Efficaz Consulting & Solutions

Aug 2022
www.efficaz.in
 The Jaipur Oil Depot Fire broke out followed by Explosion on 29th of
October 2009 at the Indian Oil Corporation (IOC) at Sitapura Industrial
Area on the outskirts of Jaipur, Rajasthan

 Fire lasted for about 11 days after it started !

 The fire was a major disaster in terms of

 deaths,
 injury,
 loss of business,
 property
 man-days,
 displacement of people
 Legal issues
 And environmental impact in Jaipur, the capital city of the Indian state of Rajasthan.
 Factor Estimated Loss
Loss of Life 11 people
Injury 45 people
Compensation 30 lakhs for each life loss given by IOC and State Govt

10 to 20 lakhs for each injured person given

Material Damage 60,000 KL of Petroleum Product
Material Worth INR 500 Crores (today's value)
Property Damage Entire Depot Got Collapsed.
Off Site Emergency Impact Till 3km window glasses are damaged .
Public 400 crore public property damage instantly.
Production Loss of 200 crore per day, it continued for
a month.
 A Legal Notice has been issued to IOC for violating
 The Water Act 1974,
 The Air Act 1981,
 and The Environment Act, 1986 by Rajastan State Pollution Control Board

 FIR was filed against Directors by the Chief Judicial Magistrate on

 IPC 304 A (Causing death by negligence )
 IPC 166 (Public servant disobeying law )
 IPC 102 B (Punishment of criminal conspiracy)
 IPC 511 (Punishment for attempting to commit offences punishable with
imprisonment for life or other imprisonment)
 IPC 337 (causing hurt by act endangering life or personal safety of others)

 Many employees got arrested which includes operator, officer, mangers, general manager
and chief of operation

 Ordered to review the location of all Oil Terminals throughout India and shift these
terminals beyond city limits within a period of next 12–18 months.
 The incident occurred when Petrol & Kerosene
was being lined up from the IOCL oil depot
through a pipeline to the neighboring BPCL
Terminal, at 6:10 PM, a huge leak of the product
took place as jet of liquid from “Hammer Blind
Valve” on delivery line of the Petrol Tank.

 Oil depot’s giant tank holding 8,000 kilolitres of

petrol was leaking and at 7.30 PM fire incident
happened
 Absence of site specific written Operating
Procedure (SOP) on usage of Hammer
Blind Valve
 Valve leak was the trigger point of incident
 In HAZOP Study Report, not considered
about leak from this scenario
 Malfunction of leak stopping device like
Motor Operated Valve from past one year

 For manual operation- MOV station was not

at safe location
 In case of emergency it cant be used
 Dyke Drin Valve is in open position leading to
storm water. Hence open drain line given
more vapors.

 Drain Valve to ETP was in close position.

 In both cases, Hand wheels missing to

operate the valve.
 There was no gasket found in the Blind eye
of the Hammer Blind Valve , whereas the
Open eye was found with gasket, which
might have resulted in high flow of liquid
from the Bonnet of the Valve
 Drains near the Tank found with Thick Black
Soot marks, clearly indicating a drainage
channel failure.
 Drain valves (Spindle) of the dyke found to
be made of Brass instead of Cast Iron &
Ductile Iron.

 Incompatible material was selected

 Record on Mock Drill was not there
 IOCL claimed they were doing mock drills.

 Record does not had participants names to

whom they trained on Fire Fighting.
 In this site, electrical contractor suppose to
operate and maintain the Fire Fighting
Pumps.

 At second shift, only one person was present.

Two of its associates absent.

 Even after One and half hour from leak, fire

fighting was not started.
 Out of two, One Fire Fighting water tank was
completely empty.
 Every year External Safety Audit was not
conducted
 6 years back Audit done

 Previous Audit Report Pointed out lack of

training, issues with the valves etc.. These
points were not addressed.
 The “emergency and disaster management
plan” failed to indicate major leak resulting in
a large vapor cloud and the measures needed
to deal with it.
 Near miss reporting were not recorded.
 IOCL not aware and not planned for the
impact of maximum risk.
 Like QRA ( Quantitative Risk Assessment) not
done.
 The Shift log entry system found with no
efficient information about the next shift
control officer

 Communication gap between one shift to

other shift
 A Poor Performance of TFMS (Tank Farm
Management System) noticed with
mechanical float gauge showing wrong tank
dips measurements
 No accurate data, Radar Gauges or multiple point
measurement were not available
 One of the escape route from installation was
blocked by a wall which had been constructed
to close the gate

 Approachability of valves difficult due to

congestion.
 Human Factor Engineering was not considered
 Clear Separation Distance from one item to
other was not ensured
 Like distance between the Pump and Tanks are
not adequate
 At the time of accident
1st operator gone out

2nd Operator working for 16 hours from past 3 days

3rd Operator is emotionally stressed due to family

reasons
 From past 14 years of operations, in-charges
changed too frequently
 For one post, 8 persons were changed , high
attrition
 Accidents don't just happen, they
are caused due to multiple flaws at each
level. Lets commit safety at each level.

Source: M. B. Lal Committee Report

 List of Efficaz’s EHS Consulting Studies

 Fire Safety Chemical Safety Others:

• Chemical Compatibility Study
• Fire & Gas Detection Mapping Study • Human Factor Engineering and
• Respiratory Fit Testing
• Design Adequacy of Fire Protection System Ergonomic Studies
• Personal Exposure Study / Workplace
• Business Process Re-Engineering Monitoring Study /VOC Study / Chemical • Emergency Response Disaster
Exposure Monitoring Study / Industrial Hygiene Management Plan (ERDMP)
• Fire Load Calculations Monitoring Study / Occupational Exposure Limit
Testing (IDLH, STEL, TLV) • Statutory Safety Audit/Comprehensive
• Fire Risk Assessment /Fire Safety Audit Safety Audit
 Electrical Safety • Dust Explosion Study • Preparation or Vetting of On Site
• Arc Flash Study • Dispersion Modeling Emergency Plan
• Lightning Protection Study • (Flare, SRV, Dump tanks, Scrubbing Vent • Preparation or Vetting of Off Site
Hazards)
Emergency Plan
• Hazardous Area Zone Classification Study (HAC) • Minimum Ignition Energy Study (MIE)
(ATEX Study) • Incident Investigation
• Bulk Chemical Storage Risk Assessment
• Electrical Thermography Process Safety • Pre Occupancy Audit
• Electrical Safety Audit /Electrical Safety Audit • PSM Gap Analysis • Behavior Based Safety / Safety Culture
• Process Safety Management (PSM) Survey
• E HAZOP Implementation
• Industrial Hygiene Monitoring Study
• Inspection of Flameproof Electrical Equipments • Quantitative Risk Assessment (QRA)
• Static Electricity Study • Safety Integrity Level (SIL) Study / LOPA / • Security Vulnerability Assessment
Functional Safety (Security Audit)
• Energy Conservation Audit • Hazard Identification and Risk Assessment • Machinery Risk Assessment
 Civil Safety: (HIRA) /HARA / HAZID Study
• Hazard & Operability Study (HAZOP)
• Deputation of Safety Officer
• Building Structural Stability Study
• Pre-Startup Review • Logistics Risk Assessment
• Building Risk Assessment – using Non • Business Process Reengineering (inside or out side the plant truck
Destructive Testing (civil) • Business Continuity Plan movement) /
• PHSER Study • Process Hazard Analysis (PHA Study) • Marine Loss Minimization Study
• Project Risk Assessment • Job Safety Analysis
• COPE and Probable Maximum Loss
• Inspection behalf of insurance & Brokerage firms
• Erection Risk Assessment Study (PML) Study
(for under writing or value addition or safety
• Construction Site Safety Audit improvement)