Near miss awareness for Petroleum oil refinery

1. Near miss awareness for Oil Refinery Definition ,explanation, Examples, Reporting & Investigation formats, Online reporting portal & Near miss incident cases A.K.Singh, General Manger (F&S) Indian Oil Corporation Limited Gujarat Refinery, Vadodara Feedback & Comments on email : singhakindianoil@gmail.com or singhak@indianoil.in 16 Sept 2020

2. Understand-What is a Near Miss

3. Before that understand Various terms/Definitions

4. Types of incidents Incident Work-related event(s) in which an injury or ill health (regardless of severity) or fatality occurred or could have occurred. Accident An accident is an incident which has given rise to injury, ill health or fatality. Potential Incident Unsafe practices or hazardous situations that could result in an incident… Incident has not occurred Near miss An incident where no injury, ill health, or fatality occurs may also be referred to as a “near-miss”, “near-hit”, “close call” or “dangerous occurrence”. First Aid Case Any single treatment and subsequent observation of minor scratches, cuts, burns, splinters, etc. that do not normally require medical care by a physician. Such treatment and observation is considered first aid case even if provided by a physician or registered professional personnel. Medical Treatment Case Any work-related injury that involves neither lost workdays or restricted workdays, but which requires treatment by a physician or other medical specialist. Medical treatment does not include first aid even if a physician or registered professional personnel provide this. Restricted work case Any work-related injury which renders the injured person temporarily unable to perform all, but still some of their normal work on any day after the day on which the injury occurred.

5. Lost Time Incident Any injury that has at least one full day lost time, the day of the accident doesn’t count and the day the employee returns to work doesn’t count no matter what time of the day the accident occurs or when the employee returns to work. Occupational Illness Any work-related abnormal condition or disorder, other than one resulting from an injury that is caused by, or mainly caused by exposure to environmental factors associated with the employment. Environmental Incident It is an unplanned event or a chain of events that has or could have a negative impact on the environment. Incidents like oil and chemical spills atmospheric emissions and complaints regarding high noise levels etc. Reportable Cases Occupational death, nonfatal occupational illness, and those nonfatal occupational injuries which involve one or more of the following: Loss of consciousness, restriction of work or motion, transfer to another job, or medical treatment (other than first aid) Total Recordable Incident Rate Total Recordable Incidence Rate (TRIR) is a measure of the rate of recordable workplace injuries. The factor is derived by multiplying the number of recordable injuries in a calendar year by 200,000 and dividing this value by the total man-hours actually worked in the year.

6. Definition of Near Miss from JR-SEED Standard on incident reporting and investigation NEAR MISS : An event that could have resulted in an incident is a near miss General examples of near miss when: • A person trips over an object and falls to the ground but did not get injured • A person must dive or jump out of the way to avoid a collision with a motorized vehicle, or a suspended load that is swinging • A person has to jump from a falling ladder but did not get injured. • Failure of an emergency equipment (fire extinguisher, Air Pack, Oxygen sensor, eye wash, Gas Detectors , fire or smoke alarm ) during emergency. High-Potential (Hi-Po) Nearmiss in IOCL Any Near Miss that has potential to convert into a major incident under slightly different circumstances shall be termed as Hi-Po Near Miss. This is categorized based on Consequence-Probability Risk Matrix The Same Things That Cause Accidents Cause Near Misses 3

7. IOCL Model of Hi Potential /Critical Near Miss Consequence-Probability Risk Matrix

8. OISD GDN -206 defines Near Miss An incident which does not result in any injury or damage to property but has the potential to result in injury and / or property damage. Near miss is always an inch or two away from a tragedy

10. The Hazard Pyramid Du Ponts’Model Truck trailer moves, driver jumps to ground and truck rolls over him/her 1 Fatal 30 Truck trailer moves, driver jumps to ground and breaks leg Majors (LWCs and RWCs) Truck trailer moves, driver jumps to ground and sprains ankle 300 Recordable Injuries Lift truck is driven into truck trailer and trailer moves 3,000 Near-Miss 30,000 Hazards - Unsafe Acts - Unsafe Conditions Wheel chocks not in place at rear wheels of trailer The Same Things That Cause Accidents Cause Near Misses

11. Different Scenarios when a person works at height on a beam

12. Unsafe Act Unsafe Condition नियर मिस Near Miss Property Damaged Injury (LTI or Fatal) 2

13. The Same Things that Cause Accidents Cause Near Misses

14. Unsafe Condition Near Miss Accident Unsafe Act Unsafe Condition Near Miss Accident Unsafe Act

15. Hope - it is amply clear now what is a near miss Various other terms used to describe near miss incident are – Close calls – Near hit – Close save – Misfire – ज़रा सी चूक – बाल बाल बचिे की स्थिनि – करीबी कॉल घटिा – निकटविी घटिा

16. Examples of Near Miss 1. Failure of a safety device without causing any damage to plant, equipment or injury to a person. 2. Falling of a ceiling fan without hurting any person. 3. Slipping on floor without getting hurt or injured. 4. Failure of brake or controls on mobile equipment or vehicle. 5. Collapse of excavated earth without causing damage Release of toxic or inflammable gas without causing fire or injury. 6. Dropping of material from overhead without causing injury . 7. A forklift tipped over while carrying a load that shifted on an uneven work surface. The driver escaped without a scratch by staying buckled inside the cage. 8. A Railway Exchange Mechanic working under Rail Tank Wagon had just stepped away when the Rail wagon was struck by another wagon being positioned in TW gantry. 9. A forklift ran over a welder’s foot which was protected by his steel toed boots when the driver backed up and did not see him walking behind his lift.

17. Examples of Near Miss 10 . Breaking of a hand tool, coming out of hammer from handle without injuring. 11. Falling of load from height, without causing any damage or injury. 12. Sudden failure of brake/locking device of EOT crane during lifting of load in compressor house in any unit. 13. Snapping of wire rope of coke bucket of Kone crane in DCU without any damage or injury. 14. Failure of magnetic lock or brake of elevator in FCCU or MSQU or opening of floor lift door without having lift at designated floor. 15. Tripping over an unsecured cable or Electrical cord . 16. If a person walking in a warehouse and he felled due to cable in his way but he didn’t have any injury. 17. A vehicle has been stuck with other, but no major damage occurred.

18. Examples of Near Miss 18. While working on height a spanner slipped from hand and fell down on a head of person, due helmet on head nothing happened to him. 19. A lifted load felled down on the deck due to breaking of sling, but nothing happened to anyone. 20. While tightening a bolt your hand slips from spanner due to wet hand and spanner felt on floor very close to a person who is assisting you. 21. While bending backward in a office chair , its wheels slipped and you fell down without hurting. There are many examples of near miss added everyday……….

19. What is NOT a Near Miss ? 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Complaints regarding scrap removal 11. Non-availability/ damaged safety shower, windsock etc 12. Dog, snake, mosquito menace. 13. Empty drums removal requirement. 14. CCTV complaints 15. Requirement of warning signs 16. Damaged safety & other sign boards 17. Complaints on foul smell without identifying the source 18. Cleaning requirement of unit area 19. Seepage from roof or chajja . 20. Missing/damaged PG/loss of level in equipment/ Power failure/DCS black out etc. 21. Township related civil & Electrical complaints 22. Maintenance related regular work request 23. Plant related production /process QC lab issues An important email composed on PC but forget to transmit- some people report it. Spelling /verb mistake in display boards or document Damaged road/walkways . Water leakage from tape or leaking fire hydrant. – Many people report it A.C or tube light not working Repair request of office furniture-Damaged furniture/lockers/doors /windows/broken glasses etc Water leakage from service water line. Choked sewage / bathroom drains Complaints regarding grass growth and tree/bushes causing hindrance

20. Examples of Unsafe acts & unsafe conditions UnsafeActs Operating without permission Defeating safety devices/interlocks Using defective equipment Using the wrong tool for the job Not using Equipment Incorrect lifting techniques Working while atmospheres Horseplay Non-authorized restricted areas. Falling or flying objects that do not make contact with individuals nor cause any significant property damage. Exceeding equipment conditions/parameters. Deliberate/willful disobeyance of safety rules (ex carrying of mobile phone inside battery area) The Unsafe conditions are mostly man created. Thus, they are unsafe acts too. Unsafe Conditions Lack of guarding on machinery Crowding workers into one area Using the wrong tool for the job Inadequate alarm systems Fires & explosions risk Housekeeping Excessive noise Inadequate lighting Faulty equipment Waste going into the wrong stream. Failure of any equipment systems that are in place to protect health and safety. Failure identified by statutory testing. equipment or machinery • • • • • • • • • • • • • • • Personal Protective • • intoxicated Hazardous waste • • personnel entering or associated • • • operating • • -Says Dupont EI

21. Examples of Unsafe acts & Unsafe conditions Unsafe Acts Operating Vehicles without license or authority Bypassing safety interlocks without authorization Not tagging field equipment when isolated from electrical Sub Station Starting maint job on machines/pump/motor without isolating power locally and from sub station Opening of flanges on live equipment/line w/o permit Miscoordination between two working groups in same enclosure Fueling running vehicles/cranes Carrying a suspended load over personnel/standing under that. Keeping files on floor in movement areas. Unsafe Condition Working on perforated roof or weak roof Blocked exit/entry/stairs Undressed cable /wire of computer /printer etc Open manholes /Open trenches Working in areas with oil spillage Broken/missing wire net on revolving fan/machines. Missing rung on ladder /missing stop, bar on monkey ladders Hanging electrical fittings Hanging overhead load/material Chemical spillage Dusty atmosphere Low illumination High noise Torn tyres of vehicles/hydra etc Blind corner on roads with low visibility • • • • • • • • • • • • • • • • • • • • • • • • The Unsafe acts are linked to our behaviour.

22. Factors which can lead to unsafe acts or conditions Human Factors System Factors Lack of knowledge or skills due to inadequate training Physical limitations of the worker Substandard equipment design Poor equipment maintenance Distractions which interfere with the worker’s ability to concentrate on task Purchase of substandard equipment , material , tools & tackles Unusual increases in usages of equipment Non-existent or poorly developed work standards

23. Examples of system factors ( Often employee select inappropriate system factor while reporting Near Miss Online) Slippery Floors • Water leaked on floor • Algae formed on floor • Oil spilled on the ground. • Muddy soil spread on the ground • Dust or sandy surface Defective equipment • Any part of the grinding machine is damaged which is not being used. • Any part of the welding machine is damaged which is not being used. • Using an equipment or machine or tool having defective parts such as the electrical terminal box, broken bearing, damaged protective guard, broken oil cup , leaking pipes , leaking valves etc. and exposed to potential risk which could cause incident. In adequate illumination • Poor lighting in unit area. • Poor lighting in control rooms • Lights not working as per requirement i.e. some lights are not working Studies says – more skilled a worker becomes, they’re likely to show more unsafe behaviour pattern

24. Examples of system factors ( Often employee select inappropriate system factor while reporting Near Miss Online) Poor Housekeeping • Scrap from maintenance jobs not removed from site. • Daily cleaning not done in plant. • Oil spillage near the oil loading point in the equipment. • Grass/vegetation not removed from tank farm area. • Material not stored properly at storage site. • Drums kept on roadside in scattered manner. • Material brought for some job are not stored properly. • The tools and equipment used for a job at a work site are kept in scattered way. Defective PPE • PPE (Helmet, Goggles etc.) in damaged condition. • Ropes/ belt of safety harness in damaged conditions. • Goggles glass became nonvisible • Helmet Chin strap missing or broken. Helmet is damaged having crack, brim damaged etc Non-Adherence of SOP • Flagman not provided for hydra /crane. • Moving of Hydra while carrying/hanging load like motor, pipes etc on its boom • Working on /adjusting a moving machine-like changing V belt, filling diesel in a running engine, generator , etc • Not following SOP for doing a job.

25. Examples of system factors ( Often employee select inappropriate system factor while reporting Near Miss Online) Use of Defective Equipment • If a person is found using the equipment which is faulty as mentioned in S. No.2, that comes under this heading. Violation of Safety Norms • Mobile phone not allowed inside refinery • Match box not allowed inside refinery • Always drive the vehicle below 25kmph • Don’t park near fire hydrants etc. • Lifting and moving is not allowed for hydra /cranes. • Standing under suspended load is a safety violation • Non compliance to work permit conditions Un-authorized Activity • Operating a EOT crane without formal training • Operating a lifting equipment without authorisation • Driving vehicle inside refinery without license. • Doing working at height job without green card. Non-use of PPE • Not using PPE required for a particular job.

26. Lack of Knowledge(LOK) • Cable pulling job at height and walking haphazardly without providing side railing/guide rope. • Lack of knowledge of making extra provision for temporary work at height etc • Change Operating procedure not known/MoC communication not confirmed with Operating group after sharing • Leanings through SOP not available for critical equipment • Lack of skill in using specialized PPE like BA set, trolley BA set. • Changes in process design, work methods,equipment,materials,etc. not understood properly /followed in actual job performance • Using water instead of DCP/CO2 fire extinguisher on electrical fire. • Lack of knowledge of plant /equipment running plants. • Lack of knowledge of surrounding work conditions/environment • Lack of knowledge of consequences of operating /playing wrongly with local push button switches for starting /stopping motor/compressors in units and resulting in shutdown of equipment. by contract workers where they work in

27. Unsafe Act or Unsafe Condition?

28. Unsafe Act or Unsafe Condition?

29. Unsafe Act or Unsafe Condition?

30. Unsafe Act or Unsafe Condition?

32. Du Ponts’ Model Real improvement requires a disciplined approach to understand and reduce root causes of incidents and injuries Example The Hazard Pyramid Truck trailer moves, driver jumps to ground and truck rolls over him/her 1 Fatal 30 Truck trailer moves, driver jumps to ground and breaks leg Majors (LWCs and RWCs) Truck trailer moves, driver jumps to ground and sprains ankle 300 Recordable Injuries Lift truck is driven into truck trailer and trailer moves 3,000 Near-Misses or First Aid 30,000 Hazards - Unsafe Acts - Unsafe Conditions Wheel chocks not in place at rear wheels of trailer The Same Things That Cause Accidents Cause Near Misses

33. Report only genuine Near Miss Incidents, analyse them and measures, close them in Sabarmati On line near miss reporting portal after corrective For Hi Potential Near Miss incident, use standard IOCL Ref Divn Reporting format given in next 5 slides and OISD reporting format in 4 slides

34. Refineries HQ,New Delhi Health, Safety & Environment Dept

38. OISD Incident Reporting Format 1. Organization 2. Sector 3. Location 4. Incident Sr. No 5. Date of Incident 6. Time of Incident 7. Major / Minor / Nearmiss 8. Report - Preliminary / Final 9. Fire / Accident 10. Duration of fire – hrs / min 11. Type of incident with loss of life/ injury; Electrocution, Fall from Height, Inhalation of Gas, Driving, Slip/Trip, Others, Fire, Explosion, Blowout, 12. Location of the Incident (Name of the Plant / Unit / Area / Facility / Tank farm / Gantry / Road / parking area etc) 13. Whether plant shutdown / caused outage of the facility? Yes / No. 14. Fatalities nos. a) Employee= a) Employee = a) Employee = b) Contractor = c) Others = 15. Injuries nos b) Contractor = c) Others = 16. Man-hours Lost b) Contractor = c) Others = 17. Direct Loss due the incident (Rs in Lacs). Loss to equipment / Machinery as per Insurance claim etc.

39. 18. Indirect Losses: T'’Put / Production Loss 19 Status of the Facility: Construction / Commissioning / Operation / Shutting down / Turn around, Maintenance / Start up / Any other. 20 Brief Description of the Incident including post incident measures. (Attach details in separate sheet) 21. Whether Similar Incident has occurred in past at the same location, If yes, give brief description of the incident and attach details in separate sheet. 22. Whether Internal Investigation has been completed. If no, likely date by which it will be completed. 23. Whether internal investigation report (Major Incident) has been submitted to OISD. If no, likely date by which it will be submitted.

40. 24. Cause of the Incident (Tick the most relevant cause preferably one, maximum two)-nil a) Deviation from Procedures i) Not using the PPE b) Lack of Job knowledge j) Equipment failure c) Lack of supervision k) Poor design /Layout etc d) Improper Inspection /checking l) Inadequate facility e) Improper Maint (Mech./El./Inst.) m) Poor house keeping f) Improper material handling n) Natural Calamity g) Negligent Driving o) Pilferage / Sabotage h) Careless walking/climbing etc p) Any other (give details) 25. Cause of leakage - Oil, Gas or Chemical (Tick one only) -Nil a) Weld leak from equip / lines e) Leakage due to improper operation b) Leak from flange, gland etc f) Leak due to improper maintenance c) Leak from rotary equipment g) Normal operation: Venting/draining d) Metallurgical failure h) Any other

41. 26. Cause of Ignition leading to fire (Tick only one cause): a) Near to hot work f) Static Electricity b) Near to furnace / flare etc g) Hammering / Fall of object c) Auto-ignition h) Heat due to friction d) Loose electrical Connection i) Lightning e) Near to hot surface j) Any other (pyrophoric etc) 27. Was the incident Avoidable? (Yes / No) 28. The incident could have been avoided by the use of/or by: (Tick the most relevant point preferably one, maximum two) a) Better supervision f) Personal Protective Equipment b) Adhering to specified operating procedure c) Imparting Training g) Better equipment h) Management Control d) Giving adequate time to do the activity through proper planning. i) Adhering to specified maintenance procedure j) Adhering to specified Inspection / Testing procedures. e) Adhering to the work permit system k) Any other:

42. ONLINE PORTAL NEAR MISS REPORTING SYSTEM

44. Reporting a Near miss

46. Closing a Near miss

47. Critical & Hi Po Near miss

48. Admin Module

49. Near Miss Cases

50. Hi Po neamiss incident “Hydrogen leak detected before hand due to Kiene valve failure at ISOM” Indian Oil Corporation Ltd Indian Oil Corporation Ltd Gujarat Refinery Gujarat Refinery Gujarat Refinery – Where Growth is Essence of Life