The document discusses the IOCL Jaipur Tank Farm fire that occurred on 29 October 2009 which killed 11 people and caused losses of Rs 280 crore. It analyzes potential factors that led to the incident such as lack of safety measures, absence of operating procedures and leak detection systems, insufficient emergency preparedness and response, and non-compliance with regulatory requirements. It suggests that implementing an effective occupational health and safety management system as per OHSAS 18001 could have prevented this incident through systematic hazard identification, risk assessment, and audit of safety controls.

1. BS OHSAS 18001:2007 OH&S Management System Standard “ Asking me to overlook a simple safety violation would be asking me to compromise my entire attitude towards the value of your life !” 01.05.2010

2. A Tragic Incidents that Shook the world Union Carbide MIC Gas Tragedy. Bhopal, India Dec 2-3, 1984 01.05.2010

3. What is Occupational Health and Safety ? Conditions and factors that affect, or could affect, the health and safety of employees or other workers (including temporary workers and contractor personnel), visitors, or any other person in the workplace (3.23) 01.05.2010

4. Hazard source, situation, or act with a potential for harm in terms of human injury or ill health (3.8), or a combination of these Hazard identification process of recognizing that a hazard (3.6) exists and defining its characteristics Ill health identifiable, adverse physical or mental condition arising from and/or made worse by a work activity and/or work‑related situation Terms and Definitions 01.05.2010

7. OHSAS Family of Standards 01.05.2010

8. OHS Family of Standards 01.05.2010

15. 01.05.2010 Hazard Identification and Risk Assessment 1 Physical hazards 2 Chemical hazards 3 Biological hazards 4 Psycho-social hazards Types of Hazard

16. Hazard Identification and Risk Assessment Likelihood of Occurrence 01.05.2010 Description Occurrence Ranking Likelihood of Occurrence Most Likely 6-7 Very high chances or likelihood of occurrence due to work activity, controls measures and process unpredictability etc Likely 4-5 Controls are in place still is it probable considering the nature of work activities or process. Remote 2-3 Due to unknown factors or system limitation or uncertainties , there is a remote likelihood of occurrence Unlikely 0-1 Not likely to happen or a very remote likelihood, Controlled and stable processes

17. 01.05.2010 Hazard Identification and Risk Assessment Severity Rating Description Severity Rating Definition Catastrophic 5-6 Permanent disability or fatality of persons, mass poisoning or contamination with cross boundary effect. Such as Atomic Power station failure, Tank farm or an entire facility on fire costing the entire facility which causing serious environmental damage causing health concern Critical 3-4 Condition which may cause serious personnel injury or ill health for a prolonged period ; severe occupational illness leading to chronic illness; Safety of People are seriously affected. Marginal 1- 2 Condition which may cause some minor injury or ill health and have potential if causing critical injuries or ill health unless controlled. Minor physical injury or momentary exposure with minor effect on OH&S

18. 01.05.2010 Hazard Identification and Risk Assessment Likelihood Severity Unacceptable Risk Moderate Risk Improbable/ Unlikely Marginal Critical Catastrophic Trivial Risk Acceptable Risk Moderate Risk Remote Acceptable Risk Moderate Risk Moderate Risk Likely Substantial Risk Most Likely Moderate Risk Unacceptable Risk Unacceptable Risk

20. IOCL Jaipur Tank Farm Fire 29 October 2009- Some Facts. IOC Jaipur fire due to lack of safety measures: Probe BS Reporter / New Delhi February 3, 2010, 0:24 IST The October fire at Indian Oil Corporation’s (IOC) Jaipur terminal was caused by the non-observance of normal safety procedures, according to the report of a committee set up by the government to probe the mishap. The fire raged for 11 days, killed 11 people and resulted in losses worth Rs 280 crore. “ The basic or root causes were an absence of site-specific written operating procedures, absence of leak-stopping devices from a remote location and insufficient understanding of hazards and risks and consequences,” said the report. The state and local civil authorities were alerted by IOC officials and within 30-45 minutes, personnel and agencies in the city and around had gathered at the site. However, the non-availability of self-contained breathing apparatus and fire suits left the entire response team helpless. Source of Information: Business Standard 01.05.2010

21. IOCL Jaipur Tank Farm Fire 29 October 2009- Some Facts. Petrol leakage at the depot continued for one hour and 20 minutes from tank no. 401A, which carried over 5,500 kl of petrol, before it caught fire...IOC personnel present at the site could not switch off the tank valve as petrol vapours suffocated them, while the switch at the control room was non-functional since 2003,” M B Lal, an industry veteran and head of the inquiry commission, told reporters. J B Verma, executive director of the Oil Industry Safety Directorate (OISD) and a member of the probe committee, said the directorate, in its audit during 2003, had found the remote switch was non-functional and had asked the company to get it rectified Source of Information: Business Standard 01.05.2010

22. 01.05.2010 Why Audit? IOCL Jaipur Tank Farm Fire 29 October 2009 What has Gone wrong? Could it be prevented ? An effective OH&S Management System as per BS OHSAS 18001 : 2007 Management standard implementation could have prevented this. -This is what I feel. What do you feel?

23. 01.05.2010 Why Audit? Was there an audit ? Was all recommendation Attended? Hazards Identified? Risk assessed? No Disaster management Plan and Emergency Preparedness- Govt. acknowledged that there was no Disaster Management plan- Early detection of hydrocarbon vapour and Communication System?- Leak Started at around 4 PM – Severe Vapor Cloud formed making breathing Difficult. Accident /explosion took place 7.30 OM Compliance to statutory requirements? Top Management Commitment to prevent accident incident? Communication of Hazards and Risks to interested parties? Operational Control ? In Normal and Abnormal Situations? Emergency communication?

24. 01.05.2010 Why Audit? Emergency preparedness ? Foam Spreader ? Fire monitor, Tank Cooling System? Accident Happened in the evening-Work environment-infrastructure adequate? Evidence of Root Cause analysis and Corrective actions? Tanks spacing ? Preventive maintenance ? Detection system of hydrocarbon vapour Emergency shutdown Adequacy of Firefighting system? A systematic Audit would have identified this areas of concern and possibly would have prevented the accident or prevented this catstrophy or could have mitigated the loss.

25. 01.05.2010 Disclaimer The incident of IOCL is brought for discussion based on information available in public domain such as Wikipedia and other public media This presentation does not include and make reference to any classified information about IOCL organization neither is the intent of this presentation. The case is discussed for sharing common and potential causes which can prevent similar catastrophe and save lives There are references to similar or even more catastrophic disasters and incidents in public domain such as Piper Alpha in North Sea published by BBC for public interest. Also there is reference to Woodward, Oklahoma Oil Storage Tank Fire, 12-10-08, Crude Oil Boilover Explosion which may be viewed for the “learning Lessons” form past incidents Our intent is that the lessons learnt make professionals aware of the risks and Hazards to ensure adequate control and save assets - property and life of People

26. Further Recommended Studies IRCA Registered OHSAS 18001:2007 Auditor Training Course by TCB The Course is in developmental stage . The case studies and workshops are designed based on high risk Oil and Gas Sector and a Typical Tank Farm Operator- A Storage facility of Petroleum product. The Course will be applied for IRCA Approval soon. TCB is an IRCA approved Training organization and offering IRCA Approved QMS Auditor/Lead Auditor training ISO 9001:2008 01.05.2010

29. Thank you for Listening 01.05.2010