Near miss awareness for petroleum oil refinery

1. A.K.Singh, General Manger (F&S)
Indian Oil Corporation Limited
Gujarat Refinery
Examples of Near miss incident
Near Miss Awareness for Oil
Refinery
The Same Things That Cause Accidents Cause Near Misses
18 Aug 2017
तेल शोधन ऊद्योग के ललए ननयर की घटनाओ की जागरूकता
Comments on email : singhak@indianoil.in
0265 -2237110

2. Understand - WhatisaNearMiss?

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

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

5. 2
Unsafe Act
Unsafe Condition
Near Miss
Property Damaged
Injury (LTI or Fatal)
ननयर लिस

6. OISD Definition of 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.(OISD GDN 206)
The Same Things That Cause Accidents Cause Near Misses 2

7. The Same Things That Cause Accidents Cause Near Misses 2

8. Definition from SEED Standard on incident reporting and investigation
NEAR MISS CASE (NMC):
An event that could have resulted in an incident is a near miss
Generally the following events are some examples of near miss when:
• A person trips over an object and falls to the ground but did not get
injured
• A person has to 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
• Any emergency equipment (fire extinguisher, Air Pack, Oxygen sensor, eye
wash, etc) fails to operate properly when called on in an emergency.
HIGH-POTENTIAL (Hi-PO) NEAR MISS
Any Near Miss that has potential to convert into a major incident under
slightly different circumstances shall be termed as Hi-Po Near Miss.
The Same Things That Cause Accidents Cause Near Misses 3

9. Unsafe Condition
Unsafe Act
Near Miss
Accident
Unsafe Condition
Unsafe Act
Near Miss
Accident

10. 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.
The Same Things That Cause Accidents Cause Near Misses 4

11. 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 ware house 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.
The Same Things That Cause Accidents Cause Near Misses 5

12. 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……….
The Same Things That Cause Accidents Cause Near Misses 6

13. What is NOT a Near Miss
1. An important email composed on PC but forget to transmit- some people report it.
2. Spelling /verb mistake in display boards or document
3. Damaged road/walk ways .
4. Water leakage from tape or leaking fire hydrant. – Many people report it
5. A.C or tube light not working
6. Repair request of office furniture-Damaged furniture/lockers/doors /windows/broken glasses etc
7. Water leakage from service water line.
8. Choked sewage / bath room drains
9. Complaints regarding grass growth and tree/bushes causing hindrance
10. Complaints regarding scrap removal
11. Non-availability/ damaged safety shower, wind sock 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
The Same Things That Cause Accidents Cause Near Misses 7

14. Examples of Unsafe acts & unsafe conditions
Unsafe Acts
• Operating equipment or machinery without
permission
• Defeating safety devices/interlocks
• Using defective equipment
• Using the wrong tool for the job
• Not using Personal Protective
Equipment
• Incorrect lifting techniques
• Working while intoxicated Hazardous
atmospheres
• Horseplay
• Non-authorized personnel entering
restricted areas.
• Falling or flying objects that do not make
contact with individuals nor cause any
significant property damage.
• Exceeding equipment operating
conditions/parameters.
• Deliberate/willful disobeyance of safety
rules (ex carrying of mobile phone inside
battery area)
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 waste stream.
• Failure of any equipment or associated
systems that are in place to protect health
and safety.
• Failure identified by statutory testing.
The Unsafe conditions are also Employee
created unsafe conditions thus being acts
as well
The Same Things That Cause Accidents Cause Near Misses 8

15. 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
Examples of Unsafe acts & unsafe conditions
The Same Things That Cause Accidents Cause Near Misses 9

16. Factors which can lead to unsafe acts or conditions
Human Factors System Factors
Lack of knowledge or skills
due to inadequate training
Substandard equipment design
Physical limitations of the worker 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
The Same Things That Cause Accidents Cause Near Misses 10

17. 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
The Same Things That Cause Accidents Cause Near Misses 11

18. 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 road side 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 non visible
• 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.
The Same Things That Cause Accidents Cause Near Misses 12

19. 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.
The Same Things That Cause Accidents Cause Near Misses 13

20. 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 by contract workers where they work in
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.
The Same Things That Cause Accidents Cause Near Misses 14
Actual picture

21. Wheel chocks not in place
at rear wheels of trailer
30,000 Hazards
- Unsafe Acts
- Unsafe Conditions
3,000
Near-Misses or First Aid
Lift truck is driven into truck
trailer and trailer moves
300
Recordable Injuries
Truck trailer moves, driver jumps
to ground and sprains ankle
Truck trailer moves, driver jumps to
ground and breaks leg
30
Majors
(LWCs and RWCs)
1
Fatal
Truck trailer moves, driver jumps to ground
and truck rolls over him/her
Real improvement requires a disciplined approach to understand and
reduce root causes of incidents and injuries
The Hazard Pyramid
Du Ponts’ Model
Example
The Same Things That Cause Accidents Cause Near Misses 15

22. Report only genuine Near Miss Incidents,
analyse them and after corrective
measures, close them in Sabarmati On line
near miss reporting portal in Sabarmati
For Hi Potential Near Miss incident, use
standard OISD Reporting format given in
next 4 slides (17 to 20)
The Same Things That Cause Accidents Cause Near Misses 16

23. 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; Fire, Explosion, Blowout, Electrocution,
Fall from Height, Inhalation of Gas, Driving, Slip/Trip, Others,
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= b) Contractor = c) Others =
15. Injuries nos a) Employee = b) Contractor = c) Others =
16. Man-hours Lost a) Employee = b) Contractor = c) Others =
17. Direct Loss due the incident (Rs in Lacs). Loss to equipment / Machinery
as per Insurance claim etc.
OISD Incident Reporting Form
17

24. 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.
18

25. 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
19

26. 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 g) Better equipment
c) Imparting Training h) Management Control
d) Giving adequate time to do the activity
through proper planning.
i) Adhering to specified maintenance
procedure
e) Adhering to the work permit system
j) Adhering to specified Inspection /
Testing procedures.
k) Any other:
20

27. Thanks