New Delhi: An expert group on Tuesday blamed human
error for the devastating fire at Indian Oil Corp`s fuel depot
at Jaipur that killed 11 persons and injured 45 in October
Headed by former Hindustan Petroleum Corp Chairman M B
Lal, the seven-member committee, which went into the causes of
the October 29 fire, blamed "gross negligence" for causing a
leakage of petrol during transfer from storage tank and the
subsequent fire that engulfed the entire depot.
The panel, which submitted its report to the government,
glossed over the role of Oil Industry Safety Directorate
(OISD), a government agency tasked with conduct of safety
audits of oil installations and ensure compliance of its
Lal said "non-observance of normal safe procedure"
resulted in a 10-12 meter fountain of petrol spreading vapours
over a 250 meter radius for 75 minutes before a spark caused
by start of two-wheeler or kitchen within the radius, breaking
out the fire.
An OISD audit had in 2003 pointed to deficiency in the
offloading valve, OISD Executive Director J B Verma, who was
part of the committee, said.
"The compliance report did not indicate any action on the
deficiency pointed out and thereafter it was for IOC`s
internal audit, the latest done in February 2009, to ensure
the installation complied with standard safety procedures," he
Lal said it was not in the committee`s mandate to look at
OISD audit compliance.
Lal said, it was not for the committee to decide on who
was to be blamed for the fire.
Asked specifically as to where the responsibility for
non-compliance of the safety audit rested, he said "it is
with IOC management."
It was the duty of the board to ensure safety audits of
its installations are conducted periodically and deficiencies
and lacunae pointed out is addressed, he said.
The committee said petrol leaked from a valve, while it
was being transfered from the storage tanks caused a huge leak
as a jet of liquid at about 1810 hours on October 29, 2009.
For over 75 minutes the `fountain` disbursed petrol
vapours which had in the initial stage led to collapse of the
attendant and the persons who went to help him.
"The basic or root causes were an absence of site
specific written operating procedures, absence of leak
stopping devices from a remote location and insufficient
understanding of hazards and risks and consequences," he said.
The committee recommended automation of installations and
remote operation of such facilities besides, periodic safety
audits and their compliance. It also wanted OISD to be made an
autonomous body, free from industry linkage.
"Further even after the leak started the "accident" could
have been managed if safety measures provided in the Control
Room were not made and kept defunct," Lal said.