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OFF THE JOB INCIDENT LEARNINGS
Prepared By: Arslan Hussain
INCIDENT NUMBER(1): FIR-NPFS-1-Township-2021
2021
Incident Description:
On 3rd of Oct-21, Power plug of desktop computer's monitor sparking observed.
Key Findings:
1. Desktop was used by kids for school work.
2. During Lunch time Desktop was shut downed while Power socked remained connected to plug and remained alive.
3. At 1600hrs Sparking observed at power plug of desktop.
4. Power switch was immediately unplugged after switching it off but sparking lead to melting with other computer cables
and causing smoke.
5. Immediately DCP fire extinguish used to stop sparking/Smoke of melted power cable to avoid any fire.
6. Melted power cable was purchased from local market and its was not built as per standard. Non standard cable caused
over heating and melted.
Root Cause:
Due to non standard power cable of computer, Cable over heated and melted.
Key Learnings:
• Home appliances power cable especially computer cable must be purchase as per standard
• Electrical appliances must be switched off from Main power socket instead of machine switch off button to ensure that
power source must be cut from switch.
INCIDENT NUMBER(2): VI-1-Plantsite Roads-2022
2021
Incident Description:
On 3rd of Feb-22, two bikes (one was being driven by a security supervisor and other one by two of PH&S contractor persons
of A-Hameed contractor) met a road accident on south side road of KLP gate.
Key Findings:
1. USLs were going back to their home after evening duty at PHS.
2. As per security personal at nearby check post, USLs were over speeding.
3. To avoid road bumps and damage portion of road, USL moved his bike suddenly and hence collided with other bike.
Root Cause:
Incident happened due to reckless driving of USL as he suddenly moved his bike to incoming lane owing to damaged road.
Key Learnings:
1. Always follow speed limits and drive safely. (follow defensive driving rules.)
2. Take into consideration road & weather conditions while driving.
3. Always inspect your vehicle prior to use.
INCIDENT NUMBER(3): NMI-NM-1-Township-2022
Incident Description:
On 10th of Feb-22, During half yearly township safety articles inspection by HSE, a fire extinguisher reported empty in one of
G-type house. Usage of DCP fire extinguisher was not reported by house owner.
Key Findings:
1. Resident was cooking in frying pan.
2. During cooking oil in frying pan caught fire, house resident immediately extinguished fire by using fire extinguisher.
3. House resident did not reported the incident, as per house owner he was not aware about the incident and his family
taken it casually.
Root Cause:
Hasty and complacent behavior. Due to over heating of cooking oil. Oil in frying pan caught fire.
Key Learnings:
That fire extinguishers are provided in houses for emergency fire extinguishing purpose but in case of its usage or health
check (pressure reduction or leakage) immediately inform HSE team, report the incident get the fire extinguisher refilled
without any hesitation.
INCIDENT NUMBER(4): FIR-NPFS-1-Township-2022
Incident Description:
On 17th of April-22, Janitorial staff observed smoke from club staff office and informed to Mr. Sajjad (Mngt, club staff) who
called ERT. LED TV installed inside Executive club office was completely burnt along with associated duct.
Key Findings:
1. When unlocked Executive club office: it was observed that LED TV installed in office was burnt & fallen on floor. (internal
PCB board of LED screen also found at spot in burnt condition.
2. Associated electric socket, cable duct, some portion of LED / TV cable & LAN cable routed nearby also found
burnt.(observation / impact showed that this burning was due to propagation from LED TV side)
3. Heat impact was there on rear side of AC installed on other side of same wall in club staff office. (path was through hole
which was there for AC pipes). No further finding related to AC as checked after dismantling.
4. Breaker for sockets of Executive club office was also found tripped inside DB (Sub DB-2 Ground floor).
5. Information shared by Mngt. club staff - LED TV brand: LG & installed approx. 8 yrs. ago.
6. Incidents are there where spark / fire reported in LED TV - as checked from Internet.
7. Fire alarm system (smoke detectors, alarm bells) not installed in Mngt. club and as well as in other buildings (except
Medical center which also is a stand alone system). Neighboring industries were consulted; no fire alarm is installed in
club, residential buildings, other township premises & common practice is to install for record rooms only.
8. Inquired about Fire extinguisher practical training of staff. Last training conducted approx. 2.5 years ago.
Root Cause:
Spark / ignition inside LED TV which propagated smoldering.
INCIDENT NUMBER(4): FIR-NPFS-1-Township-2022
Key Learnings:
1. Always ensure that power supply to LED TV & other appliances like Air Conditioners etc. must be off when not in use
2. There should be a key box placed at an appropriate location & keys of Club offices/ other rooms must be available in that
box so that one can get easily in case of any emergency while offices / rooms are locked.
3. Always ensure building residents are trained on the use of Fire extinguishers.
INCIDENT NUMBER(5): FIR-NPFF-1-OSBL-2022
Incident Description:
On 15th of May-22 at around 23:20 hrs. fire incident happened in cabin on loaded CAN fertilizer Truck (Reg # TCF-736) at back
side road of cooling tower (Truck canteen road) which was moving toward weigh bridge.
Key Findings:
1. Only visual inspection of is done by carriage contractor representative and no documentary evidence is available.
2. As per driver, fire was initiated due to short circuiting in wires under steering wheel.
3. No fire extinguishers are available in fertilizer vehicles, same practice is being followed in industry.
4. Nearby fire hydrants / Fire extinguisher or fire truck is usually utilized for such fires as these random in nature.
Root Cause:
Fire incident happened due to insufficient inspection checks which lead to short circuiting inside vehicle cabin.
Key Learnings:
1. Always ensure the health inspection of hired vehicles as per plant KPI’s
2. Ensure safety awareness sessions with carriage contractors & drivers prior to utilizing their vehicles.
INCIDENT NUMBER(6): VI-2-Township-2022
Incident Description:
On 26th of June-22, Vehicle ASZ-773 was parked at designated place in township to with draw cash from ATM. Motorbike
driver while parking motorbike at near vicinity touched with vehicle leading to minor dent on front side bumper. Driver of
motor bike remained safe from falling.
Key Findings:
1. Motorbike and car driver found with valid driving license and both are resident of township.
2. Motorbike driver could not assess that car is in START condition and its front and back lights are ON.
3. Motorbike driver was in hurry and he took very short turn in front of car for parking of motorbike to with draw cash from
ATM.
4. Car driver did not take 360 views before putting the vehicle in operation.
Root Cause:
Wrong parking of motorbike (Left to Right) with short turn is the root cause of this incident.
Key Learnings:
Always follow vehicle parking norms.
The person driving the car should always ensure 360* view before moving vehicle in parking areas.

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Off the job incident learnings.pptx

  • 1. OFF THE JOB INCIDENT LEARNINGS Prepared By: Arslan Hussain
  • 2. INCIDENT NUMBER(1): FIR-NPFS-1-Township-2021 2021 Incident Description: On 3rd of Oct-21, Power plug of desktop computer's monitor sparking observed. Key Findings: 1. Desktop was used by kids for school work. 2. During Lunch time Desktop was shut downed while Power socked remained connected to plug and remained alive. 3. At 1600hrs Sparking observed at power plug of desktop. 4. Power switch was immediately unplugged after switching it off but sparking lead to melting with other computer cables and causing smoke. 5. Immediately DCP fire extinguish used to stop sparking/Smoke of melted power cable to avoid any fire. 6. Melted power cable was purchased from local market and its was not built as per standard. Non standard cable caused over heating and melted. Root Cause: Due to non standard power cable of computer, Cable over heated and melted. Key Learnings: • Home appliances power cable especially computer cable must be purchase as per standard • Electrical appliances must be switched off from Main power socket instead of machine switch off button to ensure that power source must be cut from switch.
  • 3. INCIDENT NUMBER(2): VI-1-Plantsite Roads-2022 2021 Incident Description: On 3rd of Feb-22, two bikes (one was being driven by a security supervisor and other one by two of PH&S contractor persons of A-Hameed contractor) met a road accident on south side road of KLP gate. Key Findings: 1. USLs were going back to their home after evening duty at PHS. 2. As per security personal at nearby check post, USLs were over speeding. 3. To avoid road bumps and damage portion of road, USL moved his bike suddenly and hence collided with other bike. Root Cause: Incident happened due to reckless driving of USL as he suddenly moved his bike to incoming lane owing to damaged road. Key Learnings: 1. Always follow speed limits and drive safely. (follow defensive driving rules.) 2. Take into consideration road & weather conditions while driving. 3. Always inspect your vehicle prior to use.
  • 4. INCIDENT NUMBER(3): NMI-NM-1-Township-2022 Incident Description: On 10th of Feb-22, During half yearly township safety articles inspection by HSE, a fire extinguisher reported empty in one of G-type house. Usage of DCP fire extinguisher was not reported by house owner. Key Findings: 1. Resident was cooking in frying pan. 2. During cooking oil in frying pan caught fire, house resident immediately extinguished fire by using fire extinguisher. 3. House resident did not reported the incident, as per house owner he was not aware about the incident and his family taken it casually. Root Cause: Hasty and complacent behavior. Due to over heating of cooking oil. Oil in frying pan caught fire. Key Learnings: That fire extinguishers are provided in houses for emergency fire extinguishing purpose but in case of its usage or health check (pressure reduction or leakage) immediately inform HSE team, report the incident get the fire extinguisher refilled without any hesitation.
  • 5. INCIDENT NUMBER(4): FIR-NPFS-1-Township-2022 Incident Description: On 17th of April-22, Janitorial staff observed smoke from club staff office and informed to Mr. Sajjad (Mngt, club staff) who called ERT. LED TV installed inside Executive club office was completely burnt along with associated duct. Key Findings: 1. When unlocked Executive club office: it was observed that LED TV installed in office was burnt & fallen on floor. (internal PCB board of LED screen also found at spot in burnt condition. 2. Associated electric socket, cable duct, some portion of LED / TV cable & LAN cable routed nearby also found burnt.(observation / impact showed that this burning was due to propagation from LED TV side) 3. Heat impact was there on rear side of AC installed on other side of same wall in club staff office. (path was through hole which was there for AC pipes). No further finding related to AC as checked after dismantling. 4. Breaker for sockets of Executive club office was also found tripped inside DB (Sub DB-2 Ground floor). 5. Information shared by Mngt. club staff - LED TV brand: LG & installed approx. 8 yrs. ago. 6. Incidents are there where spark / fire reported in LED TV - as checked from Internet. 7. Fire alarm system (smoke detectors, alarm bells) not installed in Mngt. club and as well as in other buildings (except Medical center which also is a stand alone system). Neighboring industries were consulted; no fire alarm is installed in club, residential buildings, other township premises & common practice is to install for record rooms only. 8. Inquired about Fire extinguisher practical training of staff. Last training conducted approx. 2.5 years ago. Root Cause: Spark / ignition inside LED TV which propagated smoldering.
  • 6. INCIDENT NUMBER(4): FIR-NPFS-1-Township-2022 Key Learnings: 1. Always ensure that power supply to LED TV & other appliances like Air Conditioners etc. must be off when not in use 2. There should be a key box placed at an appropriate location & keys of Club offices/ other rooms must be available in that box so that one can get easily in case of any emergency while offices / rooms are locked. 3. Always ensure building residents are trained on the use of Fire extinguishers.
  • 7. INCIDENT NUMBER(5): FIR-NPFF-1-OSBL-2022 Incident Description: On 15th of May-22 at around 23:20 hrs. fire incident happened in cabin on loaded CAN fertilizer Truck (Reg # TCF-736) at back side road of cooling tower (Truck canteen road) which was moving toward weigh bridge. Key Findings: 1. Only visual inspection of is done by carriage contractor representative and no documentary evidence is available. 2. As per driver, fire was initiated due to short circuiting in wires under steering wheel. 3. No fire extinguishers are available in fertilizer vehicles, same practice is being followed in industry. 4. Nearby fire hydrants / Fire extinguisher or fire truck is usually utilized for such fires as these random in nature. Root Cause: Fire incident happened due to insufficient inspection checks which lead to short circuiting inside vehicle cabin. Key Learnings: 1. Always ensure the health inspection of hired vehicles as per plant KPI’s 2. Ensure safety awareness sessions with carriage contractors & drivers prior to utilizing their vehicles.
  • 8. INCIDENT NUMBER(6): VI-2-Township-2022 Incident Description: On 26th of June-22, Vehicle ASZ-773 was parked at designated place in township to with draw cash from ATM. Motorbike driver while parking motorbike at near vicinity touched with vehicle leading to minor dent on front side bumper. Driver of motor bike remained safe from falling. Key Findings: 1. Motorbike and car driver found with valid driving license and both are resident of township. 2. Motorbike driver could not assess that car is in START condition and its front and back lights are ON. 3. Motorbike driver was in hurry and he took very short turn in front of car for parking of motorbike to with draw cash from ATM. 4. Car driver did not take 360 views before putting the vehicle in operation. Root Cause: Wrong parking of motorbike (Left to Right) with short turn is the root cause of this incident. Key Learnings: Always follow vehicle parking norms. The person driving the car should always ensure 360* view before moving vehicle in parking areas.