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
1. IOC Oil Terminal , Jaipur ,2009
2. IOC Oil Terminal, Hazira ,2013
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.
MS TANK 401A
THE INCIDENT: SCHEMATIC LAYOUT
Standard Operating Sequence Likely Sequence
1. Ensure MOV and HOV are closed
2. Reverse the position of Hammer Blind Valve
3. Open the HOV
4.Open MOV (initially inching operation to
establish no leakage from Hammer Blind Valve
1. MOV opened first.
2. Hammer Blind Valve opened
3. Leakage started.
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.
S. No. Activity Time
1. Sealing of tank lines, valves etc. for PLT Before
2. Tank handing over by Pipelines to Marketing 17:50
3. Start of hammer blind reversal work After
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
8. Formation of vapor cloud across the terminal 18:10-19:30
9. Vapor Cloud Explosion 19:30
MOV was in open condition before the start of hammer blind reversal
Opened by someone anytime between the previous blinding operation.
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
Non-availability of one of the shift workman, who was supposed to be
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
Not checking the MOV for its open/close status and not locking it in
Not using proper protective equipment while attempting rescue work.
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 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 “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.
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
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 accident investigation report blames the lapses by senior
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.