-near Miss-back Fire From Flash Back Arrester- - DOCX Download - CiteHR
Boss2966
Industrial Relations
Raghuvaran Chakkaravarthy
Environmental, Health And Safety
Hansa Vyas
A Good Learner Always
Tajsateesh
Recruitment/talent Acquisition, Career Counselling
Vviji75
Health And Safety

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Dear All FYI,

On 7th July 2014 @05:10 PM, HDS,Sub Contractor of XYZ Gas cutter Mr. Chandra Pal was engaged in Chanel cutting with gas cutting set in ABC Fabrication yard at ground level. Flash back arresters (FBA) were fixed both sides (cylinder & torch). During the Gas cutting job, unfortunately Oxygen Hose pipe blasted with fire, due to Back fire from torch, distance was approx 1.5 meter from torch ,immediate the gas cutter control the situation and loose all pressure gauge and release the pressure of hose pipe from torch, Nobody got injured.(Photo Attached)

Investigation Report-

After opened the FBA-Flash back Arrester, we found that back fire control system of FBA was not proper.

The spring and Nozzle which controls the back fire, not given by manufacturer in FBA



Action Require/Taken

-Use Only ISO Marked FBA & All Gas cutting set material.

-All Flash Back Arrester-FBA working system Should be check before issue from store

-Awareness Training to be conduct for all gas cutter by HSE Department as well as possible by manufacturer

-Check all FBA Back fire control System at site/plant which using.

If you have more idea for back fire protection ,Please input your suggestions......


Attached Files
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File Type: docx PHOTOS-Near Miss.docx (159.7 KB, 317 views)

Dear C.R.Siani,

Your clearly addressed on your investigation report that 100% its happened because of manufacturer defect.

Did you notice this issue to manufacturer?

Did you read the manufacturer O&M manual for FBA?

Did you have the proof of training documents that you provided to your employees on this equipment?

Are you sure it will not happen in ISO marked FBA’s?

How do you check the FBA working system – Who is responsible to check?

For your info - FBA’s are generally reliable in performing the intended function so long as the device is used according to the manufacturer’s instructions. If an end-user neglects or ignores the manufacturer’s stated or published safety and maintenance recommendations, that person is an accident waiting to happen and no accessory safety device will prevent all possible accidents. As one who has handled accident litigation cases for the past several years, I can state unequivocally that most oxy-fuel accidents are caused not by equipment malfunction, but by user neglect, impatience or lack of experience in using equipment safely.

Do me a favor provide me a details of FBA that you used on your plant/work site. I will talk to the manufacturer get some information which will help to educate ourselves.

According to your report - Action required should include the below points:

Manufacture manual should be available on-site or practically accessible; whoever operating the equipment should go through the O&M manual prior to operating the equipment – (It should be supervisor and EHS personnel’s responsible).

Appropriate training should be provided to all personnel’s whoever involve with this task – As per manufacturer requirement (Its should be management and safety responsibility).

Choose the right materials for the task

manufacturer instruction should be followed whenever operating the equipment

I don’t think it’s a small issue if it’s really a manufacturer defect am sure I’ll bring that issue to next level without involving you please provide me a details that’s what I need from you.

I’m eagerly looking forward your reply if you’re not comfortable to share the info in social network – I’m available at

Thanks in advance.

Dear All,
FBA should comply IS 11006-1984. But i never seen any IS certified FBA in India. Most of us using FBA which normally act just as a NRV. Some of the Branded items are complied with EN 730. At the same time. they are manufacturing the product with different serial number which is not complying IS or EN code. So, we should aware and careful while selecting a product.
Thanks

Dear Raghu,
I would also like to add one more point here which i doubt might have also been there. It is also to be investigated that was it repaired in-house or by any one who is not authorized to do so.Its maintenance history should also be checked along with points that you mentioned above.
Also if you have FBA of same make used by other contractors, should also be checked for the same.
Regards,
Hansa Vyas

Dear Hansa,
Welcome back! Your'e right.
I spoke to some technical experts back in states. I wrote a email to Mr.Saini he provided manufacturer details but am not able to find them online so have to get some more details from him again as quick as i get the information which i need will contact manufacturer and find out the real cause of accident - If its manufacturer defect am sure i will take it to next level banned that product in market. will see....

That's the reason we are insisting to use the standard product of Flash Back Arrester while doing cutting and welding activity. If the Flash Back arrester is not working properly then it may endanger the lives of so many people working around the area.
To the extent I know about FBAs, I think Hansa Vyas's hunch is right--more of an O&M issue than related to the Manufacturer.
We Indians are known world-over for what we call 'Jugaad'--improvising.
But I know that, many times, we go overboard even when the necessary Tools / Systems / SOPs are in-place.
Anyway, let's wait for Raghu's inputs.
Rgds,
TS

Team,
I can't find the vendor contact details through product name however, I chat with Mr.Siani as per our conversation on this issue they contacted service engineer who came to visit the site but i haven't get service engineer comments from Mr.Siani as soon as i get that report will get the service engineer contact number from Mr.Siani which will easy to communicate and move forward on this issue.
Additionally - I spoke to Mr.Suman Das who is working for HIND MEDICO PRODUCT. He offered a site visit to his factory as well.
HIND MEDICO PRODUCT
(An ISO 9001:2000 Certified Company)
3/1, Ashutosh Mukherjee Road, Belurmath, Howrah, West Bengal, India 711202
Contact:91-9836848888, 91-33-26548185, 26544766, Fax: 26542251,
Email: ,
Website: Gas Cutting Equipments,Welding Gas Equipment Manufacturer,Personal Protective Equipments Supplier
Will update further on this subject matter.

Dear Members,
FYI,We have changed all FBA at site ,
Thanks to All, and special thanks to Mr.Raghu, who did investigation deeply.
I have discussed to our Project head for send MOM copy to our team for more investigation, He is not allowing for MOM & visit another agency at site .We have limitations.
So sorry I can’t send Company’s document.(I have given company name ABC in Report)
Thanks to all again……………………………………………………………..

Dear Raghu,
The FBA shown in the website is not FBA. It is just a NRV and am sure it is not ISI certified. The FBA should have
1. Flame arrestor
2. NRV
3. Temperature sensitive cut-off valve
4. Pressure sensitive cut-off valve
Pls let me know if i am wrong. and looking forward comments from our senior members.


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