The tank number four had almost 5,000 kilolitres of petrol, half of its capacity, when it caught fire.

The probing team has ruled out the use of mobile phone by a worker as having caused the fire. The only call received by one of the workers ended at 12:36:21 hours while the vibration of the explosion captured by the CCTV at the accident site puts the disaster time at 12:38:08 hours.

THE INCIDENT – POSSIBLE SCENARIOS

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The most likely cause of the explosion appears to have been a spark or the falling of a metal object on a metal plate during checking of the seepage, it has said.

The probe also shows that the procedure for repair was not followed by IOC officials, as instructions are to carry out such a task only after emptying a tank. Tank No. 4 contained 5,027 kilolitres of petrol at the time of the fire.

THE INCIDENT – POSSIBLE SCENARIOS

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The accident investigation report blames the lapses by senior officials.

Allowing any repair work on the tank filled with product could be either due to lack of job knowledge or (due to) ignoring of hazards knowing its consequences.

Senior management has been hauled up for not adhering to the OISD recommendations and for the lack of preparedness in firefighting as the systems in place had ineffective fire water coverage.

Moreover, workers were allowed in the battery area without work permits or gate passes and without being checked for possessing any hazardous tools or equipment, including mobile phones which are prohibited under OISD norms.

ACCIDENT INVESTIGATION REPORT:

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Firefighters work to douse flames at a storage tank of the state-owned Indian Oil Corporation in Hajira near Surat. 

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