REPORT OF CASE STUDIES IN THE STATE OF MEGHALAYA

(DURING THE PAST 15 YEARS)

 

 

CASE STUDY - 1

 

Name of accident           

 

Cut injury; right and left thumbs.

 

Category of accident

 

Non fatal

 

Description

 

An accident had occurred on 10-7-1991 in a printing press factory in East Khasi Hills District. The accident took place in a paper cutting machinery

 

Causes

 

During normal operation, a worker has to apply right  foot’s pressure on a foot, paddle so that the cutting blades comes ­down and cuts the papers as desired but before taking, out these cut papers, the foot paddle has to be released so that the cutt­ing edge/blade lifts upwards.  However, in the present case after he had released the paddle, unfortunately the cutting blade got stuck at half the vertical range by itself; the victim was not ­aware of the situation while taking out the cut papers and the blade suddenly came down and cut his both thumbs seriously. This accident was caused due to the fact that the locking device of the machine was out of order and did not function properly.  Also, there was an inbuilt “Safety Bar" interlocked with the machine which automatically pushes the hands of the worker away should the worker accidentally put his hands under the blade while it descends for cutting purpose. This safety device was also out of order.

 

Advice

 

The factory occupier was advised not to allow the machine to be operated till the above defects were rectified

 

 

CASE STUDY  -  2

 

Name of accident

 

Burn injuries received on legs, arms, knee-joint, right side of cheek, neck and ear and also a small portion of the abdomen

 

Category of accident

 

Non fatal

 

Description

 

An accident had occurred on 18-2-1992 in a coal mill-department of a cement plant in East Khasi Hills  District.

 

Causes

 

The hot air alongwith coal dust coming from the furnace, enters the duct (in the hot air ducting process) and there is a hopper below the duct which has a close-open plate for clearing/cleaning purposes. The accident took place when the injured person was opening the plate by pulling, to allow the coal dust collected in the hopper to fall down.  But unfortunately the coal dust caught fire and while coming out it came into contact. with his knees, legs, arms, etc because as the plate is situated at a lower/knee level, a person has to bend his body for the said work.

 

Advice

 

Erection pf a cell concrete wall of required specifications to restrict the consequences incase of any such fire or hot. Substances was advised so as not to cause any hindrances/operational difficulties or accidents.

 

 

CASE STUDY - 3

 

Name of accident

 

Cut, fracture and swelling injuries.

 

Category of accident

 

Non fatal

 

Description

 

An accident had occurred on in a coal dryer department of a cement factory situated in East Khasi Hills  District.

 

Causes :

 

The accident took place while the injured person was cleaning the slippery coating (substance) which appears on the surface of the revolving drum due to continuous rubbing between the drum and the hopper-discharge belt. His intention was to produce more friction (i.e. increase the co-efficient of friction) between the two contact surfaces i.e. the belt and the drum hence he used an iron rod and started hitting or tapping with its tip on the    surface of the revolving drum, but unfortunately, in doing so the rod slipped and his right hand was dragged in between the moving drum and belt. This happened because of the short, length of the rod he was using and consequently he had to extend his hand beyond the moving edge of the discharge belt.

 

Advice :

 

In order to avoid such type of accident the following ­ advice was given : ­

 

1.            An iron rod of. suitable length is to be used so that a person can operate/do such job from a safe distance away from ­the moving edge of the conveyor belt.

 

2.            Fencing of the hopper discharge belt is necessary in such a manner so as not to cause any hindrance from operational point of view.

 

CASE STUDY - 4

 

Name of accident

 

Cut injury

 

Category of accident

 

Non fatal

 

Description

 

An accident had occurred in the kiln Department of a cement factory situated in East Khasi Hills  District on 24-12-1993.

 

Causes :

 

The injured person was applying grease by means of a ­hand pump into the second compartment of a cooler [air seal of the fuller (grate) cooler] through an inlet pipe; accidentally the throttle of the pump slipped off the inlet pipe and at that in­stinct his right hand went inside and his index finger got rapped in between the reciprocating clamp of the rotating wheel and the static steel block(casing).

 

Advice :

Work Permit System should be followed.  Only persons with sufficient experience should be engaged for such work.

 

 

CASE STUDY - 5

 

Name of accident

 

Injury in the lips and front two teeth

 

Category of accident

 

Non fatal

 

Description

 

An accident took place on 16-05-1994 in a roller flour mill factory situated in East Khasi Hills District, Meghalaya.

 

Causes :

 

The accident had happened while the injured person was tightening the nut and bolt of the motor of an elevator.  The motor’s position is located at a height of about 4(four) feet from the floor level.  His intention was to fit the motor in its position on and while doing so unfortunately the wrench slipped while pulling towards himself and hit his upper lip and two of his front  teeth were broken

 

Advice :

In order to avoid such accidents in future the management should adopt a “Work Permit System” for their workers in such repairs or any over-haul works.

 

 

CASE STUDY - 6

 

Name of accident

 

Crush injury of the right middle and ring finger

 

Category of accident

 

Fatal

 

Description

 

An accident had occurred on a stone crusher section of a cement plant on 31-08-1996.

 

Causes :

 

Due to stone jamming in between a fixed steel wall of the crusher and a to-and-fro moving jawplate, the crushing process was interrupted.  In order to free the jam a steel wedge tied with leather strap was used while doing so the stone suddenly got re­leased also dragging along the steel wedge downwards creating -  tension on the leather strap.  As the injured person was also hol­ding the other end of the leather strap by foot, his right hand’s fingers got trapped in between the leather strap and the edge of the window-like opening steel wall, thereby causing ,crush injury.

 

Advice :

 

Holding of the leather strap, by foot should be prohibited while clearing a jam as mentioned above.  It is advisable keep the ether end of the strap free and avoid standing over it.  Also, the strap could be fixed to some point at a length covering its maximum downward travel distance.  Proper training should be imparted to the workers and safe working practice should followed.

 

 

 

CASE STUDY - 7

 

Name of accident

 

Fall from a height of about 4 m.

 

Category of accident

 

Non Fatal

 

Description

 

An accident had occurred in a cement plant on 31-031998 where a victim received a small injury I the head and upper part of the right lower limb.

 

Causes :

 

On the day of the accident a repair work was being carried out in the retention ring inside the horizontal kiln at point of about 12m from the entrance to the kiln.  Just right from the entrance there is an opening space of 2m breadth, 2.5 m length and 4.00 m height which is used to collect the just  burnt material/clinker coming from the horizontal kiln for cooling purposes (to the cooler).  In order to make access to the kiln one has to cross over the breadth of this open space  of about ­ 2.00 m and for doing so a temporary removable wooden plank was used.  A welder who was already at the job site inside the kiln 12 meters away from the entry point alongwith an illuminated electric bulb was waiting for the two fitters to come one of whom was the victim was attached to the cement mill department for fitting  purposes.  The victim who was not familiar with the condition inside the kiln moved his way towards the welder who was waiting at the job site and without knowing that there was a plank provided for crossing, stepped in an open space and accidentally had a ­fall. This caused due to the following :­ 

 

1.            No lighting was provided at the entry point in view of the on-going repairing work. This is contrary to the provisions of ­the Factories Act and Rules, which requires that sufficient ­lighting should be provided in and around any work area.

 

2.            The victim who was entrusted as a helper for the repair work was actually from other section (cement mill department) and was not well conversant with the present section (Kiln department).  In fact it was obligatory on the part of the management to instruct the supervisors/foreman of the present section to give proper training and necessary prior instructions before enga­ging any worker in other work areas which does not belong to his own section.

 

Advice :

 

1.      The work place should be well illuminated.

2.      Necessary training should be imparted to the workers.

   3.      Unsafe conditions should be eliminated.

 

 

CASE STUDY - 8

 

Name of accident

 

Crush injury due to fall of heavy object on the victim’s right fore arm and left foot.

 

Category of accident

 

Non Fatal

 

Description

 

An accident had occurred in the clinker yard shed in cement factory situated in East Khasi Mills District of Meghalaya on 12-061998. The injured person is an employee/worker of a contractor's firm/erector which was engaged by the factory's management for renovation work of a factory shed which was damaged due to cyclonic storm. Thus the category falls under that of the construction. workers.

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Causes :

 

The above mentioned cyclonic storm had damaged a portion of the factory's clinker yard shed in which the G.I. Sheet  roofing alongwith steel truss. were bent due to the storm in some portion as found during the spot investigation.  It was learnt that a day before the accident, the worker/victim had completed gas cutting of 6 (six) number of steel columns which were reinforced in a cement concrete of approx O.70m x O.70m size and  about 1.5m height above ground level. The victim, while cutting the 7th such column and due to loss of balance and heavy weight of the already cut portion of the steel column it stripped towards the worker.  Due to heavy lead of the steel truss together with G.I. Sheetroof of approximately 2.5 tons weight the victim fell down on the gr­ound and his face, arm and foot got crushed.

 

Advice :

 

Had the worker made use of the manual crane available at the site for holding purpose or the truss, the accident could have been averted.  Hence, doing any type of work without necessary precautions and in a haphazard manner should be prohibited as it may endanger  the life of other workers, as well as safety of the machines.

 

 

CASE STUDY - 9

 

Name of accident

 

Crush injury

 

Category of accident

 

Fatal

 

Description

 

An accident had occurred in a mosquito repellent coil manufacturing factory situated in the Ri-Bhoi district of the state of Meghalaya on 26-11-2002.  It is a crush injury of left arm between pneumatic moving parts and fixed metal; where the injured person received a minor fracture in left arm.

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Causes :

 

During the investigation conducted by the Factory Inspec­tor it was found that a coil stamping machine in this case was pneumatically operated with the aid of an air compressor through a small cylinder (size about O.70m length anti O.05m diameter) of the mould pusher which has get air release/close valves at both ends. It was learnt that the moulds (dies) has to be cleaned periodically,  The accident had actually happened when the injured person, after cleaning the, mould was removing the mould-cleaning-tub at which instant the mould pusher activated and through its horizontal motion his left hand got trapped in between and had a minor fracture just above his wrist. This was caused due to air valve leakage in the coil machine and that the air valves present in the small cylinder were not checked; before doing such jobs.  Compressed air in the cylinder should have been released first.

 

Advice :

 

To avoid such type of accident in future, the management was advised to adopt a “Work Permit System” and allow only skilled workers to perform such works.

 

 

CASE STUDY - 10

 

Name of accident

 

Fire Accident

 

Category of accident

 

Non Fatal

 

Description

 

A dangerous occurrence (fire accident) which did not result in death or bodily injury except property damaged had occurred on 16-01-2006 in a Mosquito coil/mat manufacturing unit situated at Ri-Bhoi district

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Causes :

 

On the day of the occurrence .at around 6:30 AM only 9(nine) to 10(ten) of its employees of the first shift (6:00AM - 2:00 PM) had arrived at the factory after a two days break (being a holiday due to Bihu festival on 14/01/06 and Sunday (15/1/06) when a fire broke out. They could not ascertain the exact cause of the fire.  During investigation by the inspector all the witnesses were interrogated and the sequence of events based on statements made by ­these witnesses were taken into consideration.   It was. concluded that the fire started from the chemical storage area from where the smoke was first observed.  It was noted that this factory uses, various chemicals having various flash points and the minimum flash point of certain chemical is 66oC.  Since the time of the incident was early in the morning and the burner used for drying purpose was not yet started, the room-temperature around that area was much below the above said flash point temperature 66oC. However, prlor to the incident the fac­tory was closed for two days as mentioned above.  Hence a accumulati­on of chemical vapours around chemical storage area could not be ruled out.  Also, there must be a source of ignition or spark to st­art the fire Thus current leakage or electrical short circuit producing spark  in presence of chemical vapours was presumed to be the cause of fire producing fog like smoke which quickly turned  ­black smoke as seen by one of the witnesses.  A fire with tremendous  heat in that area was caused as it was evident from the bent  steel truss of the roof.  It may be mentioned that since the fire had started from the chemical storage area all the burnt chemi­cals must had already been evaporated by the time the fire-fighting personnel arrived the scene. Otherwise, the consequences and after effect of these chemicals on them would. have been serious if they were not equipped with proper personal protective equ­ipment like SCBA, etc.

 

Had the, chemicals been stored separately away from the work floor a huge fire would not have been caused inspite of ­the electrical short circuit or spark.

 

Advice :

 

The management was advised to take corrective measures as follows :

 

1.            All chemicals should be kept separately away from the 'work floor area in a cool, dry and well ventilated room/place away from any source of ignition, heat, etc. Information from the MSDS should be strictly followed while handling, storage of such chemicals.

2.            ­Storage of finished products and raw materials should be kept away from the machineries or from aisle ways, so as to keep more breathing space for the workers.

3.            It is observed. that with the introduction of additional tunnel for drier and mezzanine floor the working space have become  congested-same should be rectified.

4.            On-site and off-site/emergency plans should be formulated

5.            Safety Audit by Govt. agencies like Rhl Kolkata or DGFASLI, Mumbai should be carried out.