Khargone Bibiyana South LMB

FATALITY ANALYSIS & PAST LMTG LTH

LESSONS
2019-2023
LTSL

Power IC / L&T Energy-Power

EHSCC

Nishil G. Jos
FY2022-23/ 30 October, 2023

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 Brief Details – Fatal Accidents in FY21-22

Project Name / Date of Brief description of accident, number of

Year Cause of Accident
Location / State accident fatalities

The scaffold gang was assigned to complete

installation of handrail on the platform. In the mean
FGD DVC time, rebar gang completed tool box talk and
2021-22 26.02.2022 Fall from Height
Raghunathpur entered the platform area and started tying works.
While exiting the platform DP fell from platform to
sand filled ground.

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 Brief Details – Fatal Accidents in FY20-21

Project Name / Date of Brief description of accident, number of

Year Cause of Accident
Location / State accident fatalities

While fixing a tie beam between 2 columns,

LMB, Ghatampur 22-Sep-20 another tie beam gave way and the column and tie- Fall from a height
beam fell down along-with the victim

During lowering of yoke assembly of slipform of

Chimney using pulley & PP rope arrangement, the
Entanglement with
FGD Lara, Raigarh 20-Feb-21 rigging crew lost grip of the rope resulting in its
2020-21 rope
acceleration and entangling the victim’s leg due to
which he fell down and got dragged.

Hit by moving
The garbage collection tractor ran over victim while vehicle
EPC, Buxar 28-Feb-21
taking a turn in the road inside the Labour Colony
(Tractor)

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Brief Details – Fatal Accidents - FY 2019-20

Project Name / Date of Brief description of accident, number of

FY Cause of Accident
Location / State accident fatalities

While climbing down from scaffolding working

NTPC, Tanda 23-Aug-19 platform to another, lost his balance and fell on Fall from height
the ground

While securing panels on the trailer, victim slipped Material Handling

& fell along-with 2 panels and got trapped
2019-20 LMB, Ghatampur 6-Jan-20 Trapped between
between the panel and the ground.
the object which fell
from the trailer

While removing the Office roof panel, victim Fall from height
RRUVNL, Chhabra 4-Mar-20
slipped and fell down from a height

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 FY 2023-24
H1 - Nil

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 FY 2022-23
NIL

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 FY 2021-22

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Brief details: Fatal Accident
(1/3)
Corrective /
Project Date of Type of
preventive actions
name / acciden Brief description of accident employmen Cause of accident
taken / planned
Location t t
with timelines
Direct Causes of the
Activity in progress was Column preparation at
incident:
Gypsum De-watering building. Mr. Ramesh Bauri • Investigation team and
(Deceased Person), Fitter and co-workers were • Work on incomplete Safety reinstatement
assigned task of tying rebar stirrups for RCC Scaffolding committee formed at
column at elevation 14.50 Meter. • Short cut of permit to work Power IC.
process
The scaffold gang was assigned to complete • 100% Anchoring of full body • Zero tolerance Policy
installation of handrail on the platform. In the harness has been adopted for
mean time, rebar gang completed tool box talk work at height
The Contributory Factors:
2x600 MW and entered the platform area and started tying noncompliance.
works. While exiting the platform DP fell from • Safety Culture – Acceptance
Raghunatpur platform to sand filled ground. of safety infringements • All Scaffolding
26.02.202 • Lack of demonstrated platforms are being re-
Contract
TPS, DVC – DP was immediately transferred to DVC Hospital Communication between inspected for
2 Raghunathpur site. Later he was transferred from supervisors improvements with
Raghunatpur, DVC Hospital to Sibani Seva Niketan Hospital Pvt. • Inadequate safety review Safe for use Scaff Tags.
Ltd, Katjuridanga More, Kenduadihi, Bankura. He before start up
West Bengal had pain and swelling in Right hand. At hospital • Lack of a competent • Skill & Competency of
doctor checked his physical condition and took X scaffolding Inspector scaffolders are being
ray. During observation period at Sibani hospital, reviewed.
The Root Causes:
doctor noticed sudden abnormality in physical
condition and victim was shifted to ICU. Repeated • Standing committee
• Systemic failure of safe start
attempts to resuscitate had failed and victim was will formulate safety
process- Pre-start review,
declared dead. culture improvement
Permit to work, Area site
plan.
supervision, Work Direction
and site preparation

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Brief details: Fatal Accident
(2/3)
Safe System of Work (SSOW) /
Reasons of failure
SOP updated
Lessons learned
Human failure Process / Yes / No
(worker / supervisor / Managerial) System (If Yes, reference no.)
Yes, SOP & Method statement for
Managerial Process Refer CAPA
scaffolding erection

Family details and Accident location photograph

Name of the victim Age
address

Mr. Ramesh Bauri Unmarried

Working for M/s Sri Ma 24 Years

Address: Purulia,
Engineering West Bengal

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Corrective Actions (3/3)

Immediate preventive actions : 7 days Action Plan

 72 hrs. action plan to improve working platforms (Clean up platform/housekeeping)

 Zero tolerance on safety non-compliances
 Refresher training to address behavioral aspects
 Repeat on all sites

Medium Term Correction : 21 days

 Committee set-up to revisit key impact area for reinforcement
 Develop a safety roadmap

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 FY 2020-21

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 Fatal Incident- EPC Buxar Labour Colony – Q4
1/4
Date & Time of Accident : 28.02.2021, 11.45 AM

Details of the Person Injured : Mr. RAJKUMAR

Vill. - Saurabh, Distt. – Ghazipur, State – Uttara Pradesh, Pin
Code - 233302
30 Years (Married and having 02 children)
Working for M/s Yogendra Prajapati
Location of Accident : Labour Colony
Incident Brief:
On dated 28.02.2021, around 11.45 AM an incident has took place in labour colony
where a tractor ran over a workman (Mr. Rajkumar) while taking turn inside colony
road, resulting in victim succumbing to his injury.

The tractor was deployed for disposal of garbage at Labour colony. While the tractor
was inside the colony and taking right turn near a drain, it came across the victim
who was crossing in front of the vehicle. Driver of the tractor could not control the
movement of the tractor and one wheel ran over the victim.

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 Incident Brief
2/4

Victim Victim was hit by tractor at

head light Position and
tractor front right wheel
ran over the victim,
resulting in death.

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 Incident Brief
3/4

The victim was hit by the front-left light

before fell on ground and ran over the
front-left wheel of the tractor

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 Incident Brief
4/4

Road and Turning

from where the
vehicle moved
through

Position of vehicle
immediately after
the incident

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FGD Lara Site - Fatal Incident – Q4
1/6
• Date & Time of Accident : 20th February 2021, 5:50 PM

• Details of the person injured : Mr. Sheikh Afroj

State – Raigarh, Chhattisgarh
28 Years - (Married & having 2 children)
Working for M/s. Dilip Choudhury Pvt.Ltd

• Site Location : Chimney #1, Slip form top deck (144

meter elevation)

• Scope of project work : FGD Lara Project Site

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Incident Brief
2/6
Dismantling of slipform work was being done by a rigging crew of 5 persons at top deck (144 meter elevation) of Chimne#1.
They were removing yoke assembly weighing approx. 450 kg.

They were handling and lowering it by using 25 mm dia. PP rope and pulley arrangement. While guiding the rope, the rigging
crew lost the grip over the rope.

As a result, the rope got accelerated and the loose end of PP rope, which was lying on the platform in a coil form, got
entangled on the victim’s feet and he fell and was dragged.

While being dragged, he hit the rigging crew members on his way and they also fell. The victim’s leg got stuck in the adjacent
structure. This sudden jerk resulted in the severing of his left leg below the knee and suspected injury on his head.

Due to this impact, the temporary rope restraining rod on which the rope was wound before the pulley, broke from its welding
and the rope also got cut. As a result, the yoke assembly fell from a height of approx. 100 meters and got damaged.

The Victim was rushed to Metro hospital where he was declared brought dead.

In addition, one of the rigging crew members, Mr. Sahid Anwar Ansari, Khalasi of M/s. Dilip Chaudhari, aged 21 years, suffered
a hairline crack on his left foot and cut injury on his forehead as he fell on the floor.

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Incident Brief
3/6

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Incident Brief
4/6

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What went wrong ? 5/6
Causes of the accident:
Technical:
Unsafe Action
• Wrong and unsafe practice adopted of lowering heavy assembly of 450 kg. by using pulley and rope
arrangement instead of using winch, diversion pulleys and wire rope.
• Speeding up the process of lowering by releasing the rope faster which resulted in its uncontrolled
acceleration.

Site Conditions
• The temporary rope restraining rod was fixed by tag welding and was not having adequate strength to
take the impact load.

Management:
• Allowing the work to be carried out by adopting wrong and unsafe practice of lowering heavy assembly by
pulley and rope arrangement.
• Not followed the emergency protocol of ensuring transport of victim after providing first aid and/or with
proper first aid measures.

Job Factors:
• The spoke assembly was too big and heavy and should have been partially dismantled and handled by
Winch & diversion pulley & wire rope arrangement only as is followed for this activity.
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What is being done to prevent reoccurrence ?
6/6
• Comprehensive Method Statement of Slip-form dismantling to be developed by technical expert
team in close consultation with execution members and implemented after approval of Client.
• Based on the Method statement, SOPs, JSA, checklists to be developed and implemented for
dismantling activity for slip-form assembly.
• Supervision to be strengthened during the critical to safety activities like slipform dismantling.
• Emergency Plan for safe transport of injured to be followed.
• Rigging crew of the Contractor to be changed.

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Ghatampur Site - Fatal Incident – Q2
1/9
• Date & Time of Accident : 22nd September 2020, 7:35 PM

• Details of the person injured : Mr. Kewal Singh

State - Punjab
41 Years - (Married & having 2 children)
Working for M/s. Kunal Global Fabtech Pvt.Ltd

• Site Location : Boiler Unit#1, Back end duct (ESP to

Chimney), Ghatampur

• Scope of project work : LMB, Ghatampur Site

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Incident Brief
2/9
During the Backend Duct Support erection for unit 1, a tie-beam at a height of 5 meter between
two columns (18 meter Height each) was being erected by a team of 6 workmen of M/s. Kunal
Global Fabtech Pvt. Ltd.

To insert the tie-beam (held by a crane) between the 2 columns, the foundation bolts and nuts of
one column were loosened and a wedge was inserted and hammered to create the gap between
the columns. The victim had gone to the scaffolding platform at a height of 9 meter, to check the
proper placement of beam inside the columns.

This loosened column was already stitch welded to another tie-beam at 9 meter. During this
process of hammering of the wedge, the other end of this tie beam gave way and the column and
the tie-beam fell down.

As a result, the victim also fell along-with the column and his head was trapped between the
column and beam. He succumbed to his head injury.
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Incident Brief
3/9

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Incident Brief
4/9
ESP Side

ID Fan Side

C-1
C-2
C-4 C-3

B-1

B-3 B-2

B-4

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Incident Brief
5/9
Erection of C-4 (preassembled 18Mtr with splice
joint at 11 Mtr and 1.729MT total weight with 2
nos. guy ropes at 180 deg, two cages and a
ladder

Erection of B-3 Tie Beam of weight 1.191 MT,

tack welded with C-3 and C-4 at 9Mtr elevation,
without inserting erection bolts

Inserting B-4 Beam of 0.424 MT at 5Mtr

Elevation between the C-1 and C-4. Column was
having I Section with webs facing the beam, it
rested one side on C-1 and gas was required to
be created towards Column C-4.

The victim instructed fitter to loose the

foundation bolts and hammer wedges at bottom
to move the column outward for creating the
gap

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Incident Brief
6/9
There was a build up of huge tension on
members shown in yellow, the Column C-4
and B-3 (which was tack welded on both side
with columns) due to the gap which was
created for insertion of beam B-4.

This stress resulted in breaking of the tack

welding in column C-3 with a huge jerk, thus
making the column C-4 unstable, while the
crane was still holding the beam B-4

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Incident Brief
7/9

The beam B-3, B3214 fell down with the

column and the victim’s head hit the
beam’s flange at the side and eventually
got stuck between the beam flange and
the ladder welded with the column

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What went wrong ? 8/9
Causes of the accident:
Technical:
1. Job specific ‘Method Statement’ with detailed sequence of erection was not prepared
2. Only 2 nos. guy ropes were placed at 180 deg, not following the approved procedure of minimum 3
nos. (tied at 120 deg) or 4 nos. (tied at 90 deg)
3. Erection bolts for fixing of beams B1324 were not used. Only stitch welding was done at both ends
with the column C1314 and C1313 at 9m elevation
4. Wedges were inserted and hammered while person was still on the column

Behavioral:
5. The victim, a ‘Sikh’ person was wearing full ‘pagri’ but no helmet, although he was wearing harness
and safety shoes and his harness was latched to column
6. The victim was advised by the fitter to come down from the column, which he refused

Supervision:
7. The concerned package engineer, safety supervisor and erection manager did not comply with the
erection procedures, considering these light structures a low risk activity as compared to the heavy
boiler structures
8. Proper area lighting was not ensured for late evening activity

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What is being done to prevent reoccurrence ?
9/9
1. Method statement, with details of erection sequence, alignment and job completion
must be prepared for all erection activities before start of work
2. Safe erection procedure must be emphasized during ‘tool box talk’
3. Proper area lighting and supervision must be ensured for late shifts
4. Guy ropes must be placed as per approved procedure, minimum 3 ropes at 120 degrees
or 4 ropes at 90 degrees
5. Guy ropes with chain blocks would eliminate the need for wedging and hammering
6. Wedging and hammering must not be done when person is still on the columns
7. Erection bolts must always be provided for placement and alignment of beams
8. Full welding must be carried out immediately after completion of alignment
9. Package Engineer, Unit In-charge, Head mechanical, Erection in-charge, Safety In-
charge and Quality In-charge must carry out a weekly walk-through at site to cover all
aspects related to technical, completeness, quality and safety
10. Vigorous training related to construction principles must be conducted at site
11. Quarterly training of LMB employees, third party supervisors and erection gangs of
contractor must be made mandatory

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 FY 2019-20

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 Tanda - Fatal Incident

• Date & Time of Accident : 23rd August 2019, 2:40 PM

• Details of the person injured : Mr. Ravi Shanker

Village – Basuka, District – Gazipur, UP

26 Years (Married & having 2 children)

Working for M/s. Taj Constructions

• Site : ESP outlet duct near ID Fan 6A

Tanda

• Scope of project work : NTPC Tanda STPP – Stage II (2X660MW)

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 Incident Brief

• At NTPC Tanda project, on 23rd August 2019, a gang of 15 workmen were engaged for ESP duct
alignment and final fit-up activities.
• For carrying out this activity, several temporary scaffold platforms comprising of 2 or 3 nos.
scaffolding planks were built at different locations and elevations over the external surface of the
duct.
• Post lunch session, it was required to lower the gas cutting set along-with gas pipe from one of the
scaffolding working platform. Around 2.40 PM, the victim lowered the gas cutting set by standing on
one of the scaffolding platform.
• After completing lowering of the gas cutting set, he started climbing down the platforms one after
another and during this process, lost his balance and fell on the ground from approx. 20 meter
height to ground level.
• He became unconscious and was rushed to NTPC Hospital immediately where he was declared as
brought dead by the Hospital authorities.

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 Incident Brief

Persons are
entering here

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 Incident Brief
The victim removed the
gas torch from this
platform, lowered it &
gave it to fitter. Then,
he started climbing Access ladder
down from one platform +
to another Life Line
+
Guard rails
not provided
While trying to climb
for safe access &
down from this
work on
platform, the victim fell
temporary
down.
working
platforms

Safety net
not provided
Below the
bottom working
platform Life Line

After receiving the gas

cutting torch set, the
fitter went inside the
platform which is under
the duct.

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 What Went wrong ?

Causes of the accident:

A. Unsafe Action
• Allowing the work to be carried out at height without access ladder, life line, safety net,
etc.

B. Unsafe Condition
• Rope & pulley arrangement was not adopted to lower / shift the gas cutting set & pipes.

• There was no life line available in the temporary platform from where the victim fell
down. The lifeline was below this platform.

• No Safety net was provided as a secondary protection measure.

• Unsecured temporary scaffolding platform without railings and toe-guards.

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 What is being done to prevent reoccurrence?

Corrective Actions:

 Remove all temporary scaffold structures which are not in use.

 Secure all platforms with top and middle rails and toe guards at all elevations as per the
requirement of green Scafftag.
 Provide life lines at each and every temporary working platform.
 Provide proper access ladders for scaffolding platforms at different elevations.
 Install Safety nets as secondary protection without fail.
 Only authorized scaffolding inspecting personnel to verify the scaffolding structure. List of
authorized persons to be released.
 Sensitize all the workmen regarding the hazards related to fall of person, material, and importance
of adherence to protocol of working at height and permit system.
 RCM to review minimum two work permits on a daily basis from adequacy of the measures.

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 Ghatampur Site - Fatal Incident

• Date & Time of Accident : 6th January 2020, 12:50 PM

• Details of the person injured : Mr. Ramchandra Yadav

State - Bihar

41 Years - (Married & having 3 children)

Working for M/s. Jai Maa Sarada

• Site : APH Basket Store, Ghatampur

• Scope of project work : LMB, Ghatampur Site

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 Incident Brief

• At Ghatampur project site, on 6th January, 2020, activity of loading of

duct panels on a trailer was being carried out.
• After completion of loading all the duct panels on the trailer, the
victim climbed up on the duct panels for tying the material with
trailer using ratchet plate.
• During this process, two duct panels weighing around 758 kg each
slipped out of wand & one of the duct panel fell down from the trailer
along-with the victim.
• Victim got trapped between the panel and the ground.
• His legs and other parts of the body got injured.
• He was rushed to Lala Lajpat Hospital (Kanpur) for medical
treatment. After examining him, the doctor declared him dead.

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 Incident Brief

Workman

Duct Panel
Material
Workman

Trailer
vehicle

Duct Panel slided and Fell down along-with Victim. He got trapped
between panel and ground

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 What went wrong & Counter-measures

Causes of the accident:

Unsafe Condition

• Inclined condition of loaded stack of duct panels

• No packing provided to level up the inclined loaded stack of

panels

Corrective Action:
Counter-measures:

• Stoppers will be provided at all the sides of the trailers.

• Guidelines for loading and unloading of uneven shape material

made.

• Competency of the workmen will be verified by LMB Engineer

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 Chhabra Site - Fatal Incident

• Date & Time of Accident : 4th March 2020, 11:30 AM

• Details of the person injured : Mr. Yasin

Shahpur Kalan, Amroha, Hasanpur, UP

45 Years (Married & having 5 children)

Working for M/s. Synergy Thrislington
Instacon Pvt. Ltd.

• Site : L&T Site Office in front of the

present L&T Project Office, Chhabra,
Rajasthan

• Scope of project work : 2X660 MW RRUVNL Chhabra TPS

(Stage – II)

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 Incident Brief

• M/s. Synergy Thrislington Instacon Pvt. Ltd. was given the contract to
dismantling and shifting work of site office at Chhabra Project Site.
• A team of 6 nos. workmen were doing the dismantling activity under
one Supervisor.
• On 04.03.2020 around 11.30 AM, the Victim was working without
securing himself on the structure frame for removing the frame.
While doing so, he slipped and fell down from a height of 2.75 meters
and sustained head injury.
• He was taken RRUVNL Medical Centre After getting the necessary
first-aid, he was referred to Chhabra Hospital.
• After getting initial treatment, he was referred to MBS Hospital, Kota.
He was declared brought dead by MBS Hospital, Kota

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 Incident Brief

Workman
Frame
Structure of
Site Office
being
dismantled

Duct Panel slided and Fell down along-with Victim. He got trapped
between panel and ground

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 What went wrong?

Causes of the accident:

A. Unsafe Action
• Allowing the work to be carried out at height without
access ladder.

• Victim was not wearing Safety Helmet during the

activity and did not secure himself.

B. Unsafe Condition
• Loose frame of the structure.

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 What is being done to prevent reoccurrence?

Corrective Actions:
• Plan the dismantling methodology with the Contractor considering all the site specific
hazards and associated risks, specially the risk of fall and collapse of structure.

• Provide proper access ladder / platform to carry out the dismantling activity and ensure that
the workers are always wearing the required PPEs.

• Explore the feasibility of safe anchoring on a independent stable structure.

• Remove all the debris from the site on regular basis.

• Ensure the competency of all the workmen being deployed by the Contractor

• Sensitize all the workmen regarding the hazards related to fall of person, material, and
importance of adherence to protocol of working at height and permit system.

• Ensure supervision and monitoring of the activity.

TECHNOLOGY | ENGINEERING | MANUFACTURING | CONSTRUCTION | LIFE CYCLE SERVICES

Sensitivity : This Document is Classified as "LNT Internal Use".
 High Risk Activity ( HSR Groups) Where Fatalities have occurred
Group Number Group Element
GROUP – I (4) • Working in & around (Existing utilities) Underground & Overhead Services
• Working adjacent to operational facilities
• Working with electricity (Brown field risks/Electrocution/Unauthorized shutdown works)
• Working adjacent to or near Public Areas
GROUP –II (3) • Operation of Cranes and other lifting machinery (Collapse / Malfunction of those equipment)
• Vehicles, Plant & Equipment
• Commissioning of Heavy Structure/ equipment

GROUP –III (3) • Hot work/Fire / Explosion

• Handling and storage of explosives/ Blasting
• Radiography Works
GROUP – IV (4) • Temporary Works/ Formwork/ Scaffold
• Work at Height
• Precast Elements Lifting
• Demolition works / Major dismantling works
GROUP – V (2) • Material Transportation & Erection
• Material Handling
GROUP – VI (2) • Excavation
• Piling
GROUP – VII (2) • Working over or adjacent to water
• Barge Movement
GROUP – VIII (2) • Tunnel
• Confined space
GROUP – IX (2) • Behaviour Based Safety
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Sensitivity : This Document is Classified as "LNT Internal Use".

 Thank You…

Together we succeed!
STRONG FINISH 2023

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Sensitivity : This Document is Classified as "LNT Internal Use".