Mahad Fire Incident investigation report

Fire Incident investigation report

1. MAHADFIREINCIDENT
This Document is Prepared in April -2024
By Efficaz Consulting & Solutions

2. ABOUTTHEACCIDENT
APharmaPlantlocatedinMahadMIDC,RaigadDist,Maharashtra
wasmetwithanFireandExplosionIncidenton3
rd
ofNovember-2023.
Therewere11Fatalities;7BurnInjuries.
HeavylosstoPlantBuildingsandMachineries.
PlantusedmultiplechemicalsincludingToluene,Acetone,IPA,
Methanol,MethyleneChloride.
MaharastraStateGovernmentformeda9MembersProbeCommittee.
BasedontheinformationgatheredfromSecondarySources,Efficaz
havepreparedavaluableinsightsandlessonslearnedfromtheIncident
arepresentedbelow.

3. FACT1:
MULTIPLEFIRETENDERS(10 NOS.) WEREUSED
TOFIGHTTHEFIRE
Interpretation:
InitialstagecontrollingofFireisalwaysbestandeasy,bythat
timefireishuge,damageisalreadydone.
SourcingmultipleFireTendersisthekeyduringcalamity,
On-siteEmergencyPlanshallidentifyandshallhaveMutualAid
Agreements.
MovementofmultipleFireTenders,Ambulance&Cranesshallbe
unobstructedinsidethePlantPremises.

4. FACT2:
BASEDONMAHARASHTRA POLLUTION
CONTROLBOARD(MPCB)'SREPORT, DEPUTY
COLLECTOR(MAHAD) ORDERED TOSTOPTHE
PRODUCTION ANDREMOVETHEINFLAMMABLES
FROMFACTORYWITHIN72 HOURS
Interpretation :
ForgainingshorterbenefitsofBusiness,peopletendtodeviate
theSafety,butultimatelyitwillstoptheBusinessforLongTerm
andincurtohugeProductionLoss.

5. FACT3:
INCIDENTHAPPEDAT10.30 AM
Interpretation :
Safety is always important but few Crucial Movement for
being High Alert will be
Pre-Start Up
Start Up,
Ramp Up,
Running at Full Capacity
Close Out Time
Shift Change Over,
Planned Shut Down
Emergency Shut Down
Test Run
Cleaning
Batch Change
Manual Mode
Less Or More Than Prescribed Capacity

6. FACT4:
F.I.R REGISTEREDUNDERSECTIONS
Interpretation
MultipleLegalActionsisinevitable,ifIncidenthappened.
WhenissuebecomesPublic,allSafetyGapsarefoundand
discussed.
TremendousReputationLossforalltheStakeholdersofthe
Company.
304 (Punishment for Culpable Homicide not amounting to Murder)
308 (Attempt to Commit Culpable Homicide),
285 (Negligent Conduct with respect to Fire or Combustible matter)
286 (Negligent Conduct with respect to Explosive Substance) and
34 (Common Intention) of the Indian Penal Code

7. FACT5:
VICTIMSBELONGTOJHARKHAND, UTTAR
PRADESH& WESTBENGALSTATES
Interpretation :
When multi State labors are deployed, language barriers shall
be addressed Properly.
Training and Development of Manpower is crucial for diverse
Workforce.

8. FACT6:
POLICEARRESTED MAINTENANCE HEADAFTER
7 DAYSOFINCIDENTANDBOOKEDCASE
AGAINSTPLANTHEAD
Interpretation :
Predictive, Corrective and Preventive Maintenance shall be done.
Maintenance Activity shall be done with Letter and Spirit.
Maintenance is not mere support activity, it is essential activity.
Negligence to Maintenance is a serious deviation.

9. FACT7:
NDRF 30-MEMBER TEAMDEPLOYED
Interpretation :
RescueOperationrequiresSpecialexpertise,whichtakes
significanttimeandhugeCost.
Insuranceshallbecomprehensivetocoverdifferentstagesof
Disaster.
Off-siteEmergencyPlanshallbepreparedconsideringthe
multipleagenciesworkingtogethertocontroltheEmergency.

10. FACT8:
GASVAPORSGOTDETONATED DUETO
ELECTRICALSHORTCIRCUIT
Interpretation:
SuitableLeakDetectorsrequired.
SuitablyMounted(quantity,locationandheight)basedonDetector
MappingStudy.
Functionalityshallbeensuredwithuninterruptedpowerbackup
andcalibration.
ElectricalSafetyAuditshallbeconductedatregularintervalto
addresstheElectricalHazards.
ElectricalEquipmentsshallbeincompliancewiththeFlameproof
RequirementsofHazardousZones.

11. FACT9:
FIRESPREADTOOTHERAREASFROMTHE
ORIGIN; LIKEDRUMSTORAGEAREAWHERE
BARRELSCREATEDSERIESOFEXPLOSIONS
Interpretation:
FireshallbecontainedlocallybymeansofProperlyused
“MaterialOfConstruction”
StorageAreaWallsshallwithstandfirefor2Hours,butinthis
caseitwasnothapped
SeparationDistancefromOneBuildingtoOtheriscriticalto
limitthedamage
MaximumProbableLossshallbecalculatedandaccordingly
ActiveandPassiveFireProtectionshallbeselected

12. FACT10:
FIREFIGHTINGANDRESCUEWASDIFFICULT
DUETOHEATANDPRESSUREFROMCHEMICALS
Interpretation :
MSDSofalltheMajorChemicalsarecriticalandshallbe
accessibleatthetimeofEmergency.
ChemicalCompatibilityshallbedonetoavoidthemixingof
incompatiblematerials.

13. FACT11:
PLANTHADPERMISSION TOMANUFACTURE 22
PRODUCTS
Interpretation :
BusinessContinuityPlanisessentialforestablishing
commitmenttomarket

14. FACT12:
OUTOFTOTAL57 EMPLOYEES ATTHETIMEOF
INCIDENT; FEWWEREUNABLETORESCUED&
THEYARETRAPPED
Interpretation:
EvacuationStrategyshallbeplannedindetailed.
Peoplewithspecialneedshallbeidentified(PregnantWomen,Differentlyabled,
ColourBlind,Visitors)
Areaswheredifficulttoreachshallbehighlighted.
ExactHeadcountonEntry/Exitofemployees,labors,visitors,vendorsanddrivers
ofvehicleshallbemadeavailablewithoutlosingthetime.
ExitAdequacyshallbecalculatedforeveryareaconsideringthemaximum
expectedpersonnelwhichshallensure
MaximumTraveldistancetoExit
AlternateExitPoints.
ExitRoute.
TimeTakenforEvacuation.
WidthofExits.
SuitableAssemblyPoint.

15. THEEND
Efficaz Consulting & Solutions
www.efficaz.in
[phone]
[email protected]

16. LISTOFSTUDIESEFFICAZCONSULTING&
SOLUTIONSCARRYOUT
Fire Safety
•Fire & Gas Detection Mapping Study
•Design Adequacy of Fire Protection
System
•Fire Load Calculations
•Fire Risk Assessment
•Fire Safety Audit
•Water Demand Calculations
•Life Safety, Exit Adequacy and Passive
Fire Protection Studies
Electrical Safety
•Arc Flash Study
•Lightning Protection Study
•Hazardous Area Zone Classification
Study (HAC) (ATEX Study)
•Thermography
•Electrical Safety Audit
•Electrical Safety Audit
•E HAZOP
•Inspection & Adequacy of Flameproof
Electrical Equipments
•Static Electricity Study
•Energy Audit
•Relay Coordination Study
•Power Quality Audit
•Harmonics Studies
Chemical Safety
•Chemical Compatibility Study
•Respiratory Fit Testing
•Personal Exposure Study
•Workplace Monitoring Study
•VOC Study
•Chemical Exposure Monitoring Study
•Industrial Hygiene Monitoring Study
•Occupational Exposure Limit Testing
(IDLH, STEL, TLV)
•Dust Explosion Study
•Dispersion Modeling
(Flare, SRV, Dump tanks, Scrubbing Vent
Hazards)
•Minimum Ignition Energy Study (MIE)
•Bulk Chemical Storage Risk Assessment
Process Safety
•PSM Gap Analysis
•Process Safety Management (PSM) Implementation
•Quantitative Risk Assessment (QRA)
•Safety Integrity Level (SIL) Study
•LOPA
•Functional Safety
•Hazard Identification and Risk Assessment (HIRA)
/HARA / HAZID Study
•Hazard & Operability Study (HAZOP)
•Pre-Startup Review
•Business Continuity Plan
•Process Hazard Analysis (PHA Study)
•Job Safety Analysis

17. LISTOFSTUDIESEFFICAZCONSULTING&
SOLUTIONSCARRYOUT
Others Studies :
Human Factor Engineering
Ergonomic Studies
Emergency Response Disaster
Management Plan (ERDMP)
Statutory Safety Audit
Comprehensive Safety Audit
Preparation of On Site Emergency Plan
Preparation of Off Site Emergency Plan
Incident Investigation
Pre Occupancy Audit
Behavior Based Safety
Safety Culture Survey
Security Vulnerability Assessment
(Security Audit)
Machinery Risk Assessment
Deputation of Safety Officer
Logistics Risk Assessment (inside or out
side vehicles movement)
Marine Loss Minimization Study
Construction, Occupancy, Protection,
Exposure (COPE) Study
Probable Maximum Loss Study (PML)
Study
Risk Inspection behalf of insurance &
Brokerage firms (for under writing or
value addition or safety improvement)
Civil Safety:
•BuildingStructuralStabilityStudy
•BuildingRiskAssessment–usingNonDestructiveTesting
(civil)
•PHSERStudy
•ProjectRiskAssessment
•ErectionRiskAssessment
•ConstructionSiteSafetyAudit
EnvironmentalStudies
EIAStudy
EnvironmentalAudit
WaterAudit
SustainabilityStudies
ESGAudit
EHSAudit
Trainings
SafetyTraining(topicofneed)
DefensiveDriversTraining/RoadSafety
ProcessSafetyorChemicalSafetyorPSM
TrainingonHAZOP,QRA,SIL,LOPA