LEARNING FROM INCIDENT Division TPDDL Date of

LEARNING FROM INCIDENT Division : TPDDL Date of Incident : 28 th July 2014 Type of incident : Fatal 1

CONTENTS 1. 2. 3. 4. 5. 6. 7. 8. Description Of Incident Pictorial Depiction Events Leading To Incident Events After Incident Observations Analysis Root Causes Recommendations 2

1. DESCRIPTION OF INCIDENT IRIS Reference : TPCL/DELHI DISTRIBUTION LIMITED/INJ/FY 15/5 Location : Pole no-423 -4/37/1/2, Khasra no-9340, Katra Ganaga Bishan, Gali Ghode Wali, Gaushala Road, Delhi Incident : Fatal Incident Date : 28 th July 2014 Incident Time: 02: 30 Hours (Approximately) Description of Incident : While repairing main service line (2 CX 25 mm 2), a lineman got an electric shock and lost his balance. As a result, he fell on the concrete road. Immediately he was taken to nearby Jeevan Mala hospital where the doctors tried their best to save his life but failed and declared him as Dead Deceased : Ram Charitra Yadav Designation: Lineman Business Associate : M/S IEC 3

2. Pictorial Depiction Congested Work Area 4 Deceased standing on wall

2. Pictorial Depiction Deceased accessed via staircase Street Light in the vicinity of work area 5

2. Pictorial Depiction Deceased Training 6

3. EVENTS LEADING TO INCIDENT 1. At approximately 00: 50 hours No Current Complaint (NCC) was forwarded by Telephone Operator (T. O. ) to the lineman 2. Lineman (Deceased) along with his Assistant Lineman (ALM) Mr. Deepak went to the site at Khasra no-9340, Katra Ganaga Bishan, Gali Ghode Wali, Gaushala road to attend this NCC 3. Pre-inspection at site, the lineman observed that the main service line (2 CX 25 mm 2) from pole no-423 -4/37/1/2 was burnt (Statement of ALM) 4. In order to repair the main service line he asked his ALM for switching off the LT supply to the area from DCM Garment Sub Station which is feeding to that particular area. 5. The lineman directed ALM to stay back at the sub station till he repairs the faulty service line 6. ALM switched off the LT Air Circuit Breaker (ACB) and confirmed the same to the lineman telephonically 7

3. EVENTS LEADING TO INCIDENT 7. At approximately 02: 21 hours an Outage Management System (OMS) ref no 2084915 was taken 8. ALM took almost half an hour to reach the sub station via long route due to closing of the main gate 9. The lineman didn’t ask ALM to switch off the street lighting of the site area which was from the other source sub station at Gaushala Baradari Substation 10. Deceased was wearing the helmet, safety shoes and safety gloves climbed up the staircase of nearby premises and was standing on a narrow wall (12 feet x 4 inches) without safety belt to repair the service cable 11. During the repairing, lineman removed his right hand glove to apply LT tape on the joint prepared by him and got an electric shock 8

4. EVENTS AFTER INCIDENT: 1. Deceased got an electric shock, screamed, lost his balance and fell on the concrete road. 2. Deceased became unconscious 3. No substantial external injury. 4. The local residents first tried to re-gain his consciousness by rubbing his hands and feet 5. The local residents realized that the lineman’s condition is not improving and very serious 6. Immediately they immediately rushed him to nearby Jeevan Mala hospital where the doctors tried their best to save his life but after some time they declared him as Dead 9

5. OBSERVATIONS 1. 25+ work experience of Deceased 2. Deceased attended training on : q 27. 05. 2013—Two days training in CENEPID-HOTT q 3. 11. 2013—One day training at CENEPID q 2. 02. 2014—Two days training at CENEPID-HOTT 3. Burnt cable was approximately 6 -8 feet away from the pole 4. Area is congested 5. The street lighting connection on the said pole was alive. 6. The ALM stayed back at the SS after informing the LM about the switching off of ACB. 7. The Lineman decided to work alone. This is in complete contravention to the process of attending No Current Complaints. 10

6. ANALYSIS Investigation team investigated the incident sequentially and the root causes were identified accordingly. 1. Inadequate recognition of hazard by the victim. 2. Clear process gap as ALM operated ACB for which he is not authorized 3. Violation of PPE usage and working at height 4. The Lineman worked alone as ALM stayed back at SS. 5. Overconfidence of the victim. 6. Death was due to electrocution. 11

7. ROOT CAUSES Human Factors: 1. 1 Violation by Individual – a)ALM operated Air Circuit Breaker (ACB) for which he was is not authorised. b)Deceased decided to work alone. 3. 2 Personal protective equipment not used – Deceased failed to use Safety Harness 4. 8 Routine activity without thought – Deceased failed to visualize surrounding hazards and risk as this was a routine activity. System Factors 5. 1 Inadequate guards or protective devices – Deceased stood on 12’ x 4” wall without using protective system i. e. Safety Harness 8. 1 Congestion or restricted motion – No easy access was available as the area is congested 12

7. ROOT CAUSES System Factors: 8. 3 Inadequate correction of prior hazard / incident – The joint in service cable should have been removed earlier. 14. 4 Inadequate enforcement of PSP (Inadequate monitoring of work) - The Lineman decided to work alone. This is in complete contravention to the process of attending No Current Complaints 13

8. RECOMMENDATION Sl CAPA details suggested Responsibility Timelines No Centre 1 Identification of poles with constraints ZM/DM/EICs Immediate based on physical/ GIS/OMS data and mapping in GIS for ensuring enhanced level of supervision while working on such poles and further action for rectification in phased manner, wherever possible. 2 Ensure working with PPEs , tool/ladder at all ZM/DM/EICs Immediate times and if a location is found where any one PPE, tool/ladder can not be used, the work to be stopped and inform ZSO/ZRDMO/ZM/EIC, who has to get the work done under supervision 14

8. RECOMMENDATION Sl CAPA details suggested No 3 Ensure no L/M works alone at any point of time. 4 ACB/LT switchgear to be operated only by a person having at least Secondary tagging list authorization. This is to be clarified to all Linemen, ALM, TOs and all zonal persons again in Safety talks/safety oaths/LSCs/Seekh sessions. 5 Ensure regular night audits of Linemen by BA supervisors/BA Safety Engineers/Zonal representatives. The schedule as per Annual Safety Plan to be enforced. Responsibility Timelines Centre ZM/DM/HOGs Immediate ZM/DM/HOGs, Immediate Safety Co Ordinator, Circle Safety in Charges 15

8. RECOMMENDATION Sl CAPA details suggested Responsibility Timelines No Centre 6 Training of TOs to be more cautious and DOSEC, 20. 09. 2014 SHE&DM responsive to Lineman’s activities. COS, 7 In long term hydraulic type ladders COS, 31. 03. 2015 retrofitted in small vehicles to be explored SHE&DM, Engine ering and implemented. 16

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