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Team Members:: Aryan Raj Snoihik Chakraborty Aashutosh Pathak

The document details a fatal incident at the IOCL LPG Bottling Plant in Ujjain on October 10, 2021, where two workers fell into a degassed bullet tank during maintenance, highlighting serious safety lapses and non-compliance with Standard Operating Procedures (SOP). Key issues identified include lack of supervision, inadequate training, and failure to use personal protective equipment, leading to potential health risks and hazards associated with LPG. Recommendations for improving safety include better training, adherence to SOPs, and regulatory oversight of LPG plants.

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10 views22 pages

Team Members:: Aryan Raj Snoihik Chakraborty Aashutosh Pathak

The document details a fatal incident at the IOCL LPG Bottling Plant in Ujjain on October 10, 2021, where two workers fell into a degassed bullet tank during maintenance, highlighting serious safety lapses and non-compliance with Standard Operating Procedures (SOP). Key issues identified include lack of supervision, inadequate training, and failure to use personal protective equipment, leading to potential health risks and hazards associated with LPG. Recommendations for improving safety include better training, adherence to SOPs, and regulatory oversight of LPG plants.

Uploaded by

snoihik2004
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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TEAM

TEAM MEMBERS :
ARYAN RAJ
SNOIHIK CHAKRABORTY
AASHUTOSH PATHAK
Problem Statement
The incident that occurred on 10th October 2021
in IOCL,UJJAIN LPG Bottling Plant, involving a fatal
incident, has raised serious concerns and
necessitates a Comprehensive investigation
WHAT IS A LPG BOTTLING PLANT?

• LPG bottling plant is the place where LPG is stored


in bulk (large quantity) and distributes in small
quantity through small cylinders
• It receives bulk LPG via pipelines from source
WHAT? WHEN? WHERE?
• HOW?
Two workers fell inside the degassed bullet tank on
October 10th,2021
• Incident happened during maintenance of the 150-
tonne bullet tank
• Its contents were to be flushed out using high pressure
water
• One of the labourer peeped through a 21-inch
opening to check flow of water but slipped
and fell inside the tank due to inhaling poisonous gases
escaping through it
• The second labourers went to check on him and also fell in
• The rescue team didn’t even use torches or oxygen cylinders
to enter the tank, due to fear of inflammable gases

:- The ‘Bullet Tank’

Picture from the day of incident


:- The IOCL bottling plant is located in Ghattia tehsil of Ujjain district in
Madhya Pradesh, India.

Inside view of the Ujjain LPG Bottling Plant


Satellite view of the Plant
What is sop?
• Standard Operating Procedure
• These are stepwise guidelines laid down by
organization to enable employees to perform
assigned tasks
• These are main principles that must be followed,
neglecting which accidents occur
• Very much important in petroleum, LPG, gas plants
Sop of the job
1. Empty out the LPG bullet tank
2. De-pressurize the bullet tank
3. Degassing (removal of dissolved gases from liquids)
4. Water draining
5. Check LEL(Lower Explosive Limit) Inside Bullet Tank
6. Use magnetic level gauge (it is used for measuring the level of fluid inside tank)
7. Hydro test the BULLET TANK (filling the tank with water)
8. BULLET TANK Commissioning SOP
Actual Procedure followed
1. Empty out the LPG bullet tank
2. De-pressurize the bullet tank
3. Degassing and Water filling
4. Water draining
5. Check LEL(Lower Explosive Limit) Inside Bullet
Tank
6. Magnetic Level Gauge
LAPSES/OBSERVATIONS
1.Non compliance of Standard operation
procedures(SOP).
2.Lack of supervision by IOCL personnel and contractor.
3.Non – compliance of Work Permit System.
4.Emergency handling response.
5.Lack of exposure/proper training of IOCL officers
6.Access control/gate pass system for personnel.
ROOT CAUSE OF EVENT
 Human Error :
• Workers did not follow the SOP
• No Regulatory Body that checks whether SOP is
followed or not
• Low “TECHNICALLY SKILLED” workers
Lack of supervision and short cuts adopted
to do work in a hurry.
ROOT CAUSE OF EVENT
 Safety Lapse and Equipment failure :
• Leakage of LPG from Valves
• Pressure relief valve malfunction
• No use Personal Protective Equipment (PPE)
such as respirators
IMPACTS OF LPG LEAK
 Short Term Exposure Effect
• Rapid Oxygen Depletion
• Suffocation for workers
• Hypoxia
• Increased Risk of Fire Explosion
• Shock-wave effect
IMPACTS OF LPG LEAK
 Long Term Exposure Effects
• Health issue like Asphyxiation and Heart problems
• High risk of loss of life
• Fugitive emission during LPG transportation
can cause Air Pollution
IMPACT OF FLASH FIRE DURING LPG LEAK
POSSIBLE HAZARDS of lpg plant
• Boiling Liquid Expanding Vapour Explosion

• Since LPGs are stored at pressure range between 2-9 bar , its
sudden expansion can leads to explosion
• Fire and Explosion Hazard
• Overfilling of cylinders can cause leaks and ruptures
• At high concentrations, LPG mixed with air can be anasthetic,
leading to asphyxiation
POSSIBLE HAZARDS of lpg plant
• In bottling plants, one hazard can be that smaller LPG cyclinders
should be filled carefully as it is going directly for public use

• During the transportation of LPG from trucks, make sure to discharge


the static electricity from tank

• One more possible hazard is during the transmission of LPG


through pipelines, trains and trucks
HAZARD assesment
• HAZARD IDENTIFICATION
• RISK ASSESMENT
• JOB SAFETY ANALYSIS
• CATEGORIES FOR LIKELIHOOD OF HARM
STEPS TO COUNTER
HAZARDS
• Only well trained individuals and staff members
should be there for handling LPG plant
• Following the SOP provided
• Personal protective equipments should be kept
• All machineries should be examined on regular
basis
• Fire fighting/sprinkler system should be installed
REGULATORY IMPROVEMENTS
• LPG Bottling Plants should be located away
from the densely populated area
• LPG Bottling plant should be a single storey building with
proper ventilation
• Appointment of a committee that keep checks on
the compliance of SOP and other safety measures
• Escape routes should be marked for evacuation of workers
TEAM

THANK YOU

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