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COMPENDIUM OF CASE LETS

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					INDIAN OIL CORPORATION LTD.
  3

  COMPENDIUM OF CASE-LETS                             AVIATION

                                                      SAFETY AND
                  T & D MARKETING DIVISION            STANDARD
                                                      OPERATING
                                                      PRACTICES FOR
                                                      OPERATIONS

                                                      CONSUMER SALES

                                                      FINANCE

                                                      GENERAL
                                                      ENGINEERING

                                                      HUMAN
                                                      RESOURCES

                                                      LPG

                                                      LUBE
                                                      INSTITUTIONAL
                                                      SALES

                                                      LUBE RETAIL

                                                      QUALITY
                                                      CONTROL

                                                      RETAIL

                                                      MAINTENANCE &
SO MANY OPPORTUNITIES………..
                                                      INSPECTION
                          TO MAKE A REAL DIFFERENCE
                                                      SHIPPING
COMPENDIUM OF CASE-LETS




           1
                EXPERIENCE SHARING!!!


                             INDEX
Sr.          Discipline                No. of Case-    Starts From
No.                                   Lets Generated    Page No.
 1            Aviation                      90              3

2      Safety and Standard                 63             120
      Operating Practices For
           Operations
3       Consumer Sales                      4             195

4             Finance                       6             201

5       General Engineering                 1             210

6        Human Resources                    2             212

7               LPG                        14             216

8      Lube Institutional Sales             2             231

9            Lube Retail                    1             235

10    Maintenance & Inspection              2             237

11         Quality Control                  6             247

12              Retail                      2             257

13            Shipping                      7             262

                Total                      200


                                  2
T&D in its continuing process of learning brings to you a unique experiment in learning.
We help in generating a conducive climate in our training programs so that participants
feel encouraged to share their knowledge from the field through “Experience sharing
sessions”.

We appreciate the ‘Spirit of Sharing Knowledge’ displayed by the participants during
the training sessions and gratefully acknowledge the contributions made by them. And
we bring to you individual case-lets, which essentially deal with

   a)   Product & Process failures
   b)   Near miss incidents
   c)   Lessons learnt
   d)   New process / equipment innovations
   e)   Benefits obtained


This booklet can be used by
   a) Newly joined Probationary officers – This may ignite interest to pursue
      reading manuals
Function Specific caselets can be utilized by
   b) All the officers of the function particularly those who have newly joined.

It would be out great pleasure if this knowledge sharing continues further and we would
be happy to be the catalyst in this process.

Wishing you happy learning...!


                                                      The Training Team
                                                      Indian Oil Corporation Ltd.
Mumbai
29th August’ 2011




                    EXPERIENCE SHARED IN
            ADVANCED AVIATION REFRESHER COURSE

                                            3
         HEAD OFFICE




Learning the X-factor for
 Sharing of Experience




  TRAINING & DEVELOPMENT,
         Head Office

          Caselet – 1

               4
   ________________________________________________________________________

                              Experience shared by

                      Ms Beena Gandhi, APTM, Coimbatore, AFS

                            Issue under Discussion:

Frequent malfunctioning of Brake interlock and breakage of Hose Beads

                                     Background:

We have received new Refuellers AR 438 during July, 2007. Though the Refuellers
working was excellent, we were facing problems while the hose was being wound.
There was a provision for nozzle holder stowage for under wing nozzles with flap and
hook for easy placement and removal as well as a provision for brake interlocking. (See
Fig.1.)




                                        Fig. 1

While the hose was being wound, the hose beads would hit against sharp edges of the
nozzle holder stowage which resulted in the flap getting folded completely as well as
cause frequent damage/ breakage to the beads ( each costs Rs.250/- ).Further it would
also alter the settings of the brake interlock system.(See Fig.2)




                                          5
                                      Fig. 2




                      Solution/ Innovation developed:
We have devised a horse-shoe shaped pipe and the same was fitted to the sharp edges
                 using nut and Bolt arrangement. (See Fig. 3 & 4.)




                                       Fig.3




                                        6
                  Fig.4
                               Benefits obtained:

With the fixing of the above mentioned horse-shoe shaped pipe, we did not face any
further breakage/ damage to hose beads as well as the nozzle holder stowage and
brake interlock system did not suffer any damage or malfunctioning. The same was
implemented in another refueller AR 444 also.



      REPLICABILITY: At Locations with AR- 43x and 44x series Refuellers




                                        7
                                  Caselet – 2

                      Ms Beena Gandhi, APTM, Coimbatore, AFS

                       Issue under Discussion/Problem:
Reflection of correct Batch No. in AV-7

There are chances that the correct Batch No may not get reflected in the AV-7 due to
the work load when we may not be able see the Batch book or when there is an
interchange of tanks.

       Solutions suggested & implemented and benefits accrued:

While writing the 11 code, the Batch No can be mentioned against the same in the
respective refueller AV-2 itself. Subsequently whenever a topping-up is done and a 10
code is written, if the same Batch as in 11 code continues then the Batch Number need
not be written against the 10 code. However if there has been a Batch change after
topping up, then the fresh Batch No can be written against the 10 Code. Since the AV-2
is carried by us for refueling the correct Batch gets reflected.

We have implemented this system at Coimbatore AFS, and it helps us reflect the
correct Batch No.



        REPLICABILITY: All regions at locations with into the aircraft refueling




                                           8
                                       Caselet –3
    ________________________________________________________________________


                      Ms Beena Gandhi, APTM, Coimbatore, AFS

                            Issue under Discussion:
Detection of Rod inserted into Dip Pipe

During the checking of dips of one of the Tank Trucks by the undersigned, it was found
that the dip level in one compartment was slightly above the Oil level. This aroused my
suspicion and I immediately inserted the Dip rod into the Fill pipe and found that the
Proof level of the rod was matching with the top of the Fill pipe. Based on the logic that,
if the Proof level of the dip rod matched with top of the fill pipe then the Oil level should
also match with that seen while the rod was inserted in the Dip pipe . However to my
astonishment it did not match but instead showed a level much below the Oil level. The
difference in quantity was assessed at 200 its.

            Methodology used for siphoning the product:
We opened up the manhole of that particular compartment and found that a rod closed
on all sides except for a pinhole at the bottom was inserted over the dip pipe. We
assume that at the Loading Terminal, when product is filled in the compartment, the dip
pipe(as above ) does not get filled in the normal course. On the pretext that there is a
shortfall in that particular compartment, product may be poured from the top, hence the
higher dip . Enroute after siphoning off the product from that particular compartment the
TT reported at AFS and apparently that particular compartment shows an excess dip
thus not arousing any suspicion. The product in the dip pipe empties out after the rest of
the product gets unloaded through the pinhole. While checking the TT after unloading,
we normally check the Fill pipe and very rarely the dip pipe.


    Solutions suggested / implemented and benefits accrued
-   Dips of TT’s at random should also be checked in Fill Pipe and the difference
    observed should match with the level difference in Proof level
-   .While TT is getting unloaded the rate of emptying of dip pipe should be the same
    as that of the rest of the product in compartment.
-   While checking the empty of TT after unloading it is advisable to check the dip pipe
    also.


REPLICABILITY:All regions (at Locations with Refuellers/Dispensers)



                                             9
                                     Caselet –4
   ________________________________________________________________________

                                Experience shared by

                  Shri Ramesh Kumar, Mgr (Avn)/ NITC AFS

                            Issue under Discussion:

Display board on refueling equipment.

                                  Earlier system:
Various check tests/calibration/filter inspection dates were painted on individual
pressure gauges, hoses, flow meters, filter casing, etc.

                                  Problem faced:
Whenever an updation was missed at various places on the refueller, inspecting
authority/customer used to observe the same, creating an embarrassing situation.

Besides, it always involved painting job to be done by a specialized man at frequent
intervals.

                       Solution suggested/implemented
At a convenient place on the panel, a single display board has been installed. Entire
periodic data pertaining to all equipments/parts installed on a dispenser are being
updated in this system. a print out of the same is taken in A4 sheet and installed in a
single display board provided, duly signed by the authorized signatory.

As and when any check/test is conducted, the date is updated and a new printout
replaces the older one.

A specimen print out is enclosed in the next page.


        REPLICABILITY :All regions (at Locations with Refuellers/Dispensers)



                                           10
                                 TABLE: 1


.
         PREVENTIVE MAINTENANCE SYNOPSIS
                      AHD23



S.NO.                  ACTIVITY            ID.CODE DONE         DUE
  1     FLOW METER CAL. BY W&M DEPTT                    B-08     B-09
  2     MILLIPORE TEST                                17.02.09 15.05.09
  3     SELFMETER CALIBRATION                         17.02.09 15.05.09
  4           FILTER ELEMENTS: PUROLATOR (3477:3608) 1 MICRON
 4.1    FILTER ELEMENT INSTALLATION                   21.07.08 20.07.11
 4.2    FILTER ELEMENT INSPECTION                     21.07.08 20.07.09
  5     HOSE PRESSURE TESTING
 5.1    REEL HOSE                              H-1    30.08.08 01.03.09
 5.2    DECK HOSE (L)                          H-2    30.08.08 01.03.09
 5.3    DECK HOSE ( R)                         H-3    30.08.08 01.03.09
 5.4    INTAKE HOSE                            H-4    28.11.08 27.11.09
 5.5    HECV EFFICIENCY TEST                          27.11.08 26.05.09
  6     PRESSURE GUAGE TESTING
 6.1    PCV PRESSURE GUAGE (1)               ( 1/23)  30.10.08 29.04.09
 6.2    AIR PRESSURE GUAGE (2)               ( 2/23)  30.10.08 29.04.09
 6.3    INLET PRESSURE GUAGE (3)             ( 3/23)  30.10.08 29.04.09
 6.4    LEFT NOZZLE PR. GUAGE (4)            ( 4/23)  30.10.08 29.04.09
 6.5    RIGHT NOZZLE PR.GAUGE(5)             (5/23)   30.10.08 29.04.09
 6.6    SURGE PR. GUAGE INLET                 S–1     30.10.08 29.04.09
 6.7    SURGE PR. GUAGE OUTLET ( RT)          S–2     30.10.08 29.04.09
 6.8    SURGE PR. GUAGE OUTLET ( LT)          S–3     30.10.08 29.04.09


                                                   Authorised Signatory


    REPLICABILITY :All regions (at Locations with Refuellers/Dispensers)

                                    11
                                      Caselet –5
   ________________________________________________________________________

                   Shri Ramesh Kumar, Mgr (Avn)/ NITC AFS

                             Issue under Discussion:

Installation of rubber chocks on ref. equipment:

                                  Earlier system:

Two numbers of metal chocks were used to be put on two sides of the front wheel of
dispenser, whenever it was positioned for carrying out refueling.

                                  Problem faced:

On one of the flt, immediately after positioning the refueling equipment and putting
metal chocks on both the sides, the rear chock slided backward along with the
dispenser, causing a near miss.

It happened in view of rainy/wet condition prevalent at that time, coupled with slope
given to tarmac surface for draining rain water.

                      Solution suggested /implemented:
Rubber chocks, similar to what are being used for putting on the wheels of aircraft, were
developed with the assistance of a supplier. These chocks were not only light but also
provided much better grip/stability. Its make and design totally eliminates the above like
situation.

                Most of the NR locations are using these rubber chocks.


        REPLICABILITY :All regions (at Locations with Refuellers/Dispensers)




                                           12
                                                        Caselet – 6
     ________________________________________________________________________
                                         _
                                                Experience shared by

                           Shri Aakash Sethi, Sr. Mgr (Avn), Palam AFS

                                           Issue under Discussion:
Providing Prompt replies to delay reports received from Customers through higher
Offices (Regional & Head Office)


                                                   Problems faced:
Generally, the Customer Airlines are sending consolidated flight delay reports for delays
(due to refueling) to OMCs on a periodical basis. The periodicity of these reports varies
from Customer to Customer (it could be anything from a month to a quarter or more).
The Head Office/ Regional Office is interested in responding to these reports at the
earliest as is in keeping with the vital requirement of Customer Care i.e.
Responsiveness. Therefore, at the location level, it is imperative that the reply to these
reports is prepared and sent to higher Office in factually correct and timely manner.

The following typical difficulties in meeting the above requirement are faced at large
locations, operating in shifts with large number of Officers.

The information about sequence of events/ reasons for delays is not readily available.
The Location-in-Charge needs to contact the concerned Shift Manager and Supervising
Officer to find the information for preparation of reply. The concerned Shift Manager/
Supervising Officer has to rely on his memory to recall the events/ reasons. In case of
inability of the concerned Officers to correctly recall the events (due to passage of time
or other reasons), the reply may not be factually accurate.
Both the timeliness and accuracy of the reply are at risk under the above conditions.



                                 Solutions suggested / implemented
A simple solution to the above problem is recording of the reasons/ sequence of
events on the retention copy of the relevant AV-7 by the Shift Manager right after
completion of flight (in case of both known delays i.e. mentioned by Airlines
representative on AV-7 as well as Suspected delays i.e. not mentioned by Airlines
representative on AV-7 but likely to have been logged by him in his records). These
copies can be referred to by Location-in-Charge, whenever required. The above method
provides ready availability of factually correct information to the Location-in-
Charge for responding to delay reports. This solution is already implemented at Palam
AFS and helps the location in promptly responding to delay reports.

                                            REPLICABILITY:Metro AFSs

                                                                 13
                                Caselet – 7

                            Experience shared by

                      Shri J Satyanarayan, Visakha Lab.

                           Issue under Discussion:
New sample containers received from CIP for Jet A1 Samples.

                                Problems faced:
Once we have received Jet A1 sample from a Depot for Batch formation test after
tank cleaning. The stocks at the near by AFS are critical and the Depot is required to
send the loads on Priority once the sample passes for batch formation test. The
depot has sent the sample to the Laboratory, which is 700 KMs away. All the major
tests were completed on a sequence and the Water Reaction test was carried out
at the end. The sample was found to be failing in this test very badly. The test was
repeated nearly six times and every time the result was same. We advised the depot
to send a repeat sample after through rinsing of the sample container.
The repeat sample was found to be passing in all tests.

On observation and enquiry, we have found that the first sample was collected
                     in a Brand- new sample container

      Solutions suggested / implemented and benefits accrued:
Brand –new sample containers will have lot of particles of dust, aluminum particles
etc in side the containers. Brand-new aluminum sample containers are required to
be filled with ATF and kept for 2 days. Subsequently to be properly rinsed with ATF
and Keep in a proper place for use when ever required.

                     REPLICABILITY:All regions at Locations




                                        14
                                    Caselet – 8

                               Experience shared by

                       Shri J Satyanarayan, Visakha Lab

                            Issue under Discussion:
Rubber washers for caps of aluminum sample containers.

                                Problems faced:
Samples found to be leaky and AV Gas 100 LL samples were found to be failing in RVP
test. Repeat samples collected in leak proof containers with rubber washers were found
                              to be passing in RVP test

   Solutions suggested / implemented and benefits accrued

Avgas 100 LL samples to be collected in the morning preferably and in a leak proof
sample containers with rubber washers. These samples were found to be passing in
RVP test


REPLICABILITY :All Locations handling AVGAS 100LL




                                         15
                                      Caselet – 9
    ________________________________________________________________________

                                 Experience sharing by

                           Shri A Chakraborty, Port Blair.

                              Issue under Discussion:
Flash Flood In Port Blair FAS.

                                    Problem Faced:

There was a huge flash flood in Port Blair AFS during May,08 with its kinds never took
place in last 20 years. As soon as unusual level rise of water with heavy current was
observed, electrical line was shut down/all the materials/files etc as far as possible was
put in safer height and everybody was evacuated. All concerned was informed and
contractor was arranged for the jobs to be undertaken after water level goes down. As
soon as AFS was approachable, no leakage of product was ensured/all vehicles were
brought back in a road at elevated level. While all the QC checks of bowzer product
were being made, simultaneously the refuellers were made ready from automotive point
of view i.e. by draining /cleaning diesel tank, draining /cleaning/pouring gear oil etc.
Uninterrupted refueling was continued while pump house motors were dismantled and
sent for heat varnishing and the entire AFS was without power for 2 days. Topping up
was continued by gravity and topped up tank had helped quite a lot in topping up. We
faced a lot of trouble in restoring back the INDAIR package as back up floppy was also
washed out.


                                  Lessons learnt:

    1. Topped up tank helped us in undertaking top up open by gravity and to take care
       of depletion of stock. But another school of reading apprehends that if there is a
       leakage, the entire product would have been at stake.

    2. Back up materials should be kept in different location.


    3. All vehicles functioned without breakdown because of strict preventive
       maintenance practice at the location
.




                                            16
                                     Caselet – 10
   ________________________________________________________________________
                                Experience sharing by

                             Shri S L Meena, Mgr (Avn)

                             Issue under Discussion:

Positioning of Refueller on Air Craft bays, which are having space constraints.


                                 Problems faced:

One day there was very heavy rain and there was water all around the Airport. Water
also entered in the AFS premises and office. There were only two numbers of bays at
Airport. One rescheduled flight parked at one bay, while positioning the Refueller at the
Aircraft, Refueller one side tyres went into kaccha and Refueller got stuck just backside
of the Aircraft.

                                   Lessons Learnt
       a)     Whenever there is a space constraint at any parking bay it should be
              known to every employee. Before positioning the Refueller, we should
              see that what kind of Aircraft is parked and how much space is available
              around the Aircraft and approach of the Refueller should be made
              accordingly. Kindly avoid approach from backside if there is less space at
              back of the Aircraft.

       b)     Never take the Refueller in Kaccha areas however tempting to do so.

       c)     When there is heavy rain, the Refueller should be very carefully
              positioned with proper marshaling.

We should always have our own proper arrangement for torching and every employee
should be aware of the torching arrangement. Apart from our own arrangement we
should also have the Telephone no of the crane to deal the emergency.




                                           17
                                     Caselet – 11
   ________________________________________________________________________
                                Experience shared by

                 Shri Dalvinder Singh, APTM, AFS, HALWARA

                             Issue under Discussion:
PILFERAGE IN TANK TRUCKS

I was at Jalandhar Terminal in year 2004-05. A newly commissioned dealer from
Gurdaspur approached Jalandhar Terminal. He was quite upset over the stock loss
with every receipt of the T/T. He called field officer also and tried all the means but
could not find anything wrong except losses. The T/T Ex Jalandhar Terminal were
dispatched under locking system. His representative also used to accompany the tank
truck, even then he was getting loss of about 250 liters of petrol in each delivery. I was
deputed to investigate the case. I suggested the dealer to request for the same T/T for
the supply. Intimate me and do not unload the vehicle unless I reach Field officer was
also called. He did the same. I reached the dealer's pump. The T/T was there. We
checked all the dips, measured dip rod and locking system. The T/T was decanted but
nothing was visible. I got the chambers opened. Suddenly in one of the chamber (ch.
No.1) the chamber seems to be smaller. Then I went below the tanker body I found
some grease at one place. The grease was removed and there was a bolt supporting a
plate to move up and down. Now this was the lacuna. While the dealer's man was along
with T/T ,he could not detect the malpractice. The sequence of events was, T/T crew
before loading the T/T used to keep the additional plate in line with the chamber plates.
At the time of unloading one would find the dip o.k., other things o.k. But while
unloading crew conductor with some excuse shall go under the T/T and tight the bolt
which shall lift the plate and the product shall be transferred to fitted chamber. When the
chamber is filled again the crew shall close the plate, hence the T/T crew used to take
away the product in his hidden chamber.

The next day all the T/Ts of that particular transporter were called and it was found that
hidden chambers were there with other three T/Ts. And all the three T/Ts were banned.

                                Solutions suggested
Whenever you find abnormal stock loss investigate the case minutely irrespective of all
good systems. Look for abnormalities in the TT construction from outside as well as
inside.
                                   Benefits accrued:
Pilferage of product stopped. Customer satisfaction was achieved


REPLICABILITY:All Locations with TT bridging

                                            18
                                     Caselet – 12
     _____________________________________________________________________

                             Issue under Discussion:
Contamination detected through visual examination, though passing the batch formation
test after Pipeline receipt.




                                   Problem faced
During one of the pipeline receipts in a Terminal, the product was taken in Tank no.5
and in tank no. 6. Samples from the tank were drawn for conducting the batch formation
test. It was found that the sample from tank no 5 was visually bright and clear (W/W) .
But the sample in tank no 6 was not clear and the colour was yellowish on the darker
side.

On assumption that there is a failure in ensuring positive segregation in the system, this
incident was investigated. But no deficiency was found on this count. On further
investigation it was found that though the pipe line transferring the product to both the
tanks was common, there was another underground pipeline (old one) to tank no 6
which got mistakenly activated due to a wrong opening of a previously unused valve.
This line was lying dormant for a long time and hence the visual discolouration of the
product. Finally the entire product was downgraded.


                                   Lessons Learnt
Any pipeline especially leading to old tanks and which is underground should be
removed at the workstage itself, when the new line is being laid. The tendency is to
keep the old items for emergencies. No line should be allowed to remain dormant for a
long time.

Any valve in the manifold which is not used for product transfer and sampling should be
removed and replaced by flange connectors or welding of P/L. No standby arrangement
should be allowed in such cases.




                                            19
                                      Caselet – 13
     _____________________________________________________________________



                              Issue under Discussion:
Failure of product received from IAF in visual examination.




                                    Problem faced
Samples received in the Laboratory showed the product as ‘ not clear’ in visual
examination. The product was coming from a distance of more than 200 Kms from an
IAF base. A repeat sample was requested and was sent the next day. Even this sample
failed in similar fashion. The third sample also failed.

Hence I decided to investigate the matter and went to the station to personally draw the
samples. When I used the bottom sampling thief to take out the sample, the sample
passed the visual test. When I asked the person responsible to take the sample of this
discrepancy, he replied that he has used the rotary pump to take out the sample. On
examination, it was found that the rotary pump was sometime back used to draw diesel
from the barrels.




                                    Lesson Learnt

Sampling equipment should be flushed with the product and the result checked for a
clear product. This should be especially done when the product is being sent to long
distances and urgent requirement is there to release the product from the tanks.
Precious time can be saved and unnecessary pressure on the Lab can be reduced.

Also Visual test is an important indicator and should not be taken lightly.




                                            20
21
                                   CASELET - 14
                                Experience Sharing by
                        Shri TEHLANI RK, SR. APTM, NASIK AFS


                                 Issue Under Discussion:


Support from District Administration during the outstation VVIP refuelling in far flung
areas.


The contention:


    I got the opportunity of carrying out the refuelling of Honourable Vice President of
     India Shri Bharo Singh Shekhawat’s VVIP IAF Helicopter at a small village called
     “Amarkantak” the original sacred place for the mighty holy river”Narmada”.
    Amarkantak is around 300 km away from Nagpur, falling under a District
     (Probably Dindori in Madhya Pradesh), which itself is 80 km away from the sport
     where the actual refuelling was to be carried out. It’s a small village of around
     1000 homes where none of the modern facilities were available in the year 2003.
    As usual, we reached the spot the day before the visit of VVIP, contacted the
     Dy.Collector/Collector of the District , the advance IAF party and visited the
     temporary helipad area around it, took a recce with our Refueller etc.
    Next day just after 2 hours before the arrival of VVIP helicopter(M18), it rained a
     bit for around 15 – 20 minutes.
    Now as luck would have it, during our approach to the VVIP Helicopter for
     refuelling, the rear type of our loaded refueller got stuck in somewhat damp patch
     of made up approach road.
    All our efforts to tow, pull out the refueller with the help of another vehicle failed.
     VVIP’s hault at that place was only for an hour or so and we had already lost half
     an hour to pull the refueller out.
    I asked the District Collector to help us by providing a crane. Though he ordered
     for a crane tobe positioned, but the nearest one available was at a distance of
     around 100 km(which will take time). Moreover his contention was, we had
     never given the advance requirement of positioning the crane.
    Anyhow the Commandor piloting the helicopter of VVIP came to our rescue and
     to our good luck, the length of the gravity refuelling hose of our Refueller was
     long enough to refuel the Helicopter , from its stuck position. So the refuelling
     was done while our attempt to pull the refueller was in progress. Furthermore the
     IAF Pilot was kind , confident and experienced enough to take off the helicopter,
     inspite of our Refueller being so close. All of us thanked the Almighty for the safe
     and timely departure, only because of the pilot of the Helicopter who before
     learning shared with me that he had encountered a similar situation elsewhere in
     the past.

                                            22
    Now after the departure of the VVIP, everybody from the District Administration
     of the crow, vanished suddenly in no time, with my refueller still stuck up in the
     mind with no signs of crane around or no information. I was left high and dry.
    Somehow with great difficulty follow up and repeated requests, the crane arrived
     in the evening and we could pull out the Refueller safely.

                                       LEARNINGS:-


What I am trying to say here is that in any of the outstation VVIP refuelling in far flung
small places away from District Headquarters, we must get an unconditional support
from administration on the following issues:-
    Security, safe custody of our Refueller.
    One night stay arrangements for the Officer/Staff. It has been an out experience
     that in such a place there are either no/few Hotels which are fully occupied due
     to the VVIP visit. Similarly the Government guest houses are occupied by their
     own Officials with the result that we are forced to stay in our nearest Retail
     Outlet.
    Advance positioning of crane(as in this case). Fire Brigade etc.
    Proper Communication arrangement with our controlling Office from the spot of
     Refuelling, since the networks and telephone line from such far places do not
     respond at crucial times.

   It is my humble submission here, that a written communication should go from our
   Co-ordinating Regional Office (higher than AFSs) through E-mail or otherwise to the
   concerned District Authority requesting to provide all the necessary support.
   Specially mentioning all the standard requirement and emergency help. It is a
   common feeling among the Administration that any failure or delay of such an
   outstation VVIP refuelling is solely the responsibility of IOC, whereas we have to
   depend heavily on their support and help in case of an emergency. There is a need
   of complete coordination and harmony between us as fuel vendor and the Local
   Govt. Adminstration.



                                         Replicability:-


   In nutshell, like all our other SOP/QC procedures in case of an outstation VVIP
   Refuelling; there is a need of Standardisation of the most important points of help
   and coordination which we may need and fall back upon in case of emergency at far
   flung areas, which are beyond our network and control.
   This includes, the following(mainly):-



                                             23
i.     Safe and secure escort of our men/manpower Refuelling equipment from
       the AFSs to the spot of refuelling, particularly in sensitive areas targeted
       by naxal groups, more so when our people are reluctant due to the
       obvious threat perceptions and their sabotage vulnerability.
ii.    The availability of Crane, Fire Brigade, Ambulance security, proper stay
       arrangement and other communications.
iii.   Similarly necessary emergency and rescue covers, in case of enroute
       accidents need to be spelt.
iv.    These things need to be imbibed at all levels starting at the highest level
       of IOC first, IAF and District Administration so as to discharge the duties at
       the field level fearlessly.

                            Action By The Location:


1. We have disclosed our predicament to the CEO of the unit.
2. We have explained the “short coming” of the directives of the AQCAM in this
   regard and requested him to act on “moral propriety” instead of “legal
   propriety”.
3. Around 20 Kl of AVGAS was downgraded by IAF on their account.

                                Lessons Learnt:


1. Comprehensive Quality history of the product needs to be ascertained
   thoroughly prior to committing defueling of old fuels in large quantities.
2. SOP in regards the contention needs to be relooked for future.




                                     24
                                     CASELET -15
                                   Experience sharing by


                           Shri S.R. GUPTA, Ch. APTM, KOL AFS.

                                   Issue under discussion

The incident:


For refueling an Aircraft of M/s. Singapore Airlines, one dispenser AHD-51 was
positioned at the aircraft. After getting clearance from the handling agent, the inlet
coupler was connected to the hydrant pit and staff were getting ready to connect the
coupling. The refueling officer was standing near the front of the dispenser and he
noticed some fumes coming out of the front grill of the dispenser. He opened the door
of the cabin and found that smoke was coming out of the junction box inside the cabin.
He operated 1kg DCP but the smoke kept on coming out of the junction box inside the
cabin. He operated 1 kg DCP but the smoke kept on coming out. The dispenser was
remove from the site. While the dispenser was being driven, flames started coming out.
After driving the dispenser for about 40-50 mts away, the heat became unbearable and
he stopped the dispenser. One 10 kg DCP, one 40 KG DCP were discharged but the
fire was extinguished by Fire tender of AAI with water.

Investigations:

The incident was investigated by a team of IOC officers and also by a team of Air BP
Officials and as per their reports, it was a case of fire due to short circuit in the electrical
system of the dispenser.
The cabin of the dispenser was completely burnt out. The refueling system behind the
cabin was unaffected by the fire.



                                        Observations

1.     While the staff did a commendable job by operating 1 kg DCP and removing the
       dispenser to a remote area, no attempt was made to switch off the master
       electrical switch.
2.     It was observed that the position of such switches was different in different
       vehicles. It makes it difficult to remember the position during emergencies.
3.     The position of switch in this particular vehicle was very off. Near the clutch
       pedal. It was not easily accessible position.
4.     There was no system to check the electrical health of the refueller. The AE forms
       are mainly for the mechanical parts and laid less stress on the electrical system .
                                              25
                                      Learnings

1.   Position of Master Electrical Switches must be standardized and should be
     placed outside the dispenser/refueller so that it is easy to operate.
2.   Staff/Officers should be educated that in case of electrical fires the master switch
     must be switched off.
3.   New Electrical audit format has been introduced and it has to be done once a
     year. As per prevalent practice of Air BP, the audit should be done by Officer
     other than the maintenance Officer.
4.   All electrical maintenance jobs should be carried out by authorized electrician.




                                          26
                                  CASELET – 16
                               EXPERIENCE SHARED BY

                       Ms Usha Upadhye ,Mgr (AVN), Mumbai AFS

                              ISSUE UNDER DISCUSSION:

TESTING OF THE CARTER COUPLER ON THE TEST RIG AFTER SERVICING /REPLACING
                                THE SEAL
                 EARLIER SYSTEM OF TESTING THE 4”COPLER

Whenever there is problem in the carter coupler like passing of the fuel even after
releasing the dead man control, continuous fuel leak from the air release valve etc .it
needs replacement of seal kit .After servicing & after fitting to the hose the dispenser
has to be connected on the test rig (simulator) to check proper functioning of the pcv of
inlet coupler. This use to waste lot of time , manpower & also cuase running of main
pump, there by increase in the electricity bill.

While circulation if the problem not solved again disconnects the vehicle & take to the
workshop, rectify the problem observed & again putting for circulation.

                   SOLUTION IMPLEMENTED & BENEFIT OBTAINED

The old dismantled pit valve serviced & one 12’’ flange with ½’’extension in the center is
made ready. By using hose pressure testing manual hand pump ,inlet pressure to the
pit or line pressure of 150psi is simulated by connecting the pit with the ½’’extension .

 Air reference pressure to the coupler air sensing line can either be given from
compressor or the AHD itself by operating the dead man handle.

By this method of testing we can see visually the faulty seal, from which part of the
coupler leakage is & directly by replacing the seal the inlet coupler problem can be
solved & can release the dispenser for operation after final checking on test rig.

                                    REPLICABILITY:

All Regions (at location with Aviation Hydrant Dispenser).




                                            27
                                    CASELET -17

                               EXPERIENCE SHARING BY

                     Shri GIRISH KHANNA, CHIEF APTM AFS PALAM

                               ISSUE INDER DISCUSSION:

                      HANDLING THE ADVERSE MEDIA INSERTION

This is an experience of a different kind and is quite recent when during one of the VVIP
movements the VVIP was delayed due to damage to the aircraft at the last minute.

This incident happened when our refueller was being taken out after the final sign off
from the concerned Engineer/ Pilot. During this time the cargo loading equipment of the
Airline Operator accidentally hit the cargo hatch and damaged the aircraft. After
removing the refueller we left the site and got busy preparing for the refueling of stand
bye aircraft, which was expected in about 2 to 3 hours time.

In the mean while we got a call that the news was being flashed on some of the news
channels that the VVIPs departure has been delayed as the fuel truck/ refueller has hit
and thus damaged the VVIP aircraft.

The matter was immediately brought into the notice of the superiors (GM and ED). This
is when ED promptly acted and action was initiated through CC for rectification. The
matter was brought into the knowledge of the Director and above about the
misinformation appearing on new channels and web.

At the ground level we checked up with all those concerned i.e. the Customer and the
DGCA, and informed them about the misinformation going around. With all the Officials
present at site this became easier to handle. This incident in the mean while was
checked up with us by the Chairman and Director’s Office as well and it was confirmed
to them that IOC was in no way involved with this incident. The concern also came in
from the Industry members as well.

The incident also resulted into visit of Minister of Civil Aviation and CMD of Air India, at
the site to assess the situation.

In about 2 hours time the clipping and news item was changed and the correct cause of
damage started getting flashed. This timely correction saved us from the negative
publicity during the prime time.

This was important in the wake of current incidents linked to IOC and the image of the
Corporation.



                                            28
The proper communication at the proper time saved the embarrassment to the top and
also prevented the spread of false information into the print media.


                                    Lessons Learnt:

No time should be lost in raising the level with effective communication, when it is
required, so that timely action can be initiated to avoid spreading of rumours and save
us from the situation of further damages and initiate damage control.

The benefits we could reap from this prompt action were saving the adverse publicity
that would have harmed the corporate image and then any amount of rejoinders would
not have recovered the damage done. Prior information to superiors from with in gives
them the level of confidence to face the situation and address the issues raised to them
from any quarter.




                                          29
                                     CASELET -18
                                  Experience sharing by
                       Shri G.Krishnakumar, Ch.APTM,Chennai AFS


                                  Issue under Discussion

Improving the competence levels of officers in Quality Control, Aviation Operations and
Safe operating practices.


Generally in all the Metro & Major AFS’s , most of the officers are working in shifts
taking care of Into Plane Refuelling operations “. In their day to day work, they are
mostly confined to supervision of refueling. Though, supervision of refueling is the most
important activity, the same can not be done in an efficient manner without the overall
knowledge/awareness of QC, Aviation operations and Safety.

By virtue of their job profile , the competence / awareness levels of officers working in
QC, Maintenance and General shift is found to better when compared to the officers
who work in shifts for carrying out refueling activities.

At our location, we felt the need of improving competence levels of our officers. Every
officer at the location shall be conversant with the provisions, knowledgeable with
procedures and shall be competent to execute the work without flaw. Though our
officers are attending ‘ Aviation Refresher Course ‘ once in 3 years , ARC being
basically class room based training can only refresh Manualized procedures but can
not be a substitute for “continuous on field training on execution of those procedures.”

To achieve the same, we have started a “Learning Initiative” at our location.

                                        Methodology:

2. We have initially started giving inputs on QC and Aviation Operations by making
   around 20 capsules / sessions of approximately 2 hours each, which include
   Demonstration of various field tests and making the officers actually carryout the
   tests by themselves
3. Shift wise all Offices are made in to 4 groups. Each group is advised to report two
   hours early in their II shift duties. By this way, each officer will get a training input of
   4 hours per week. For covering the 20 capsules for all groups, we may need
   approximately 3 – 4 Months. We are conducting training almost daily for completing
   the capsules with in this period.
4. At the end of each session, a questionnaire pertaining to the subject of the session
   is given to the participants and at the beginning of each session a review/ recap of
   the previous session is done
5. The Capsules/ sessions are given below


                                              30
   a) About Storage Tanks at AFS
   b) Handling of packed products
   c) Hose specifications and HPT
   d) Nozzle Strainer checks and HECV checking
   e) The functioning Refueller mounted Gauges, PCV setting
   f) Circulation Test as per AV-1
   g) Different types of filters and its functioning
   h) Fuel Specifications
   i) Copper, Silver strip corrosion tests
   j) Gravimetric Millipore Test, Color membrane test
   k) Meter Calibration with proving tank, Importance of accuracy of the meters
   l) Receipts ( TT, PLT)
   m) Calibration of Hydrometer, Thermometer, Pressure gauges
   n) DGCA Regulations- Awareness about CAR series
   o) Ramp Safety
   p) Usage of additives- Lubricity additive and FSII
   q) Two sessions on Refueller trouble shooting/ AE forms
   r) VVIP Refuelling, Procedures to be followed incase of air accident, switch
      refueling, color coding
   s) Two sessions on understanding and implementation of QC,HO Aviation
      Circulars

5 Under each session wherever Tests/ physical activities are involved, officers will
  be given individual hands on training

We have started the Training Initiative wef 09.12.2009 and already completed 15
sessions as on date. This means each group has undergone approximately 4
sessions.

In general, training is conducted in class room and the participants are used to it.
When we have started the training with on field demonstration, the initial response
was not encouraging, whereas after 3 sessions their participation has become very
good, now officers are showing more interest than what we have expected. In
some of the cases like HECV Testing, officers could actually understand the test and
perform the same independently, when the inputs are given by demonstration. The
same was not happening when we ask them to read the material and understand

After the Completion of “ QC and Aviation Operations” , we are planning to take up a
similar initiative exclusively on “Safety “ by converting into small sessions.

                                   Replicability:

The above can be replicated in Major/Metro locations and even in small locations to
enhance the awareness / competence levels of all our officers.




                                       31
                                    CASELET -19
                                  Experience shared by

                 Shri T.Janarthanan, Ch.Manager(Aviation), Mumbai AFS

                      Issue under discussion:     VVIP refueling task

The incident:

During one of the VVIP refueling tasks, refueller was sent from location to a place about
300 Kms away. The refueller left on schedule from AFS. The officer who is supposed to
follow the refueller in car started late from the city after leaving the AFS for reasons
known to him, probably on the assumption that he would catch up the refueller en-route.
There were two routes for approaching the main high way leading to the place in
concern. Refueller developed snags and was struck. The crew was waiting for the
officer. The officer took the other route and went on searching the refueller and moving
ahead.

During the time of incidence, incidentally mobile connectivity was not available.
Meanwhile, the crew somehow contacted the AFS and informed about the refueller
failure as well as missing officer and asked for standby refueller to be sent immediately.

Another refueller with an officer accompanied by the in-charge and me in our own car
reached the spot and handed over the standby refueller to the crew and asked them to
proceed to the VVIP refueling destination. Simultaneously, another officer equipped with
VVIP sampling kits was advanced through railway so that he can reach the destination
faster than the road transport and can take care if warranted.

The first officer reached the destination and found the refueller has not reached. He
started returning back to trace the refueller. Meanwhile, we returned to AFS bringing
back the faulty refueller. Since there was no communication from the officer during
these entire activities, two of us went to the police station seeking help for tracing the
officer and his car. The police inspector started enquiring with embarrassing questions
giving the impression as if it is a part of a conspiracy for the purpose i.e. intentionally
this has been tried to be goofed up as a matter of sabotage.

At one point of interrogation, the police officer has started doubting us, and also giving a
kidnapping angle to the case. He, however saw the truth & desperation in tracing the
officer, and helped flashing a message to all police stations. One of the check posts
reported that a car with bearing the particular registration number has crossed them
twice in two opposite directions and finally went towards the destination where VVIP
refueling was to take place.
However, the VVIP refueling went on smoothly without any further hindrance and
without the knowledge of the aircraft operators about the initial chaos.



                                            32
                               Lessons Learnt:

1. Route specification needs to be finalized by and between the attending
   personnel.
2. SOP needs to be followed strictly.
3. In case of any deviation, communication needs to be established expeditiously.




                                     33
                              CASELET - 20
                             Experience Shared by

                     Shri RAVI KOLAMBKAR, MGR(QC),WR

                        INFORMATION SHARING ON
            FAILURE OF JETA-1 IN SILVER STRIP CORROSION TEST

                                  Background:

a. As per IQCM JETA-1 Tank Bottom sample ex Tank A was sent for Silver Strip
   Corrosion Test on fortnightly basis.
b. Sample found failed in Silver Corrosion Test. Lab conducted Repeat Test on
   same sample. Found failed. Rating was more than 3.
c. Asked for Repeat Sample. Test conducted on Repeat Sample. Same Result.
d. Informed concerned Location & QC Dept about failure.

                          Observations by Committee:

   Location was having multi-product pipeline facility to receive products coastal
    tanker.
   Pipeline was always filled with sea water before and after receipt of products.
   Fresh receipt of JETA-1 was taken into Tank A as per laid down procedure in
    Aviation Manual.
   Verifying LP Test Report.
   Conducting PD Test before receipt.
   Following correct procedure during discharge.
   Initially SKO discharge started.
   Pipeline water pushed into SKO tank and desired quantity of SKO was taken into
    SKO Tank.
   Followed by JETA-1 discharge. Interface cut was taken into SKO Tank.
   After getting clear JETA-1 product, switched over to JETA-1 Tank.
   Tank drained from bottom to remove water.
   All Level Sample tested for B. F. Test A/Receipt of product by giving proper
    settling time.
   Product was meeting to all B. F. parameters including Silver Corrosion Test.
   Hence there was regular movement of JETA-1 to AFS.
   Fortnightly sample found failed in Silver Corrosion Test.
   Tank Quarantined for further investigation.
   Different Level Samples (TMB) of JETA-1 tested. Found failed. Rating was 2 to 3
   Line samples tested, found failed.




                                       34
                              Cause of Samples Failure:
      Some quantity of Water found in pocket of JETA-1 line. Water was stagnant and
       having sulphide test positive. Pipeline product came in contact with sulphide
       reach water and got corroded. Same product got mixed with on spec product.
      Initially All Level Sample passed for Silver Test.
      Product started to deteriorate at bottom.


Corrective Action:
               1. Whole product down graded to SKO.




                                         35
                                  CASELET – 21
                                  Experience Shared by
                          Shri Anil Sarin, Chief APTM, NITC AFS


                               ISSUE UNDER DISCUSSION

ZERO RESET REMINDER


                                   EARLIER SYSTEM:

The bulk meter of hydrant dispenser needs to be reset to zero manually by the workmen
before the same is taken to the next flight for refueling. The same is done at the AFS
only to avoid any slippage on part of the worker.

                                   PROBLEM FACED:

Twice we encountered the problem wherein the bulk meter was not reset to zero &
dispenser was sent to another flight. The meter continued from the last figure instead of
from zero. There was uproar on the flight as the difference between the Aircraft meters
& ours was huge. While the matter could be settled by reverse working using Aircraft
initial & final figures, it was serious enough issue for us to let go. We stand to lose
customer confidence in case of more such incidents happening.

                        SOLUTION SUGGESTED/IMPLEMENTED:

The human error had to be eliminated. The core team of the location did some
brainstorming to find a way wherein you are forced to reset the meter to zero.
We developed an alarm system installed near the bulk meter. It had a relay which was
connected with the main switch of the dispenser. A cut off switch was installed inside
the meter which gets actuated by the meter resetter knob. This cut off switch in turn
would disconnect the alarm.
Now as soon as the dispenser main switch is put on, the alarm fitted near the bulk
meter starts beeping. This sound would continue till the meter reset knob is rotated
(which activates the cut off switch) to reset the meter. The sound is strong enough to
ensure it doesn’t get unnoticed or ignored.
When the dispenser is restarted next time for another flight, this alarm start beeping
again.
With this, there has been no issue of such slippage at location. Now we are trying to
work out a solution for the cases where the dispenser has to go to another flight directly
from the first one. In such cases as the engine is not switched off, the alarm will not set
off.

                                     REPLICABILITY:


                                            36
                                       Any AFSs.
                                  CASELET - 22
                                 Experience Shared by
                         Shri Anil Sarin, Chief APTM, NITC AFS

                              ISSUE UNDER DISCUSSION:
Creation of checklist /ready reckoner for officers/workmen

                                   EARLIER SYSTEM:
The NITC is in the business of plane refueling. The location operates 24x7 & refueling
operations are managed through shift manager assisted by shift officers & workmen
which consists of chargemen & operators. All these four type of employees have
different roles & slippage by anyone could become a operational hazard.

                                   PROBLEM FACED:
It was found that while all new workmen joining locations from other departments were
given adequate exposure for 3-4 weeks before being inducted for independent refueling
operation, the slippages were happening with not only workmen but officers & shift
managers too. Our internal reviews were highlighting the incomplete works / missed out
checks / non information about casual flights etc. It was happening either due to work
pressure particularly in night shift or because of casual approach.

                        SOLUTION SUGGESTED/IMPLEMENTED:
It was decided that we must have a check list of mandatory activities for all four groups
separately.
For shift managers: The list was exhaustive covering all the activities that a shift
manager needs to complete. This included even the basic tasks such as checking flight
schedules, date diary for casual flights, QC checks before shift beginning, log books etc.
Shift officers: The role of the officer is clearly defined covering the QC checks,
overseeing the marshaling, checking for any leakages, earthing, bonding etc.
Chargemen & operators: The two have distinct activities & responsibilities which were
all made part of the check list. The speed limits, marshaling, checking for zero setting,
chokes on both sides, earthing & bonding, sampling etc which are mandatory part of the
refueling drill have been listed in details.

All these checklist are provided in the shift room & shift managers are encouraged to
discuss the same as & when they get free time. The shift managers in particular have
found this list very handy & is kept under their table glass.

The list gets updated regularly as & when new activities are added to the domain of shift
managers/shift officers. This check list is also used as an internal training tool.


                                    REPLICABILITY:
                                      Any AFSs.


                                           37
                                   CASELET - 23
                                  Experience Shared by

                Shri Kamesh Kalapala,Sr. APTM / Visakha AFS


                Exemption of State Sales Tax for International Customers

With reference to the International convention of GATT at Geneva, all airlines’ belonging
to the participating countries have agreed on the exemption of sales tax on the fuel
supplies made. Accordingly, at the instance of Minister of MOP&NG, the matter was
taken up with Ministry of Finance, Govt. of India during the year 2002 and it was
resolved that no sales tax will be charged on any foreign airline visiting any of the Indian
ports. Official Gazette Notification has been brought out and all the taxation authorities
of individual states have been appraised of the development.

Very frequently there is many a casual foreign private airliner visiting our upcountry AFS
locations for refuelling. Generally, based on the communication from HO Aviation, such
foreign airliners are being refueled and billed (with exemption of state sales tax) as per
the procedure specified.

One visiting finance official has questioned the authority of the one upcountry AFS-in-
Charge to bill the foreign airliner without sales tax. It is pertinent to note the following
reasons behind the officer’s query.

   a. Communication from HO Aviation was silent or rather does not expressly forbid
      the location from charging sales tax on the customer.

   b. Bill/Invoice made in the name of the customer for the fuel refueled does not
      reveal the reasons for the exemption of sale tax to the customer.

   c. No communication either from the location or from HO Aviation on the details of
      sales tax exemption are forwarded to the State Office so as to enable them to
      take up with the Sale Tax authorities.

   d. Absence of any specific format to be submitted to the Sales Tax authorities in
      such cases of sales tax exemptions.

   e. Exemption of sales tax while billing can be done in our SAP accounting even
      without giving any reason or reference.

In the absence of such an important communication/circulars pertaining to the
exemption of sales tax to international customers at the location it has become very
difficult to the location in charge to convince the finance officer.



                                            38
While it is not the intention to pin-point the ignorance/unawareness of the finance officer
regarding the policy on exemption of sales tax to international customers, it is pertinent
to note that there is no clarity or availability of policy guidelines at the upcountry
locations.

                                  Present Requirement:

   1. Copies of the official gazette notification, list of countries exempted from sales
      tax to be uploaded to Intranet Aviation website.

   2. As and when such supplies are to be made to any casual international aircraft,
      copy of the HO communication on billing procedure to be marked to respective
      State details with copies.

   3. Manthan team to modify the SAP billing procedure to enable printing of the
      invoice in such cases with clarification on the exemption of sales tax.




                                            39
                                   CASELET -24
                                  Experience shared by

                                     Shri M.S. Wite
                               Sr. Mgr(Avn.), Mumbai AFS


                                 Issue under Discussion

                      Refuelling of Jet Airways flight at Aurangabad


                                       Background

During my tenure at Aurangabad AFS in the year 1996, Jet Airways flight Mumbai –
Aurangabad-Mumbai operated daily but did not take any fuel at Aurangabad. Prior to
my posting, the practice was that we checked up from ATC who in turn contacted the
pilot for requirement of fuel. Due to cheaper price of ATF at Mumbai, every time the
response was negative. Fuel was tinkered from Mumbai BPC. It was a practice that
the Refueller was not send for this flight. We used to keep manpower forthis fight
sometimes on overtime also which we could not justify due to nil fuel upliftment. We flet
dissatisfaction with this type of operation.

                                      Methodology

We started to place our Refueller near the aircraft soon on arrival. We used to meet the
pilot and AME and requested them to take some fuel atleast. They would ask for small
quantity fuel such as 500 lts., and slowly after some days they started taking their sector
fuel i.e. between 2500-3000 lts.

                            Lessons Learnt/Benefits obtained

Thus even though the price difference was still there, due to our keenness to serve the
customer, they started taking fuel which was nil upliftment earlier on all occasions. The
manpower was utilized in better way. Sales figure improved at Aurangabad AFS.




                                            40
                                  CASELET -25
                               EXPERIENCE SHARED BY

                             NAME OF THE PARTICIPANT

                                 Shri MD. SOHRAB ALI

                              MGR.(Lab.), Mourigram Lab

                              ISSUE UNDER DISCUSSION

In one of the Port Terminal Location, JET A-1 was being received from different
Refineries which created layering in JET A-1, storage tank. AV-3 is prepared taking
samples from all Tank Truck Chambers & send to different AFS. In one day four Tank
Trucks were loaded and send to one AFS. But in two tank trucks the receiving location
got density variation beyond permissible limit and they have not unloaded last two tank
trucks showing density variation from density recorded in AV-3. The matter was
reported to Regional Quality Control Department. The matter was investigated by QC
Dept. , and they found that the concerned officer from dispatching location have not
checked chamber wise density from Tank Truck and only due to layering in storage
tank, which is common physical property of liquid, this density variation has occurred.
The concerned Officer was issued warning letter.


                                  LESSONS LEARNT


Before preparation of AV-3, religiously density from all chambers is to be taken and in
case of variation of density beyond permissible limit of storage tank to be reported to
Location-in-charge and the reason for density variation, eg. Layering is to be written in
remarks of AV-3.




                                           41
                                    CASELET -26
                                EXPERIENCE SHARED BY

                              NAME OF THE PARTICIPANT

                                   Shri M.Mohankumar
                              Ch. APTM, Nedumbassary AFS


                               ISSUE UNDER DISCUSSION


It was one evening when a Naval visiting Cheetah helicopter from Cochin boarded for
Visakhapatnam landed at Trivandrum Airport, requesting for refueling. As the Airforce
Bay is away from the Civil dispersal, the crew was sent with the documents for
completing the refueling.
While carrying out the Refueling procedure the Overwing Nozzle Duct Cap(Stainless
Steel) has accidentally fell into the Aircraft tank. Even though the matter has come to
the notice of the technician attending the Refuelling, the Operator felt unsafe to do the
Refuelling and the mater was reported to the Office.
On reporting the matter to the Aircraft Pilot and then the Engineer, who in turn informed
Southern Naval Command, wherein, it was decided to take out the cap which is trapped
inside the fuel tanker before making the Aircraft Airworthy.

Navy arranged an Islander Aircraft from Cochin accompanied by 6 Technicians and an
Engineer to carry out the task and the next day of the incident the Foreign Object
Debries(F.O.D.) was taken out and the Aircraft was refueled and flown safety to
Visakhapatnam.

Indian Navy appreciated the act of the OPERATOR, who had shown the courage to
inform the higher up, rather than keeping silent. Indian navy did’nt charge IOC any cost.
The matter ws reported immediately to the Regional Office and through Regional Office
to Head Office also . Regional Office appreciated the efforts rather than finding fault with
the Location for dropping the Duct Cap.

                                        INCIDENT

Accident at one of the AFS, where a Jeep hit an Aircraft resulting in damage to an
Aircraft as well as injury to the person driving the Jeep.

It is an experience that in a situation like this it is very important to take care of the
individual in the operation shift.




                                            42
                                  CASELET -27
                              EXPERIENCE SHARED BY

                             NAME OF THE PARTICIPANT

                                   Shri S.S. Prasad
                              Chief APTM, Lucknow AFS


Present:

Aluminum Dust caps provided are of CAMLOCK COUPLING type on the drain points of
recent refuellers(AR 400 series) over a period of time, they become loose and start
dangling because of vibrations/refueller in motion.

Suggested Method:

Replace with threaded type dust caps ensuring that the bottom dust cap has outside
threads(male) and the top drain point projection has inside threads(female).

Benefits:

   a) Proper and secure fit of dust caps.
   b) No scope for water and dust ingress as surface contact area around the
      circumference of drain point is eliminated.




                                            43
                                  CASELET -28
                              EXPERIENCE SHARED BY

                             NAME OF THE PARTICIPANT

                                 Shri Rajeev Narula
                                Sr.APTM, Hindan AFS

                             ISSUE UNDER DISCUSSION

                      Crack in overhand of 27 KL Volvo Refueller


BACKGROUND:

2 x 27 KL Volvo Refuellers with Liquid 5th wheel were positioned 1st time at Palam AFS.
Complete length of Refueller was 55 ft and overhand behind chassis was about 6ft.
weighing two and a half tons. This overhang had filter assembly and refueling module
alongwith overhead refueling hoses and Catherine hose reels.

One evening, M&R supervisor during AE checks, spotted a 6 inch long crack on the I
section base frame of the overhand just behind chassis extension and withdrew the
refueller from Ops.

Matter was raised to NR Avn./HO Avn., and with Refueller manufacturer.


Solutions/Lessons Learnt:


1. The Refueller manufacturer welded the crack with 1 inch thick MS Plate on both
   side of “I” Section base frame on both sides of the Refueller and repeated the
   procedure on the Refueller.
2. AE checks alongwith visual check must be carried out with utmost care to keep
   refueller in healthy conditions.




                                          44
                                   CASELET -29
                               EXPERIENCE SHARED BY

                              NAME OF THE PARTICIPANT

                                   Shri Rajeev Narula

                                  Sr.APTM, Hindan AFS

                               ISSUE UNDER DISCUSSION

Fire in lose winding motor wiring during Refuelling.

                                     BACKGROUND

At around 5 PM, when an Indigo flight was being refueled at a Metro AFS, spark flame
was observed underneath refueller cabin. 10 kg DCP Fire Extinguisher was discharged
to extinguish the fire and refueller was immediately replaced. Upon investigation, it was
discovered that 24vak cable carrying current from battery to hose winding motor had got
short circuited and started flammation.

                             SOLUTION/LESSONs LEARNT

   1. Wiring carrying heavy loads should preferably be in metal conduit.

   2. Joining in wiring should be avoided.

   3. Periodic checking of switch of hose winding motor by opening should be included
      in AE checks.




                                             45
                                  CASELET -30
                               EXPERIENCE SHARED BY

                             NAME OF THE PARTICIPANT

                                   Shri Rajeev Narula

                                 Sr.APTM, Hindan AFS

                              ISSUE UNDER DISCUSSION

Chances of overflow from vertical tank during pipeline transfer due to lack of
communication.

                                  Background/Incident

PLT is regularly carried out from Bijwasan Terminal to Palam AFS. One Officer from
Palam AFS goes to Bijwasan at each PLT to gauge mother tank at start and at end of
PLT. Due to operational constraints, there is no set time for start of PLT. These
constraints can be :-
   a. No product at Bijwasn

   b. P/L or TW receipt from Mathura/Panipat/Koyali Refinery.

   c. Sample under settling/testing or

   d. Loading of TTs from Hindan AFS.

   e. Travel time from Palam to Bijwasan is approx. 25 minutes.

One day PLT was commenced in the morning and was slated to end by 8.00 pm. The
shift control room officer had been telephonically informed about probable closure time
which had to be confirmed approx. 1 hour in advance by shift officer at Palam AFS. AT
07:15 pm, shift Officer at Palam tried to telephonically inform Bijwasan control room but
could not make contact. He kept on trying for next 20 minutes but failed. Around 7:35
pm he frantically contacted the Officer who was supposed to go for tank gauging. The
Officer informed shift Officer to shift PLT in another tank in case contact could not be
made within next 20 minutes, while rushing to Bijwasan himself. PLT was finally closed
at 08:05 pm.

                                    Lessons Learnt

      1. Communication must be improved between supply and receipt points of PLT
         – apart from P&T lines and mobile.

      2. Margin for PLT closure should be maintained keeping in view traffic
         conditions.

                                           46
                             CASELET -31
                         EXPERIENCE SHARED BY

                       NAME OF THE PARTICIPANT


                             Shri Rajeev Narula

                           Sr.APTM, Hindan AFS


                        ISSUE UNDER DISCUSSION


Failure of Refueller Engine under Aircraft due to a silly mistake.


                               Background/Incident


M&R staff was informed that 1 number Refueller Engine had got shutdown while
refueling was in progress and the Refueller was not starting inspite of numerous
tries.
When M&R team reached the spot, they found that self was cranking but engine
was not picking up. They were surprised to discover that HSD fuel was empty.
HSD was topped up and after manual pumping of injector pump, refueller was
restarted.


                             Solutions/Lessons learnt



1. HSD fuel tank should be topped up regularly and a mechanism should be put
   in place for cross checking the same.

2. Driver/operator can be trained to check HSD fuel tank before taking refueller
   for refueling.




                                     47
                                  CASELET -32
                               EXPERIENCE SHARED BY

                             NAME OF THE PARTICIPANT


                                     Shri. R. Narula


                                 Sr. APTM, Hindon AFS


                              ISSUE UNDER DISCUSSION


           Leakage of ATF from ground unit of Kingfisher Flight at Taxi track.


                               BACKGROUND / INCIDENT


When a Kingfisher flight was approaching runway close to IOC Apron Building at Palam
AFS, It was observed that ATF was profusely leaking from ground unit on the wing of
the aircraft. Immediately Apron Control was telephonically informed and Pilot’s attention
was grabbed by frantic warning and finally aircraft went back to parking bay for
attention. Aircraft had been refulled by OMC.


                                  LESSONS LEARNT


1.    After refueling, walk around and look up check must be made mandatory at the
      start and end of refueling.
2.    Apron Control / ATC Phone Nos. must be widely displayed.
3.    Emergency response situations should include such a situation too.




                                           48
                                   CASELET -33
                                EXPERIENCE SHARED BY

                              NAME OF THE PARTICIPANT


                    Shri R.S. Bhattacharjee, Sr. APTM Guwahati AFS


Simplified Technique of Millipore Test on the hose fitted with OVER WING Nozzle


Existing Procedure : Overwing Nozzle is taken out from the hose and another
underwing nozzle is fitted in its place . Then the usual procedure is followed .Again ,
after completion of the test , underwing nozzle is taken out and original Overwing
Nozzle is fitted again .

Suggested Simplified Procedure : We have done small modification on an Overwing
Nozzle which is mentioned below .
   One hole has been drilled on the body of an Overwing Nozzle
   One adapter with proper internal thread was fitted with the hole
   Millipore test kit fitted with the adapter

Result observed : Fuel flow through this new arrangement is sufficient . The millipore
test can be conducted without any wear & tear of nozzles and lot of time and labour is
saved.




                                            49
                                   CASELET -34
                               EXPERIENCE SHARED BY

                              NAME OF THE PARTICIPANT


                                     V. Rangarajan,

                               Sr.APTM, Coimbatore AFS

                               ISSUE UNDER DISCUSSION


Ensuring the accuracy of Transcoder Facility provided for recording the Oil level in
vertical Tanks.

                                   EARLIER SYSTEM

The transcoder facility is provided in the location for Auto level gauging of Vertical
Tanks. In the shift room Communication Interface Unit (CIU) is provided in which the
shift officer can view the oil level in each vertical tank by selecting the tank selector
mode. The readings observed are recorded for shift handing over / taking over and for
recording OP-13.

                                   PROBLEM FACED

At one of the AFS location it is found that the shift officer recorded the dip readings of
the vertical tanks by taking the readings observed in the Communication Interface Unit
(CIU) which is provided in the shit room. During the location inspection physical
readings were taken and compared with the CIU reading and found about 3 cm
difference in one of the tank . On further analyze it is observed that for a long time
location has not verified the physical dip reading of tanks with that of CIU readings
resulting In recording the wrong dips for accounting purpose.

                        SOLUTION SUGGESTED/IMPLEMENTED

 Though the electronic gadgets gives accuracy in readings, its performance has to be
                                checked periodically.

                                     REPLICABILITY

                     All locations wherever such facility is provided.




                                            50
                                  CASELET -35
                             EXPERIENCE SHARING BY
                              LALIT MOHAN SANWAL
                            APTM, BAKSHI KA TALAB AFS

                        ISSUE UNDER DISCUSSION/PROBLEM:

                           SECURITY/PRODUCT SECURITY

When I took over Gorakhpur AFS, I noticed that regular thefts were taking place. My
presecessors were approaching Police / IAF Police but it could not get any relief.
This situation was continuing for many years.

I was keeping a vigilant watch without knowledge of others and trying to make strict
control over things. No untoward incident was noticed for first 2- months. One morning
during my round of the AFS, some marks were observed, which made me suspicious
that old story is coming-up again. Repeated observations confirmed my suspicion.

I took-up the matter with IAF Security. Their reaction was “KYA AAP KE AATE HE
CHORIAN SURU HO GAYE” DSC Guards are posted round the clock and your
people are working for 12-16 hours. How the theft can take place? There may be some
pilferage in your system.

I had no answer for the above and attidude of Civil Police was well known to me. I
was feeling at sea. I pondered over the situation and decided to take-up the issue at
the highest level.

I took an appointment with the AOC of the Air Force Station. Initially he also didn’t
show much concern. I told the AOC that it is not the theft which is worrying me, but I
am much more concerned about the security of IAF, as any intruder who can steal can
also plant a bomb, if falls into hands of anti-national elements.

This really changed the situation. I confirmed that none of our employees is conniving.
AOC assured me help. Next day AOC called me to his office where Security Officer
was also present. In this meeting it was decided that without knowledge of our IOC
employees and other security personnel a secret team of IAF shall enter IOC premises
and take position with arms and any intrude should be shot below waste line.

I overstayed in the office and let all employees go home. Closed AFS Gate as usual
and handed over Rear Gate Key to Security Officer. After some time the team entered
the premises and took position. Whole night myself and Security Officer were
monitoring from outside and the team observed no untoward incident. IAF people were
expressing the unpleasantness over this futile exercise.



                                          51
On my round of the AFS next morning I observed 1 x 40 litre cans filled and 5 empty
cans. I immediately contacted the Security Officer who witnessed and realized that
culprits had started their operation before the IAF team took position and fled away
once IAF team presence was realized by them.

It proved my point All concerned security personnel were put to severe physical
punishment. and IAF took their own course of action. Since then AOC was taking
security briefs of IOC from me and strengthened the security. In his briefing session
AOC made a special mention of vigilance of IOC officers. Knowing this the culprit will be
shot, the theft was never recurred thereafter.




                                           52
                                     CASELET – 36

ISSUE :
       Non Compliance of Standard Operating Practice during refueling of Aircraft.


INCIDENT OCCURRED :
       There was a ground incident at the tarmac where a flap track fairing of an Airbus
       A321 was hit by the railing of the hydrant dispenser’s fuelling platform when the
       dispenser departed from the aircraft after refuelling.


WHAT WENT WRONG:
   1. After completion of the refueling, Operator didn’t notice the position of wing flap of the
       aircraft (AB321) which were put down for cooling.
   2. There was no clear exit in front of hydrant dispenser. Airlines trolleys were lying on the
       way .
   3. The hydrant dispenser was positioned nose to tail. After completion of the refueling, the
       operator didn’t walk around the dispensers to check the height clearance . While
       driving away , he maneuvered steering of the dispenser towards aircraft (right side) and
       the platform railing of the dispenser hit the wing flap track fairing. The front portion of the
       flap cover was badly damaged.
   4. The Operator neither followed the SOP of refueling nor carried the SOP card while
       performing the activities.

LESSONS TO BE LEARNT :
     Following precautions are vital to prevent aircraft damage when maneuvering
fuelling vehicles under the aircraft wings:
   1. Clear Exit for the dispenser for driving away to be maintained. If the operator's
       view     from the vehicle cab is obstructed (e.g. by ground handling equipment),
       then the operator should double-check the “clear exit”from outside the vehicle
       before departing from the aircraft.


                                                 53
2. 360o Walk around should done after completion of the refuelling. Pay special
   attention to the flap track fairings during the mandatory 360° walkaround
   after refuelling. Keep in mind that the flaps might have be lowered down by the
   aircraft crew during the fuelling operation.


3. Operator should take extra precaution for height clearance while driving under
   the wing of AB-320 series aircraft .
4. Operator should take care of aircraft wing flap position before & after the
   refuelling especially in the summer day. If the wing flap is down, Operator should
   contact engineering personnel. After Clearance of AME, the dispenser will be
   positioned.
5. Operator should not drive towards the aircraft while removing the dispenser in
   case of non clear exit.
6. Operator should follow all steps of SOP of refuelling in TOTO.
7. After Completion of the refuelling , Operator will confirm to Shift manager On
   Walky Talky SOP Followed Refuelling Completed

   PICTURES OF DAMAGED FLAP FAIRING :




                                          54
                                 CASELET – 37

                           EXPERIENCE SHARED BY
                    J.Moorthy, Chief APTM, Nedumbassery AFS

                           ISSUE UNDER DISCUSSION
Protection of W&M Seals on electronic display of flow meters


                                   EARLIER SYSTEM
Mandatory verification is done by department of Legal Meteorology annually. Stamping
and sealing of the flow meters is done with lead seals and sealing wires.


                                   PROBLEM FACED
In the new electronic flow meters the register is sealed by using lead seal and wires.
The template in front of the register shows the position of selector switch and it is also
restricting the movement of the switch to calibration mode. For calibrating the meter this
plate has to be removed by unscrewing the screws that mount the template on the
register. These are the screws that are sealed after necessary calibration by the
statutory authority. The seals often tend to get rusted and due to frequent operation of
the switch the sealing wires get damaged as it fowls the operation of the knob.


                       SOLUTION SUGGESTED/IMPLEMENTED
   1. The wires were replaced with twisted SS wires.
   2. A cover made of aluminum plate was used to protect the seals and wires.
   3. An improvement over this is in the offing by changing the material to transparent
      plastic plate so that the positions on the template are visible.


                                  REPLICABILITY
All AFS where such meters are in use.




                                           55
                                   CASELET 38

                                      R.S.Rawat
                                 Chief Manager (Lab)
                                  Bijwsan New Delhi


                             Issue Under discussion :
       Failure of ATF ( Jet A-1 ) Parcel in copper and Silver Corrosion Test

ATF Batch was received through multiproduct pipeline in a marketing tank. After receipt,
composite sample of Tank was submitted in Lab for Batch Formation Test in line with
the Manual Guidelines.

During Batch Test it was observed that Composite Sample fails to meet the
specification in respect of Copper & Silver Strip Corrosion Test. Individual, Top, Middle
and Bottom samples were also tested and found failing in Copper & Silver Strip
Corrosion Test.Committee was constituted for the failure investigation


                                   OBSERVATIONS

Joint Samples drawn from the tank by the representative of Marketing Division, Pipe
line Division and Lab personnel were tested in Delhi Terminal Lab in the presence of
Committee Members. The Samples were found failing in Copper & Silver Strip
Corrosion Test.

The sequence of Pumping from Refinery to Marketing was
REAR – SKO - ATF - SKO- PNCP Napthta - PX Napthta - PNCP Napthta – SKO - HSD
-SKO FRONT
Whereas, the typical pumping sequence as per Pipelines Operation Philosophy would
be as under:
REAR- SKO-ATF-SKO-MS-SKO -PNCP Naphtha-PX Naphtha-PNCP Naphtha-SKO-
HSD-SKO- FRONT.

On review of the batch sequencing, it is noted that MS Batch was not introduced in
between SKO and PNCP Naphtha in the above receipt.

                          Testing of Retention Samples:
Committee collected retention samples from different points of pipeline division and
marketing terminals and tested for copper strip and Silver Strip test where :

   1. PNCP Naphtha and succeeding SKO ( Front) samples were found failing in
      Copper strip and Silver strips corrosion test

                                           56
  2. Naphtha sample was having high Mercaptan Sulphur content


Entire stock of 13550 kl was downgraded to SKO

                              Solution suggested :
  1. Proper Sequencing in pipeline transfer

  2. Quality of Naphtha to be established before introducing into pipeline in front of
     ATF




                                         57
                                   CASELET –39

                                   V. V. S. Trinath
                                   Sr. Mgr. (Lab)
                                    Korukkupet
                                       Chennai

The Issue:
Non adherence to SOP

The Experience:
Terminal receives Jet A-1 from HPC by a dedicated pipeline. As per the manualized
instructions, once the PLT starts, officer has to physically check line samples to Test ’H’
during first half an hour. Officer did the checks/ test H, found the sample satisfactory,
PLT initiated. Receipts from HPC started.

As per manual, officer is supposed to draw line samples of Jet A-1, for every half an
hour and check for Test ‘H’ (appearance, colour, density, sediments) to ensure that
clear products has being taken into our storage tank. However it was neglected. After
about 1 ½ -2 hours only, first sample was drawn and found that the sample was Hazzy,
did contain some moisture. PLT was stopped. But by the time, around 250-300 Jet A-1
with some amount of moisture was received into our storage.

We were forced to Quarantine the storage tank for two days, to drain off the water
received from HPC.Since there was same problem in one of the refinery units of HPC,
steam got reeked into ATF.

The Problem:
    Moisture got the Jet A -1.
    Storage tank was quarantined for 2-3 days to drain off water.
    Non availability of product.

Lessons learnt:

    Manualized instructions in Industry Quality Control Manual to Aviations products
     shall be strictly followed.
    Sampling during receipts shall strictly be followed.
    About importance of sampling to be educated/shared with down the line
     operators.



                                            58
                                  CASELET – 40
The Issue:
Improper sampling and testing.

The Experience:
Coast guard has submitted a Jet A-1 sample 15 Laboratory, expecting then the sample
would be failed in appearance.

Laboratory has tested the sample by taking the top portion of the sample as the
container was full up to the brim. That part of the sample was subjected to recertification
and found the fuel meeting the specification in verput of tests done and hence issued a
test report, declaring the Product meet specifications”.

The Problem:
Customer reported that he had expected that the sample would fail in appearance as
the fuel did contain some free water and extraneous matter. But the customer
unknowingly has taken the ATF sample up to the brim of the Aluminum sample
container, without leaving the required free space in the sample container.
While taking up the sample for testing, though the officer has followed the prevailing
practice, the settled portion of water and extraneous matter (sediments etc.) present
bottom in the did not come into the part of the sample taken up to testing.


Lessons Learnt
           Sample should not have been taken up to the brim of the sample
            container by the customer.
           Officer laboratory officer should have inspected the complete portion (2
            Ltrs) of sample before issuance of test report.
           Customer should have been educated about the sampling procedures of
            ATF.




                                            59
                                 CASELET – 41

The issue:
Sampling of Avgas 100LL


The experience:
One of the AFS has submitted an Avgas sample for testing at Korukkuper laboratory.
Sample formed to be failing in RVP test. Laboratory has asked for repeat sample.
A report sample was once again drawn from the storage tank of AFS and next to Lab.
Second sample also found tailing in RVP and hence Lab has incurred a test report
declaring that the sample does not meet specifications.

The problems:
Investigations carried out by the senior officers, and have drawn a fresh repeat sample
taking all precautions while sampling and got tested at laboratory. Sampling found
meeting specifications in all , including RVP.
     It is understood that the initial samples of Avgas were not drawn properly.
     No supervision by an officer has taken place.
     Condition of the Aluminum sample contains was not checked/ inspected.
     Leak test of drawn sample was not carried out.


Lessons learnt:
      Supervision of sampling by an officer is must.
      After sample drawal, the sample container shall be checked for leaks if any.
      Avgas sampling shall be done in the morning/ cooler part of the day.
      Condition of Aluminum sample container, that includes cramning worker/real
       condition of the lid shall be checked before drawing sample.




                                           60
                              CASELET – 42

                             Florence Macdonald
                                Sr. Mgr. (Avn.)
                                 Chennai AFS


1) Observation during meeting of Airlines (Head of Engg.) of various Airways.
2) As I was handling Customer Relations during my tenure at Chennai AFS.

3) Experience/ observation:

      1. This is particularly with reference to Cathay pacific.
      2. The head of engineering was Japanese with 42 yrs of experience, apart
         from working in more than 40 locations / countries.
      3. This senor gentleman along with the Engineers used to come to the
         tarmac about at least an hour in advance of the launching. This team
         would be in then PPE and would walk down the Bay picking up small
         things lying on the Tarmac at the Bay. They would collect all this and put it
         into the Bin. This they would do every day.

4) Lessons learnt-:
      1. Discipline.
      2. Conformance to stipulated requirements:
         - Always wearing then PPEs.
      3. Professionalism in their job.
      4. Once they commence this, they would totally be FOCUSED and would not
         speak to anyone.
      5. Commitment to their job.
      6. The Engineers, who are from Chennai, would speak and behave, like they
         belong to the country from where the Aircraft is coming.
      7. This behavioral aspects neglects on the training that they have gone
         through, wherein it becomes a HABIT.




                                       61
                        CASELET – 43
                     EXPERIENCE SHARED BY
                        DALVINDER SINGH,
                     Sr.APTM,AFS,HALWARA.


                        PRESENT SYSTEM
IN NORMAL CONDITION WHILE DOING MILLIPORE TEST,THE THREE LEG
MILLIPORE KIT IS ATTACHED WITH THE NOZZLE. WHILE LOADING THE
PRODUCT THE PRODUCT IS TAKEN OUT THGROUGH MEMBRANE FOR
MILLIPORE CHECKS FROM DELIVERY LINE TO RECEIPT LINE.
.
NORMALLY OUT OF 9 KL PRODUCT LOADED IN THE BOWSER,5 LITRES
PRODUCT IS DRAINED THGRU MEMBERANE FOR DOING THE MILLIPORE
TESTING.

NOW, WHERE THE ATF IS NOT SOLD AND THERE IS NO REFUELLER/BOWSER
TO GET THE PRODUCT FOR MILLIPORE TESTING.
AT AFS HALWARA,DUE TO RUNWAY REPAIR THE SALE IS ALMOST STOPPED.
WE DO NOT HAVE OUR OWN REFUELLER.

WE HAVE COINNECTED THE PRODUCT PIPES FROM DELIVERY LINE TO
RECEIPT LINE.THREE LEG ADOPTER IS ATTACHED TO THE NOZZLE POINT.
THE PRODUCT IS TAKEN OUT FROM ONE TANK THROUGH DELIVERY LINE TO
RECEIPT LINE AND BANK TO TANK.

IN THIS WAY ALL QUALITY/QUANTITY MEASURES ARE COVERED, AND
MILLIPORE AS WELL CIRCULATION OF THE PRODUCT CAN BE DONE .

SIMILAR METHOD CAN BE UTILIZED AT SOME OTHER LOCATION WHERE SUCH
PROBLEM EXIST.




                               62
                          Caselet – 44

                       CUSTOMER RELATIONS

LAST YEAR IN OCTOBER 2010 DASI INSPECTION WAS GOING ON AT
AFS,HALWARA.I WAS CALLED IN     THE EVENING BY SLO,9 WING FOR
DISCUSSING THE SUPPLY REPLENISHMENT PLAN AT HIS OFFICE .

I REACHED THERE WITHIN 5 MINUTES BUT SLO WAS NOT THERE.SUDDENLY
SLO CAME RUSHING AND ASKED ME,DALVINDER SINGH,PLEASE SIT IN MY
GYPSY.OUR HSD PUMP IS NOT DELIVERING PRODUCT.WE HAVE CALLED THE
MECHANIC FROM IOCL,WHO IS ON THE JOB SINCE MORNING .

WE WENT TO THE PUMP SITE AND WE SAW THAT HE HAS UNEARTHED THE
PIPE GOING FROM TANK TO THE PUMP. I TOLD MECHANIC TO FILL THE PIPE
FROM PUMP SIDE TOI TANK AND CHECK THE LEAKAGE IF ANY. MECHANIC
TOLD THAT HE HAD DONE IT AND NO LEAKAGE IS OBSERVED.THEY HAD
FILLED 2 DRUMS WITH DIESEL .

THE MECHANIC THAT AS THE DEFECT IS NOT BEING DIAGONISED, THE
EXISTING PIPE SHALL HAVE TO BE UNEARTHED TOTALLY AND SHALL BE
CHECKED AFTER THAT.

THE PIPELINE WAS BENEATH THE RCC AND SO IT WAS A DIFFICULT JOB.
ALSO THERE WAS HUE AND CRY BECAUSE MOST OF THEIR VEHICLE GOT
EMPTY. SLO HAD CALLED HIS 20 AIRMEN TO DO THE JOB OF DIGGING AND
TAKING OUT THE PIPE.

IN THE MEANTIME CENGO ALSO REACHED THERE. I TOLD THEM TO WAIT AND
LET US CHECK FOR THE PROBLEM.SINCE THERE WAS EXERCISE GOING ON
AND DASI TEAM WAS THERE SO IT BECAME THE VERY SERIOUS ISSUE AND
ALL THEY WERE HOPING THAT WE SHALL HELP THEM . ALSO SLO AND CENGO
HAD JOINED 1-2 MONTHS BACK ONLY AND WERE EXPECTING MY HELP.

LUCKILY I AM HAVING ONE FOREMAN HAVING EXPERIENCE IN PUMP REPAIRS.
I CALLED HIM AND TOLD TO CHECK THE PUMP THOROUGHL IF THERE IS ANY
LEAKAGE/AIR-BLOCKING.DUE TO HIS EXPERIENCE,WE COULD FIND THE
FAULT,AND WITHGIN 40-45 MINUTES COULD START THEIR PUMP SUPPLY.
HENCE WE STOOD BY THE CUSTOMER AND HELPED SOLVED THE PROBLEM.

IN THIS WAY I WAS ABLE TO WIN TO MAKE STRONG BOND WITH THE
CUSTOMER AND WAS ABLE TO BUILD IOC IMAGE.SUCH HELP CAN GO A LONG
WAY AHEAD.CENGO AND SLO TOOK RELIEF AND THANKED ME A LOT.


                                 63
THEN ON THE LAST DAY OF THE EXERCISE ON RUM-PUNCH PARTY,CENGO
CALLED ALL THE OFFICERS AND STAFF OIF IOC AS A SPECIAL GUEST FOR THE
FIRST TIME.
                           Case-let 45

                       EXPERIENCE SHARED BY

                       RAKESH KUMAR ARORA,
                        SR APTM ,NITC AFS

                      ISSUE UNDER DISCUSSION

             PRODUCT ASSISTANCE/EXCHANGE TO OMCs
                        EARLIER SYSTEM
SETTLEMENT OF PRODUCT TO OMCs AT @15 C AS PER INDUSTY PRACTICE

                          PROBLEM FACED

1.AS THE DESPATCH TEMP & DENSITY WERE THE MAIN FACTORS FOR
ARRIVING AT VRF(VOLUME REDUCTION FACTOR) & @15 C QUANTITY.

2.ONE OF THE OMC MEMBER MANUPULATING VRF BY ENTERING THE
FICTITIOUS TEMP & DENSITY IN SAP IN A WAY THAT @15 C QUANTITY IS
ALWAYS LESSER.

3.THERE BY VARIATION OF FINAL SETTLEMENT QUANTITY AS PER IOCL & OMC
AS PER JOINT CERTIFICATE (JC)

                 SOLUTION SUGGESTED/IMPLEMENTED

1.ACTUAL DESPATCHED DENSITY & TEMP RECORDED ON AV-7 WISE & DULY
SIGNED BY CUSTOMOR IS TO BE TAKEN & ENTERED IN SAP FOR FINAL
SETTLEMENT OF JOINT CERTIFICATE EVERY FORTNIGHT
2.NO VARIATION OBSERVED AFTER THIS SYSTEM IMPLEMENTED.

                           REPLICABILITY

                              ALL AFS




                                 64
AVIATION REFRESHER COURSE

          2010-11




Experience Sharing
     Caselets


 TRAINING & DEVELOPMENT
    NORTHERN REGION

            65
                                       Caselet–46
   ________________________________________________________________

                           Issue under Discussion:

                                Tarmac Discipline

                      Development of Problem faced:
On the receipt of the information about IC landing, the announcement was made to rush
to the tarmac for re-fuelling of the flight.

              Observation of Occurrence / Action Taken
Accordingly, in hurry the driver of the bowser drove the vehicle alone without the other
member of the crew. Also, he did not carry the VHF system with him.

Later on it was known that the re-fuelling of this IC aircraft is not to be done and the
same was being communicated to the driver / officer-in-charge on VHF system but due
to the non-availability of the same with the driver, he could not get the message and
drove the vehicle rashly and resulting into an accident by taking a steep turning at the
curve and over turned.

This not only caused the damage to the bowser but also there was a loss of product and
damage to the tarmac which was declared unfit for taxing the aircraft till it got repaired.


                         Learnings from the Incident
Driver of the bowser must always be accompanied with Operator / Chargeman.

VHF system must always be with the crew.

Fixed Speed limit has to be followed



                                    Replicability
       All AFSs



                                            66
                                     Caselet– 47
    ________________________________________________________________

                             Issue under Discussion:

                             Tracking AV-8 Payments

                                   Earlier System

There was no system in place to know the fate of AV-8 .Totally dependent on Accounts
Deptt.


                                  Suggested System

The tracking of AV-8 was introduced on Excel sheet containing all the important dates
and activities like, when was the AV-8 handed over to IAF for signature, when they
returned it , when was it handed over to Accounts Section. When accounts section
handed over back to us for BOC and when we submitted Challan from IAF for BOC,
when we got back the Challan from IAF after BOC and ultimately handed over to
Accounts for raising invoices.


                                  Benefits Obtained

This helped in proper track of individual AV-8 and also helped in BOC of challans up to
31st March on Ist April itself.




                                    Replicability

         All AFSs




                                           67
                                   Caselet– 48
   ________________________________________________________________

                      Issue under Discussion:
                 TT Decantation & Release of Empty TT

                     Development of Problem faced:
This refers to incident with reference to the subject TT during decantation at Dabolim
AFS. A TT was sent to “A” Terminal by “B” Teminal for JET A1 bridging to AFS. After
decantation of the TT, the officer-in-charge asked the TT Driver to wait as Compartment
No. 1 was having some extra product. However, instead of waiting, when the concerned
officer was busy in checking the other TTs, TT Driver picked up the keys from table,
locked the vehicle and went away from AFS before getting clearance from the
concerned officer.

             Observation of Occurrence / Action Taken
The same was reported to Ch. APTM, AFS. The vehicle was followed and asked to
report back to AFS. However, while coming back to AFS, Driver, reported that vehicle
belt is broken and cannot be brought back to AFS. Ch. APTM decided to get the keys
from AFS to open the locks of the TT and check the emptiness of vehicle. While doing
so, it was observed that out of 02 locks, one lock on top of TT was not getting opened
and appeared to have been damaged.

To check the emptiness of the TT, it was decided to cut open the lock. However, TT
Driver left the vehicle to create such a circumstances where without his presence no
one could open the lock and could blame the officer if he / she cuts the lock. Driver
was also not having the copy of challan in his possession which he had taken after the
decantation of the product at the AFS.

Later on the driver reported at 1500 hrs and the lock was cut opened in the presence of
the driver and the Comp No.4 was found 1 cm product as per Dip Stick. TT was brought
back to AFS under Terminal lock and the excess product was removed.

TT was relocked with Terminal locks (Locks kept at AFS) and asked to report to
Terminal.




                                          68
                      Learnings from the Incident

1.   All the compartments must be checked thoroughly

2.   Challan should not be signed by the receiving officer unless he /she convinced
     that the product is completely decanted

3.   Keys should always be in his / her possession


                                Replicability
     All Locations




                                        69
                                     Caselet– 49
    ________________________________________________________________



                            Issue under Discussion:

                            Using Tail blinds in lines

                                   Earlier System

In some units the blind practice was to use simple blinds in the line which was not
clearly visible so there are various instances of missing any particular line. Due to their
normal size it was difficult to view from the distance whether blind has been put into the
line or not which resulted in many malfunctions.


                                Suggested System

Now small blinds we used of tail-blind to ensure the visibility. Which is easy to identify in
case so many lines are to be blinded or deblinded in a particular case.




                                 Benefits Obtained
                             Easy visibility of blinds with tails

                                     Replicability
       All AFSs




                                             70
                                   Caselet– 50
   ________________________________________________________________



                          Issue under Discussion:

  Obtaining BOC number of air craft for faster realization of
                       payment

                                 Earlier System

It was observed that a large number of cases were pending where the Air force station
exist but BOC number was not obtained from that particular Air force station.


                              Suggested System
Matter was discussed with our senior officers and then taken up with logistic section of
the Airforce. They also agreed and were ready to take up the matter with that particular
location.



                               Benefits Obtained
The payment realisation time was reduced considerably.

                                   Replicability
      All AFSs




                                          71
                                     Caselet– 51
    ________________________________________________________________

                           Issue under Discussion:

                             Refueller Maintenance

                      Development of Problem faced:
While refueling of a small aircraft it was found that refueling pressure was not building
up. On pressing the throttle the diesel engine worked fine and then begin to sink.

              Observation of Occurrence / Action Taken
The chargeman found that there is leakage of diesel from the engine of the refueller.

Immediately the refueller was disconnected and towed away. On inspection
subsequently it was found that fuel line was cracked and it was the source of leakage.



                         Learnings from the Incident
Regular inspection of fuel pipe of refuellers must be carried out.

                                    Replicability
       All AFSs




                                            72
                                    Caselet– 52
    ________________________________________________________________

                      Issue under Discussion:
             Rust & Sediment particles in Pipeline receipt

                                  Earlier System
On line filtration through 10 micron & 5 micron filters which resulted in frequent change
of filter elements.


                               Suggested System
Introduce pre filtering system with 100/200 mesh. Indigenous permanent filters which
can be cleaned and put back.




                                Benefits Obtained
                           Cost saving by extending filter life

                                    Replicability
       All AFSs




                                            73
Experience Sharing



        AVIATION -
 TRAINING & DEVELOPMENT
    SOUTHERN REGION




           74
                                    Caselet–53
    ________________________________________________________________

                               Experience shared by

                                 Mr D P VERMA,
                              Designation : DM(AVN)
                              Location :    Agra aFS

                           Issue under Discussion:

                              IL 78 Night flying /Operations


                                  Earlier system:
We are working in a Commercial Organization and having concern about COST &
savings. Earlier we were keeping 3-4 workmen for night operation, which has now been
reduced to 2 workmen only.


                                  Problem faced:
As and when there is more IL 78 flying during the night, and it is known to all that there
is a full night operation, now what the Drivers have started to deny to stay back on OT
for night operation right at 2200Hrs.
 With a view to encash the situation to increase manpower during night.
 Under such circumstances officer has to operate with the help of MTD from 78 Sqdn.


                           Solution suggested\implemented:

   It is proposed to engage 1 or 2 standby driving hands on contract basis which will
    cost Rs.4-5 thousand per person in a month whereas we are incurring OT of Rs.8-
    10thousand per night. i.e.8x20Ops.=1.60lacs per month
   Thus a saving of Rs.1.5lacs per month and annual saving of Rs.18lacs to meet the
    customer requirement/ operation smoothly.


                           REPLICABILITY:

                                           75
All Locations.
                                    Caselet–54
   ________________________________________________________________



                           Experience shared by

                                Mr K.Hariharan
                          Designation : Manager(QC)
                          Location : Ahmedabad Lab


                           Issue under Discussion:
                                    Dormant ATF in P/L


                                  Earlier system:

      AT AFS pipelines are extended by 1 / 2 mtr. and over hanging, where blinds are
                   provided leading to dormancy of fuel in that portion.


                                  Problem faced:
        Dormant ATF in that area of P/L may lead to failure of product inadvertently.


                           Solution suggested\implemented:

      Dormant P/L to be removed or provided with a drain point and product drained
                            frequently to avoid dormancy.


                           REPLICABILITY:
       All Locations




                                           76
                                     Caselet–55
   ________________________________________________________________



                           Experience shared by

                           Mr Ashok Kumar Yadav
                      Designation : Asst.Manager(Lab)
                           Location : Ajmer Lab


                           Issue under Discussion:

                          SKO tank failure in weekly FP Test.


                                  Earlier system:

During weekly FP test of SKO tank, it was observed 3 degree less than the Batch
Formation Test report. Although sample met specification, sanctity of sample was
suspected. Again re-sampling was done and SKO tank failed in FP test.


                                  Problem faced:
After investigation it was found that MS got mixed in SKO tank during PL receipt though
expansion line of tank.


                           Solution suggested\implemented:

   1. Sampling to be done carefully.

   2. Although sample meets the specification, if there is variation in test results matter
      to be investigated.


                                    REPLICABILITY:
All Locations




                                            77
                                      Caselet–56
   ________________________________________________________________



                             Experience shared by

                              Ms.S.PRINCY RAGILA
                           Designation : DY.MGR(AVN)
                            Location : CHENNAI AFS

                             Issue under Discussion:

                Earth reel bonding in refueller loading shed & decantation bays.


                                    Earlier system:
                                      EARTHING REEL


                                    Problem faced:
      CLIPS FREQUENTLY DAMAGED BY RUNOVER
      REEL WIRE NOT WOUND AND PUT BACK IN THE REEL

      ENTIRE WIRE REMOVED IN CASE OF DAMAGE IN THE MIDDLE

      CONTINUITY CONCERN


                            Solution suggested\implemented:

      USE OF SPIRAL AIR HOSES-10M LENGTH –COMPACT IN SIZE
      INSERTED THE REEL WIRE INTO THIS SPIRAL AIR HOSE AND
       CONNECTED DIRECTLY TO THE EARTH POINT
      USED HEAVY DUTY CLIPS SO THAT DAMAGES ARE MINIMAL AND GOOD
       GRIP IS ACQUIRED
      WINDING BACK TO REEL AVOIDED
      EASE OF OPEARATION & PURPOSE OF CONTINUITY ACHEIVED



                             REPLICABILITY:
All Locations

                                             78
                                   Caselet–57
   ________________________________________________________________



                          Experience shared by

                               Mr.S.K . Sharma
                           Designation : AM(Avn.)
                           Location : Saraswa AFS

                          Issue under Discussion:

                              Obtaining the BOC from IAF.

                                 Earlier system:

        After supplying the fuel to IAF next we send the AV 8 to IAF for obtaining
     the BOC No. After getting the BOC we submit the bills to our DGS&D Section.


                                 Problem faced:
No. of times IAF EMOL module not functioning due to connectivity or any other reason
           the BOC No. are not obtained in time, resulting in delay in billing.

                          Solution suggested\implemented:

We met IAF officials (SLO) to sort out this problem when we suggested that at our
locations SAP is not working and we can do our work with other nearby location and
complete the work. Then they asked their main server operator to get the BOC through
running the EMOL. When the main server operator runs the EMOL, we obtain the BOC
number immediately.


                          REPLICABILITY:
All Locations




                                          79
                                       Caselet–58
   ________________________________________________________________



                              Experience shared by

                                  Mr.R.R.Sawant
                            Designation : Dy.Mgr.(AVN)
                             Location : Mumbai AFS


                              Issue under Discussion:
                                  Refueling of Cargo Flights.


                                     Earlier system:

                We will place dispenser immediately on arrival of cargo flights.


                                     Problem faced:
    Refueling will take about 2 ½ hours with the result, one crew could not be used for
    other flights during peak time.



                              Solution suggested\implemented:

Requested airlines to allow us to send dispenser one hour before departure to which
they agreed.



                              REPLICABILITY:
All Locations




                                              80
                                     Caselet–59
   ________________________________________________________________



                           Experience shared by

                                Mr. K.D.Rathod
                            Designation : AM(Avn)
                            Location : Mumbai AFS


                           Issue under Discussion:

                             Safety Procedure at Location.


                                  Earlier system:

   Smaller quantity refueller sent for refueling customer requested for more quantity.


                                  Problem faced:
          Equipment / refueller stopped working at tarmac/ shortage of quantity of
                                         refueller.

                           Solution suggested\implemented:

 All round checking of refueller before going for refueling to see that all safety devices
                                       are in order.


                           REPLICABILITY:
All Location




                                            81
                                   Caselet–60
   ________________________________________________________________

                             Experience shared by

                             Mr. GAURI SHANKAR

                            Designation : AM(Avn)
                            Location : Palam AFS

                          Issue under Discussion:

                            CUSTOMER SATISFACTION.


                                 Earlier system:

During raining season, we use to face serious problems while showing the sample to
AME of the aircraft.

                                 Problem faced:

                              Many a time sample used to fail.


                          Solution suggested\implemented:

We advised that we should keep two separate clean bottles inside the gypsy. When we
use to show samples, using these clean bottles, the problem was solved. So in raining
season we made it practice to show the samples with extra clean bottles.
      .

                          REPLICABILITY:
All Locations




                                          82
                                    Caselet–61
   ________________________________________________________________



                           Experience shared by

                               MR.BEDRAJ ROY,
                            Designation : AM(Avn)
                           Location : SILCHAR AFS


                           Issue under Discussion:

                          Locking of refueller sampling points.


                                  Earlier system:

   All the refueller sampling points were locked with separate key rings for each
   refueller.


                                  Problem faced:

                         Retrieval of key rings during exigencies.


                          Solution suggested\implemented:

                     Plastic seals to be used in place of lock & keys.



                           REPLICABILITY:
All Locations




                                           83
                                  Caselet–62
   ________________________________________________________________



                         Experience shared by

                           MR.AMAL MAZUMDER,
                            Designation : SSM
                            Location : ZIRO AFS


                         Issue under Discussion:

                     Signing of AV-7 only by the concerned officer.



                                Earlier system:

                                      Not known


                                Problem faced:
   In the year 2000 I was in C+A shift in Kolkata AFS. The officer on the IA flight
   completed the total formalities and started the refuelling and dropped me in the
   concerned bay and requested to close the AV-7.The AV-7 was filled except for
   signature. After closing I signed and gave the AV-7 to the engineer. The flight
   crashed before landing to Patna. Subsequently I was called for all the queries.


                        Solution suggested\implemented:

                   Concerned officer to complete and sign the AV-7

                                 REPLICABILITY:
All Locations




                                         84
                                        ER
                                      Aviation

                                    Caselet—63
                                                    Contributed by: Shri J.Sarkar,
                                                          SM(Aviation)/ER

             REFUELLING DELAY DUE BREAKING OF BONDING WIRE


BACKGROUND:
During refueling of any aircraft, as per SOP, the refueling equipment, refueller or
dispenser, after parking at proper position near the aircraft, is first grounded to the
earth, by placing a grounding plate, under the tyre. This helps dissipate and earth any
static charges generated in the equipment.
Then the refueling equipment is bonded with the aircraft, by means of a continuous
conductive wire, fixed to the refueling equipment on a rotating wheel/reel, and other end
having crocodile clip, which is attached at designated position of the aircraft. The
bonding is required to bring both the equipment and the aircraft to same potential, thus
eliminating any chance of sparking which could result during refueling and generation of
static electricity.


INCIDENT:
At one of our AFSs, while refueling was under progress, and resulting from the
movement of men and other baggage trolleys etc., the bonding wire snapped, thus
disconnecting the refueller from the aircraft. As luck would have it, the aircraft engineer
and also the captain of the aircraft, on their routine rounds at the site, noticed the
broken wire, and immediately asked the operator to stop refueling. They insisted on
resumption of refueling only after the bonding wire was replaced, or a separate refueller
to be placed. As the AFS was quite a distance from the refueling site, and also, since
other available refueller was engaged in other refueling, the whole process of getting
new wire roll, fixing one end th refueller and connecting the other end to aircraft after
fixing of crocodile clip took some time. Eventually, the refueling could be completed only
after 5 mins beyond the scheduled departure time of the aircraft. This resulted in the
aircraft departing 7 mins. after the scheduled departure, which has caused a blot in
IOC’s service record and loss of image in front of airlines and passengers.




                                            85
LEARNING:
 1. It was detected that the wire was already torn, and had been joined at several
    places. This caused the disconnection when some external force was applied
    unintentionally.
    Hence regular maintenance needs to be carried, as laid down. Stop-gap
    arrangement of temporary fixing, if any, required on emergent cases, needs to be
    rectified at the earliest opportunity.
 2. The delay caused in getting new wire roll and clip could be avoided, if we could
    make a practice of keeping a spare wire and clip, and any such important item,
    as a spare, in all refueling equipment, or with the jeep/gypsy of supervising
    officer.

 3. It may be noted that the officer, supervising the refueling, does not have proper
    knowledge of the equipment and refueling practice, and domain knowledge. It
    can be seen easily, that the process of bonding of equipment to aircraft, is
    required initially, to bring the refueling equipment and the aircraft to the same
    potential. Once this is done, at the first instance, removal of the wire is of no
    further consequence. The ATF flowing thro’ the hose is itself conductive, and
    there is also a bonding wire at the nozzle end. If the aircraft engineer and pilot
    could be properly guided on the technical details, as above, they could have
    considered, and the refueling could have been completed well in time. However,
    as marketing people, we should always comply with customer’s directive, and if
    still insisted, having backup as in Sl.No. 2, would have made the day.




                                        86
                                    Caselet—64

                     Contributed by: Shri J.Sarkar, SM(Aviation)/ER

                       Standard operating procedure

BACKGROUND:
As per standard operating procedure and manualised instruction, before connection of
refueling nozzle to the aircraft during refueling operation, a bonding is to be made
between the refueling nozzle and aircraft, at a designated point on the aircraft refueling
panel. This bonding is in addition to the bonding already established between the
refueling equipment and the aircraft, for purpose of potential equalization.
However, the process of connection of the nozzle bonding wire, to the refueling panel,
and connection of the pressure coupling, thereafter, is a cumbersome and practically
difficult task. The refueling operators, as a general practice do the reverse, i.e., they
connect the nozzle first and then the bonding, which is in contravention to the guideline.

INCIDENT:
At one of our AFSs, the supervising engineer of the airlines, on seeing the shortcut
adopted, objected, and insisted on the compliance of guidelines, to the refueling crew.
On being told that the procedure was not practical, and also superfluous, by our crew
and officer, he did not relent, and subsequently, the crew had to connect the nozzle,
only after bonding, as per his instruction, with great difficulty. After this incident, the
same engineer specifically scrutinized the nozzle connection procedure, at each
refueling, and the connection was consequently being delayed, and difficult at each
instance. As per human nature, any deviation from years of habit, is accompanied by
resentment, and it was seen that refueling crew including officers, were reluctant to
attend to refueling, for that particular flight/airline.




                                            87
REMEDIAL ACTION :
The location in-charge, when informed, could understand the crux of the issue. The
practical difficulty faced by refueling crew, was known to him, since, he had hands-on
experience, as he had to attend to refueling, during Bandhs and strikes. On the other
hand, the insistence of the engineer/customer, could not be overlooked, nor was the
bypassing of standardised and safety norms acceptable.
The location in-charge, then, after consultation with the customer, resolved the issue, by
a simple but innovative solution:
Since the purpose of the nozzle bonding, was to equalize the potential between the
refueling nozzle end of the equipment, and the aircraft refueling point, it was resolved
that –
    1. The refueling crew would first connect the nozzle bonding wire to the aircraft
       panel, as per instruction.
    2. After the bonding and equalization of potential, the wire could be disconnected,
       and the nozzle connection made, with ease.
    3. The bonding wire may be reconnected, as an additional step.

The above novel solution, thus easily solved all the issues, before both the customer,
and the refueling crew, as also safety conditions were adhered to.


LESSON LEARNT :
We have to get ourselves updated, and fully conversant with the requirements, as also
the basis of such requirements. Only then, can we face trying circumstances, with
innovative solutions.




                                           88
                                   Caselet—65

                     Contributed by: Shri J.Sarkar, SM(Aviation)/ER

BACKGROUND/INCIDENT:
One of our Defence customers, who had taken delivery of AVGAS 100 LL, in packed
containers (barrels), had to have the product tested, as per routine test requirement.
They contacted our nearest AFS in-charge, and suitable sample container, clean and fit
for the product was given to the customer, with assurance of having the sample tested
at our Regional Lab., once the sample was given to the AFS, in the container, and
mentioning all details of batch, etc.
The sample, on test at the laboratory, tested OK for all the parameters, but failed in
colour ! On being informed, the location in-charge of the AFS, intimated the defence
unit, and giving another fresh and clean sample container, asked them to submit
another ‘repeat’ sample, for a repeat test.
The second test, yielded exactly similar result as the first, i.e. all parameters passed
except for colour. The finding intrigued the laboratory in-charge, who considering that
defence was an important customer, requested the AFS in-charge to visit the defence
unit, and see the product colour for himself, before any failure report was submitted.
The AFS in-charge, promptly reported to the unit, with his sample thief and bottles from
the AFS. He personally took a sample, with AFS equipment, in glass sample bottle, and
found the product colour to be clear and as per specification (blue). The personnel of
the unit, confirmed that they too had sent samples from the same barrels, and it was not
understood as to how their sample were failing in colour.
The AFS in-charge then asked the unit personnel, who had taken the sample on earlier
occasion, to repeat the procedure, but in his presence, and with their equipment. The
unit personnel brought their own barrel unloading semi-rotary pump, which they had
used for sampling, and took the sample in glass sample bottle. This time, it was seen in
the glass container, that the colour of the sample had turned brownish (instead of clear
blue of AVGAS 100 LL).

FINDING :
On query, it was confirmed by the unit personnel, that the barrel unloading semi-rotary
pump, used by them, was the same that they used for other products, including diesel.
They had cleaned the outside of the pipe etc., to the best possible, but traces of
remnant product had discoursed the product, but fortunately not contaminated the barrel
product, in other parameters.




                                          89
LEARNING :
 1. Correct sampling procedure is to be followed, for ascertaining correctness of
    product properties.
 2. Dedicated sampling equipment to be used, for aviation products.




                                      90
                                    Caselet—66

      Contributed by: Shri D.J.Barua, Manager(Aviation)/Tejpur
                                                          AFS

Description of Accident
An IAF refueller was parked in the topping up shed. Then our operator in the topping up
shed was told to top up the bowzer with 9800 ltrs of fuel. But when the bulk meter read
9000 ltrs, fuel started overflowing from the bowzer. Our operator immediately had
closed the quick shut off valve and fuel stopped coming out from the refueller.

Cause of the Accident
The IAF refueling operator miscalculated the quantity refueled to their aircrafts from the
particular bowzer. The actual quantity refueled from the bowzer was 8000 ltrs as per
their fefuelling register instead of 9800 ltrs.

Lesson Learnt from the Accident
Before topping up, the quantity must be ascertained by taking physical dip albeit
quantity is known on paper.




                                           91
                                  Case-let—67

  Contributed by: Shri D.Basu, Sr Manager(Aviation)/Kolkata
                                                       AFS

Defueling of AVGAS100LL from Aircraft tank earlier refuelled
                         by us.


The contention:
   A fatal air accident took place at Dundigal on 31.07.09 following which the flying
    of HPT-32 (flying on AVGAS100LL) was suspended suddenly by IAF.
   Later on, after nearly two and half months, Air force requested us to defuel 80
    numbers of HPT-32.
   Since the product was “age barred”, we requested them for recertification test
    and quickly understood the inherent pitfall of our requirement because IAF would
    have advised us to arrange for testing of 80 numbers of samples (for
    recertification test), which may become stupendous task for the laboratory.
   So, we resorted to deliberately avoid the issue and keep asking IAF to arrange
    testing by their own means.
   Meanwhile, IAF advised us to refuel the aircraft instead of defueling, primarily
    with an intention to circumvent the embargo on defueling.
   It was planned by some of the quality experts of IAF to refuel the aircraft
    following which they would have forced us to defuel since the “age bar” of the
    product inside the tanks would have been removed with the fresh refuelling.
   Meanwhile, we have conducted density check on the aircraft tank samples which
    fell beyond the permissible limit of density variation in respect of the reference
    density of the batch last refuelled.
   It was also learnt that the tanks are near full and maximum of 5-10 litres may be
    refuelled which was insufficient to bring the density back within the limit of the
    current batch density.
   Also, these air craft tanks are fitted with free vents which were in contravention to
    the guideline for storage, particularly concerning RVP.
   Therefore, if we defuel the product, it was almost certain that the product would
    be failing in RVP test and the whole lot needs to downgraded.




                                          92
Action By The Location:
1. We have disclosed our predicament to the CEO of the unit.
2. We have explained the “short coming” of the directives of the AQCAM in this
   regard and requested him to act on “moral propriety” instead of “legal propriety”.
3. Around 20 Kl of AVGAS was downgraded by IAF on their account.


Lessons Learnt:
1. Comprehensive Quality history of the product needs to be ascertained thoroughly
   prior to committing defueling of old fuels in large quantities.

SOP in regards to the contention needs to be relooked for future.




                                       93
                                    Case-let—68

    Contributed by: Shri D.Basu, Sr Manager(Aviation)/Kolkata
                                                         AFS

                             Refueller Maintenance
Incident:

In one AFS, wheel replacement was taken up by the maintenance group.

 Under such situation, the Refueller is temporarily withdrawn from shift operation &
parked at a place earmarked for carrying out maintenance activities which is different
from the place where serviceable Refuellers are parked & a board is being generally
kept hanging from the external door latch of the Drivers' cabin showing "Under
Maintenance" (which maens that the Refueller is unserviceable).

However, on that particular day, the wheel replacement was taken up at normal parking
bay since the front left tyre was deflated & the Refueller could not be shifted.

After fastening only two bolts of the replaced front left tyre, the mechanic went for tea
break. Meanwhile, an employee started the Refueller & almost drove it out of the
premise of AFS to attend aircraft refueling till he was finally stopped by the rushing &
panicky mechanic. The two bolts which were loosely fastened were irreversibly
damaged & the nuts could not be unfastened till they were cut by hacksaw. The
Refueller was withdrawn from service for three days to rectify its wheel drum.


Cause of failure:

The board showing that the Refueller "Under Maintenance" was put to the helpers' end;
in this case, the driver came to start the vehicle without having any idea about the status
of serviceability.


Loss:
Refueller was out of service for three days & cost of fixing the Hub.

Lesson Learnt:

Follow SOP. Had the board being put at Drivers' side as is being done normally, this
could have been avoided.


                                            94
                                     Case-let—69

            Safety Flash            Wrist Injury – Airport, UK – 1
                                                      Source: BP Bulletin
                                              Contributed by: ER/Aviation

Brief Account of Incident:
The site manager was new to LBA and since starting in the role he had been making
some improvements to all areas of the operation, which includes a refurbishment of the
office.

The refurbishment commenced on 16 th March and involved, in part, the redecoration of
the main office building. On the morning of 1 April 2009 the manager had arranged for
tiles to be laid in the toilet storage area within the main office building To facilitate this,
the site manager asked operator 1 to assist him to clear the area of a double locker, and
its contents. After working together to clear the lockers contents they positioned the
locker ready to move it out of the room and building. The locker was to be to move it out
of the room and building. The locker was to be disposed of and was to be taken outside
to an area adjacent to the garage building, which was being used to store all the waste
being generated from the refurbishment whilst awaiting a refuse collection.

The manager and operator 1 then commenced moving the locker by laying it on its side
and picking it up between them, causing the site manager to walk backwards during the
manoeuvre. They carried the locker outside and around the main building towards the
disposal area. As they turned the corner of the portacabin opposite the garage the site
manager looked over his shoulder to check his route and then continued to walk
backwards into the area.

Being careful to avoid some scaffolding in the area they continued to carry the locker. It
was at this point the site manager felt his heel hit the step of the port cabin which caused
him to lose his balance and fall backwards onto the step. The locker fell on top of him
and he put his left arm down to break his fall. He was taken to the hospital who
confirmed the wrist was fractured.




                                              95
This picture shows the route taken whilst carrying the locker and the step the manager
fell over.
manager fell over.

Critical Factors
Although the Safe2Go principles were used to assess the risks they did not consider the
use of lifting equipment and the sack barrow available on site was not used to carry out
the manoeuvre

The site manager did not specifically see the step and tripped over it

What Went Right

The manager applied the Safe2Go principles to assess the risks associated with moving
the locker The incident was reported promptly and through the correct reporting
channels.

Medical treatment was received promptly promptly

Lessons Learnt

Focus needs to be given to non routine tasks / activities that are carried out which are
not covered by a task breakdown or work permit. Manual Handling Training is required A
comprehensive induction programme is required for new and transferring site operations
employees when new to a site or moving between sites.




                                            96
                                    Caselet—70

   Technical Flash Bulletin               Shoulder Injury – Airport, UK

                                                         Source: BP Bulletin
                                                 Contributed by: ER/Aviation
Type of Incident:Shoulder Injury

Location of Incident:Airport, UK

Date of Incident:21st May 2009

Incident:
On 21 May 2009 Operator 1 was in the Conoco yard.

He entered the bund to start the tank sampling procedure, having opened the tank
valves he walked along a raised walkway towards the sampling area The walkway is a
typical open grate walkway supported by a metal framework, where the sections of
grating would normally be clamped into place.


As he walked along the walkway he felt a lack of support under the front of his right foot
which caused his foot to roll over on his ankle. He lost his footing and fell forward. He
instinctively held onto the handrail with his right hand as his whole body fell forward
towards the metal grating of the walkway.
As he held onto the handrail his shoulder and jarred as they supported the weight of his
body and stopped him from hitting the walkway.


As he got to his feet he noticed a gap in the walkway which had opened up between two
of the sections of grating. On closer inspection Operator 1 noticed there were no clamps
on the walkway to stop the grating moving.




                                           97
The supported metal framework walkway used by Operator 1. (An example of a gap in
the walkway.)


Critical Factors
The metal grating on the walkway was not secured allowing it to move apart creating a
gap in the walkway. The operator did not notice the gap in the walkway grating.

What Went Right
The incident was reported at site level and escalated in a timely fashion. The operator
did not attempt to ride his bike home, instead arranged alternative transportation. An
RCA was conducted and the report issued within two weeks. The airport staffs were
open and cooperative during the investigation.

Key Recommendations

All walkways to be inspected to ensure the grating sections are secured with clamps and
clamps are tight as per the recommendations of M/72 issued in 2007 A one pager Safety
Flash is to be produced to ensure all global sites with similar walkways check clamps are
fitted and
grating is secured correctly.




                                           98
The supported metal framework walkway used by Operator 1 (An example of a gap in
the walkway)




                                      99
                                     Caselet—71

    Trailer-Tractor Unit Collision with Aircraft - Tanzania – 20th November 2010

                                                                    Source: BP Bulletin
                                                            Contributed by: ER/Aviation

Brief Account of Incident
At 14:15 on Saturday 20th November 2010, an Air BP Tractor-Trailer fuelling unit
collided with a Twin Otter (DHC-6) aircraft at Dar Es Salaam Airport in Tanzania, Africa.
This site is an Air BP Operated Site and the aircraft fuelling vehicles on site are owned
by Air BP.
While driving away from one refuelling to approach a second aircraft, the Operator
turned to the right before clearing the aircraft. As a result, the rear side of his trailer
brushed the aircraft nose exactly at the point where the trailer Emergency Cut Off push
button is fitted. This was activated immediately and the vehicle stopped. The Operator
heard the aircraft captain shouting at him that he had hit the aircraft and he immediately
called his supervisor who came to the accident scene with the depot manager.
Since the aircraft sustained only light damage, the pilot decided to repair it using duct
tape. The pilot then flew the aircraft to his destination (Arusha) arriving without further
incident. The pilot was not asked to sign a letter of indemnity before departing.




Position of tractor-trailer and damage to aircraft

                                            100
Critical Factors
 As the Operator drove away, he made a turn without being aware of his vehicle’s
  proximity to the airplane’s nose, resulting in trailer/aircraft contact.
 The operator improperly positioned his vehicle before starting to fuel the aircraft.

What Went Right
 The incident was reported to management promptly
 The trailer Engine Emergency Cut Off Button activated and stopped the vehicle unit.

Lessons Learnt
 Fatigue was a contributory factor due to long shifts, short sleep periods and long
  periods between meals. Review site shift patterns and overtime for individuals should
  be kept to reasonable levels.
 Clearly the Operator turned too soon. Staff should be retrained on A/C Safe Approach
  & Exit.
 The tractor unit mirrors were inappropriate and badly positioned, not allowing the
  operator to see the trailer position. Some were jammed or difficult to move. Review
  the design, position and working conditions of all mirrors fitted on fuelling vehicles.
 Provide refresher training on Smith Systems driver training (or equivalent) with
  emphasis on on-ramp driver training.

Lessons for Other Sites
 Are shift patterns/overtime leading to fatigued Operators? Is your fatigue/tiredness
  training up to date?
 Do your vehicle mirrors work well? Can you see as required and adjust them if
  needed? Are you fully aware of the risks of turning near aircraft and the clearance you
  need?
 Is your Defensive Driving training up to date and relevant to your driving issues?




                                          101
                                     Caselet- 72

                              Safety Flash Spill – Airport x

                                                                    Source: BP Bulletin
                                                            Contributed by: ER/Aviation

Brief Account of Incident:

On the evening of 31 st March 2009, an operator was discharging a bridger of Jet A-1
into an underground tank when the tank overfilled and approaching 10000 litres of
product went into the ground level bund. Some 1800 litres left the bund through an open
bund drain valve before this was closed; 600 of this being recovered in the depot
separator. However, 800 litres passed through the separator but was subsequently
recovered from the airport drainage collection system. The overfilled product which was
retained in the bund was recovered and, together with other product recovered outside
the bund, downgraded.

Critical Factors

The use of repaired dip tapes led to an incorrect dip being reported to the Supervisor.
There were potential opportunities to check/validate the dip figure/ullage but they were
not in place.

Testing during the RCA proved that the overfill prevention device was not working,
allowing product to pass. The testing procedure was being followed by the Depot, but
was inadequate to assess the effectiveness of the overfill prevention device.

What Went Right

The Operator halted the tank fill immediately upon noticing a problem. The spill was
promptly reported to management.

The spill was largely contained within the bund.

The depot and terminal staff co- operated in order to rapidly recover the spilled product.

Lessons Learnt

Modifying equipment may introduce additional hazards and risks e.g. shortening the dip
tape as happened in this instance.
Although the overfill prevention device had a system in place to enable it to be tested, it
transpired that this testing procedure was ineffective.
Bunds can minimise the impact of any spill on the environment, but only if the bund drain

                                            102
valve is closed.




                   238thAVIATION REFRESHER COURSE

                    18TH JULY TO 23rd JULY, 2010.




             Experience Sharing



                          AVIATION -
                   TRAINING & DEVELOPMENT
                      SOUTHERN REGION
                                 103
                                      Caselet–73
    ________________________________________________________________

                             Experience shared by

                                  Ms Nanda Nair ,
                             Designation : AM(AVN)
                             Location : Mumbai AFS

                             Issue under Discussion:

Delivering excess quantity to the extent of
8 to 10 liters, after the captain gives confirmation.


                                    Earlier system:

In case of some dispensers, when the AME gives any approx.
Quantity to be delivered. At times it may happen that 8 to 10 liters quantity is delivered
in excess. By the time AME gets the figure confirmed from the captain, here our
dispenser has already delivered more quantity from the prescribed quantity.


                                    Problem faced:
Delivery of excess quantity to the extent of 8 to 10 liters.



                            Solution suggested\implemented:

When we go for fuelling the crew must be instructed to immediately stop delivery after
completion of the correct quantity.



                             REPLICABILITY:
All Locations




                                             104
                                     Caselet–74
    ________________________________________________________________

                            Experience shared by

                                  Mr V.V. Vartak,
                            Designation : Dy.Mgr.(AVN)
                            Location : Dabolim AFS


                           Issue under Discussion:
Shifting of topping up point at tarmac.


                                  Earlier system:
We use to TWP bouzers during peak period of day through HRS at Civil tarmac.


                                  Problem faced:
Due to up gradation of air port /tarmac AAI-Goa has objected
& stopped our facility even though the issue was under consideration,
putting us in uncomfortable position during peak period i.e. 1300 to 1700 hrs.

                        Solution suggested\implemented:
1.Keeping in mind upcoming charter season we write to AAI-Goa for giving as space at
nearby our HRS facility top up point, so that we can refuel our tarmac & do the huge
quantity refueling account in time.
2. It is suggested to upgrade facility at HRS to avoid excess travel for our bouzers
though cut given at Naval side for entering into tarmac as well as our jeep for Officers to
attend to the refueling.




                                           105
                                 Caselet–75
   ________________________________________________________________

                            Experience shared by

                            Mr C.K.Kulkarani,
                        Designation : Dy.Manager(AVN)
                        Location : Dundigal


                        Issue under Discussion:
                             DG set during power cut.


                              Earlier system:
                DG set used to be kept on continuously even though
                             Power (main) is through.


                              Problem faced:
                                Wastage of HSD.

                  Solution suggested\implemented:
Keep 3 bulbs outside the MCC room with main power connection. When main power is
on bulbs will glow, then switch off the DG set without wastage of HSD.



                        REPLICABILITY:
All Locations




                                       106
                                    Caselet–76
   ________________________________________________________________

                                 Experience shared by

                                 Mr S.B. Saha,
                           Designation : Dy.Mgr(AVN)
                           Location      : Kolkata AFS



                          Issue under Discussion:
                   Confirmation of fuel requirement by hand signal.




                                 Earlier system:
      AME/ Technician used to confirm fuel requirement by hand signal.



                                 Problem faced:
      One technician of Jet Airways confirmed by hand signal that no refueling in
      required. Hence, we had taken back our refueller. After 10/15 minutes they asked
      for refueling and denied their previous signal given by the technician. Due to this,
      15 minutes delay of that flight occurred.



                   Solution suggested\implemented:
      We should not go by any hand signal, interpretation of which will be disputed.
      Hence, we should directly interact with the AME/Technician and take the decision
      as per requirement.

                                   REPLICABILITY:
All Locations




                                          107
                                      Caselet–77
   ________________________________________________________________

                                Experience shared by

                               Mr Sandeep .B.Alva,
                            Designation : A.M(AVN)
                            Location    : Mumbai AFS



                            Issue under Discussion:
                          Sample drawn during raining seasons



                                   Earlier system:
               During heavy rains sample gets wet before being covered with umbrella.
               As a result sample needs to be drawn again.


                                   Problem faced:
               During raining season it is extremely difficult to show the refueller sample
               before refueling the air craft & precious time is lost before refueling.



                     Solution suggested\implemented:
               It is suggested to inside a box near sample point so while drawing the
               sample the product can be protected from rain & moisture.

                            REPLICABILITY:
All Location




                                            108
                                     Caselet–78
   ________________________________________________________________

                               Experience shared by

                            Mr Umesh Chand Sharma,
                            Designation : AM(Lab)
                            Location    : Jalandhar



                            Issue under Discussion:
                    Sending of JET A-1 sample for recertification test.



                                  Earlier system:
                 For saving of courier charges, AFSs send samples to lab
                even one month in advance for recertification test for MBT.



                                  Problem faced:
                          With this, date of test report preponed.



                     Solution suggested\implemented:

     AFSs to be advised to send samples for recertification ONLY by the due date.


                                    REPLICABILITY:
All Locations




                                            109
                                 Caselet–79
   ________________________________________________________________

                             Experience shared by

                               Mr VIvek Verma,
                          Designation : Stri. Mgr.
                          Location     : Bhatinda AFS

                          Issue under Discussion:
High degree of breakage of hydrometer placed in hydrant dispensers at NITC-AFS.

                                Earlier system:
All airlines except Air India insisted on line density & temp. Hydrometers of both
ranges need to be carried as many times. Density used to vary around 0.800. Because
of handling day/night by various persons during rush hours, 4 to 5 hydrometers used to
break every week resulting in month’s loss of around Rs.5000/-(minimum). The loss in 6
months was around 40,000/-.


                                 Problem faced:
1.The high degree of breakage resulting in revenue loss.
2.Very awkward position in front of customer when an officer picks a hydrometer from
sample box to check density only to find the same broken. He has to rush to AFS
leaving flight unattended just to pick another hydrometer.

                   Solution suggested\implemented:

The existing visi-jar installed on the hydrometer dispensers was modified. Two
permanent tubes were installed one for hydrometer & one for thermometer which were
closed/ locked from the top. Cushions were provided to the hydrometer & thermometer
from below & above by installing cone shaped Teflon base & the top. It resulted in
decrease in breakages to about 1-2 hydrometers in two months & also lot of
convenience & better customer service. All refuellers in all AFSs to be provided with
this.

                          REPLICABILITY:
All Locations




                                         110
                                    Caselet–80
   ________________________________________________________________

                                  Experience shared by

                                  Mr Hoshar singh,
                           Designation : Dy Mgr(AVN)
                           Location    : Ambala AFS



                          Issue under Discussion:
                                   Choking of box strainers.



                                 Earlier system:
                  TT emptying earlier directly connecting with hose.


                                 Problem faced:
        Epi coat pieces & other particles travelled and gathered in box strainer causing
                                  choking of strainer.

                   Solution suggested\implemented:
                    Cone type strainer on the mouth of hose before
                                   Correcting to TT.


                           REPLICABILITY:
All Locations




                                          111
                                     Caselet–81
   ________________________________________________________________

                               Experience shared by

                                   Mr T.S.Ravi,
                            Designation : Dy.Manager(AVN)
                            Location    : Chennai AFS

                           Issue under Discussion:
                             Documentation / Challan filling.


                                  Earlier system:
For the scheduled aircraft we do not get signature of the authorities (Engineers) in the
AV-7 challan specified for it in the case of fuel is not needed for the aircraft.

                                  Problem faced:
Once our refueller reached the bay of Indian Airlines aircraft for refueling, after some
time IA engineer told fuel is not required. We were about to move from that place
suddenly heard the sound, ”Stop Stop. We require fuel.”

                    Solution suggested\implemented:
Initially IA engineer told fuel is not required and we were about to move with the oral
confirmation and there was no document for that. We cannot prove unless some
document with the proper signature of that engineer is available with us. Some day big
problem may arise it they first refuse and in the last minute they may call us for
refueling. It is safe to get AV-7 challan filled and getting signature from Engineers if at
all they do not require fuel.

                            REPLICABILITY:
All Locations




                                           112
                                   Caselet–82
   ________________________________________________________________

                              Experience shared by

                              Mr Zephaniah Panmei,
                          Designation : SM
                          Location    : Dimapur AFS


                          Issue under Discussion:
                        MBT sample dispatching for Defence.
                         (happened at Port Blair)

                                Earlier system:
                            IOC used to send for Defence

                                Problem faced:
Location has only two storage tanks and MBT sample dispatch is required only twice a
year. Navy & Coast Guard has 6 Dornier Air Crafts. For their A/C tank (both LH & RH)
MBT test is done once in six months. i.e. 24 samples dispatch per year. This is time
wasted and money invested.

                    Solution suggested\implemented:
Since fuel sample is certified under dangerous goods and Defence sample is unknown,
IOC officer cannot take the responsibility to undertake and sign for dangerous goods of
others while booking.
Hence, sample dispatch for Defence A/Cs deferred and left to them. However, supply of
MBT bottles to be arranged by IOC and obtaining of test report results on early basis
will be ensured by IOC location.



                                   REPLICABILITY:
All Locations which are dispatching samples of Defence.




                                         113
                                   Caselet–83
   ________________________________________________________________

                              Experience shared by

                           Mr Dillp Chandra Bora,
                    Designation : SR.STN .Manager
                    Location     : Doom dooma AFS


                          Issue under Discussion:
‘SAP’ training required on T-codes for use in Finance / operations / P & A / M & I etc.
systems.


                                Earlier system:
                                   Legacy Systems



                                Problem faced:
All T- codes are not available and operations working system not know to the officers
below. Also, as it is a “RSA” token no provided by HO (SAP not working on broad band
/P & T). Sometimes “RSA” token no. not working for 2/3 days in a week.

                   Solution suggested\implemented:
Suggested Manthan, New Delhi\ERO Systems for necessary correct development of
the system to help the Station-in-change.

                          REPLICABILITY:
All Locations




                                         114
                             Caselet–84
________________________________________________________________

                       Experience shared by

                         Mr Kehar singh,
                     Designation : AM(AVN)
                    Location     : chandigarh AFS



                    Issue under Discussion:
                  Fuel level gauge of gen .set fuel tank



                          Earlier system:
                      Using Transport / Rubber pipe



                          Problem faced:
                    Level not found clear many times.



             Solution suggested\implemented:
           Rubber /plastic level gauge to be replaced with glass
                                level gauge.



                            REPLICABILITY:
                              All Locations




                                   115
                                     Caselet–85
   ________________________________________________________________

                               Experience shared by

                                  Mr Rupak Dey,
                            Designation : SSM
                            Location     : Port Blair AFS



                           Issue under Discussion:
                              Defueling activities of aircraft.




                                  Earlier system:
Defueling activities are carried out without any charge and still this practice is going on.



                                  Problem faced:
A set of manpower is required always to decant fuel from aircraft for local adjustment
and any other reason. It is required 5 times more time for defueling than normal
refueling.

                    Solution suggested\implemented:
Since our manpower is engaged and stringent QC checks are there for defueling
activities, defueling charge should be more than the normal refueling charge.

                                    REPLICABILITY:
All Locations




                                            116
                                     Caselet–86
   ________________________________________________________________



                               Experience shared by

                                    Ms G.Devi,
                            Designation : Dy.M.(AVN)
                            Location     : Trivandrum AFS



                           Issue under Discussion:
                       Attending unscheduled customers on arrival.


                                  Earlier system:
Rushing to the aircraft as soon as the aircraft lands and connect the refueller to ensure
that we are getting business.



                                  Problem faced:
Recently the customer is showing fake authorization letters and hide the authentic cards
they are holding.



                      Solution suggested\implemented:
Get right information from region/ HO and then only start refueling.




                            REPLICABILITY:
      All Locations




                                           117
                                      Caselet–87
    ________________________________________________________________

                                Experience shared by

                                Mr Sarwan kumar ,
                            Designation : Dy.M,anager(AVN)
                            Location    : Hissar\Hindon AFS


                            Issue under Discussion:
                     Automation of electric light pole / display board.

                                   Earlier system:
After dark somebody has to switch on the lights & display board of AFS and switch off in
the morning. Because of change of shift during those timings, it was often forgotten to
switch off.


                                   Problem faced:
This results into poor visibility at night & lights remaining on even after sunlight resulting
in loss of electricity and decrease of life of bulb.



                     Solution suggested\implemented:
An automated electric time switch was installed in the PMCC Room by fixing time so
that pole light / display board switch off automatically.



                             REPLICABILITY:
All Locations




                                             118
                                      Caselet–88
    ________________________________________________________________

                                Experience shared by

                             Mr M N Viswanath Kumar
                           Designation :Aviation Officer
                             Location    : Agra AFS



                            Issue under Discussion:
                                Maintenance of Hydrant Pit



                                   Earlier system:
  Hydrant Pit is molded to fit the hydrant pit cover as is available in a glass jar i.e., the
          outer rim of the base is fixed to the ground and the pit cover sits in.



                                   Problem faced:
There is gap in between the outer rim and the cover and thereby, there is ingress of
water and dust into the hydrant pit. During rainy season though the pits are cleaned
daily there is ample quantity of water and dust entering the hydrant pit compartment.


                     Solution suggested\implemented:
The hydrant pits covers may be designed in such a way that the cover is made like a
bottle cap i.e., the pit cover will be covering the hydrant pit thereby the seepage of water
and dust can be arrested.



                             REPLICABILITY:
All New Hydrant Locations




                                             119
                                    Caselet–89
   ________________________________________________________________

                              Experience shared by

                           Mr M N Viswanath Kumar
                         Designation :Aviation Officer
                           Location    : Agra AFS


                          Issue under Discussion:
                    Refuelling of Aircraft on payment of US Dollars



                                 Earlier system:
 Refuelling of non-scheduled aircraft on payment of US Dollars. The location interacts
   with the non-scheduled customers and arranges refueling of the aircrafts against
                                  payment of dollars.


                                 Problem faced:
A non-scheduled aircraft landed and requested for refuellig. As no prior arrangement of
payment was in place, refueling could be done if the fuel cost would be paid in US
Dollars. The Pilot and Flight Engineer confirmed that payment shall be made
immediately after refueling. Hence the refueling has been done.

On completion of the refueling when the collection was being made, the handling agent
for ground work appeared and objected the airline in making the payment stating that
the agent company will arrange the payment which could not be accepted by us as
there is no prior arrangement. On persuasion US Dollars were collected.

                   Solution suggested\implemented:
The handling agents for ground work should be sensitized not to interfere in
requirement of Jet fuel when no payment arrangement is in place for the refueling of the
aircraft.

                           REPLICABILITY:
All Locations



                                          120
                                Caselet–90
   ________________________________________________________________

                           Experience shared by

                     Mr JAY RAJ KUMAR SINGH SODHI
                     Designation :DY MANAGER AVIATION
                       Location    : AMRITSAR AFS

                        Issue under Discussion:

                FREQUENT CLUTCH PROBLEM WITH 27 KL REFULLER


                             Earlier system:
        PLACEMENT OF LOADED REFULLER IN DIRECTION OPPOSITE TO
                         OPERATIONAL GATE.

                             Problem faced:
                      REMOVAL OF REFULLER FOR REFUELLING.



                   Solution suggested\implemented:

AFTER THE REFULLER ARRIVED AT AFS AFTER FINISHING REFUELLING THE
EMPTY REFULLER WAS PLACED IN THE DIRECTION OF OPERATIONAL GATE &
THEN TOPPED UP. THIS RESULTED IN LESS LOAD ON CLUTCH WHEN TAKEN
FOR REFUELLING HENCE NO BREAK DOWN.


                         REPLICABILITY:
All Locations




                                    121
    SAFETY
      &
  STANDARD
  OPERATING
  PRACTICES
FOR OPERATIONS




      122
                                       Caselet–1
   ________________________________________________________________

                                Experience shared by

                                    PERIOD: FEB’2007

                NARRATED BY: MANNA DURAI/CH.MGR(OPS)/TNSO
         LESSON LEARNT FROM COIMBATORE TERMINAL
ISSUE:

On a particular day in Feb’2007, while Closing one of the gates in the siding after
activity in the siding is over around 18 30 hrs, security guard notices spark.

Within a few days, while connecting the MS wagon for unloading, hose end to the MS
riser which leads to TW Header, there was a spark.


PROBLEM:

Matter pretty serious as MS is the product handled and there is threat source of ignition
and Fire disaster in the waiting.

Operations suspended at siding /rake not unloaded.

State Office, Regional S&EP, S&D and Railways informed


SOLUTION:

IMMEDIATE:


   1. OHT has been commissioned recently in the POL siding and the above rack handled
      was second after OHT commissioning. Secondly despite (a) maintaining the 15 meter
      statutory distance between OHT termination in the siding and the first unloading point
      and (b) insulation of two successive fish plat joints in the track after OHT due to dummy
      wagon placement along with the product wagon which was very close to OHT
      termination point. Due to Induction phenomenon and the second wheel of dummy wagon
      was after insulated joints, all the wagons were mildly charged. Dummy wagon was
      removed and separately placed.
   2. The potential difference between one gate closer to OHT siding and the other gate led
      to jumping of spark. Railways did quick investigation and found that earthing provided
      by Railways as part of their standard earthing was inadequate. An earthing strip was

                                             123
      immediately provided connecting the troublesome gate to allow charges from one gate
      to freely flow to other gate. Thus immediate safety ensured and after 2 days wagon was
      unloaded after physically measuring the potential and ensuring safety.


PERMANENT:

      MGR-LPG OPS from Pondicherry bottling plant who is from electrical engineering back
      ground was deputed to study. Further as per the advice of DGM(OPS)/TNSO,Electrical
      Engineering Dept of Coimbatore Institute of Technology/Coimbatore was requested to
      study the phenomenon and suggest remedy.

Their Findings:

      1. Since main line of Railways (electric traction) was running parallel to the siding,
         whenever there is electrical loco movement in the main line, due to drawal of 25KV
         by the loco, there will be heavy induction through concertina-barbed fencing on the
         siding compound wall.
      2. Since Fencing is continuously connected around the periphery of the location, entire
         concertina was found mildly charged.
      3. These inducted charges were not getting dissipated due to insufficient earthing
         provided by Railways.

CORRECTIVE ACTIONS:
    1. Insulation created siding fencing and the other areas by civil works. This was
    done at 2 identified to break the continuity and t o prevent flow of current from
    siding fencing to other fencing.

      2. Insulation created on the concertina in the siding area to prevent flow of
      current further into periphery concertina from siding concertina.

      3. Additional earth pits at every 200 Meters on the concertina running parallel to
      Mail line traction.

      4. Other gates inside the siding (second gate on the track segregating licensed
      area) and the gate on the ring road of the siding (meant for free fire tender
      movement) were additionally earthed.

      5. Hydrant line which was also running parallel to traction was also earthed.

IMPACT:

      On Measuring charges in the siding gates, tracks, fencing and raisers, it was
      found to be negligible and within safe levels.

      No such unsafe event recurrence since then, nearly 4 years have elapsed and
      400 rakes unloaded safely.


                                            124
                                      Caselet– 2

                             Issue under Discussion:
                       Safe Operating Practice of MCC Panel

                             Development of Hazard:
At one Terminal an electrician opened the MCC Panel to rectify a fault, without taking
permission of the concerned officer and without work permit.

                            Accident / Problem faced:
The electrician opened the panel and started checking the feeder wire by using a time
tester without hand gloves. By mistake the time tester touched two different electrical
terminals simultaneously. As the terminals were charged, it resulted in a huge spark and
smoke. The electrician fell on the ground and fainted.

                              Observation of Mishap
Another electrician, who was there in the panel and saw the incident informed all the
concerned immediately.

                                    Action Taken
The injured electrician was rushed to the hospital where he was treated for minor burn
injuries. He was discharged after one day.


                                   Details of Loss
Minor elbow injury to the electrician, minor property loss.


                           Learnings from the Incident
   1. No electrical work should be carried out without the information of the authorized
      officer and work permit.

   2. Hand gloves and rubber mats should be used while doing electrical work.

   3. Electrical isolation to be done before starting any work in panel.

                                    Replicability
       All Locations




                                            125
                                      Caselet– 3

                             Issue under Discussion:
                               Safety at Railway siding

                            Development of Hazard :
At one Depot the railway track is parallel to the Main railway line. One day when a rake
was positioned and getting unloaded, an AC Bogey of a train passing on the main track
caught fire due to short circuiting. The driver of the train stopped the train just near the
siding which posed a major threat to our installation.

                            Accident / Problem faced:
Owing to the proximity to our rake there was a distinct possibility of fire spreading to our
depot.

                              Observation of Mishap
Another electrician, who was there in the panel and saw the incident informed all the
concerned immediately.

                                     Action Taken
Sensing the danger to our siding IOC employees and contract labour present
immediately informed the location in charge who reached the scene and FE’s were
operated and the train fire was totally extinguished in about 10 minutes. The Railway
HQ issued an appreciation letter to IOC for preventing a major accident.


                                    Details of Loss
No loss to IOC. However flames could have reached the rake which was under
decantation.
                           Learnings from the Incident
   1. Extreme vigilance during operation of rakes. Any source of ignition should
      immediately be attended to and flame extinguished.

   2. Regular Fire drills to hone firefighting skills of employees/ contract labour/
      security personnel so that during an actual fire there is no panic & it is
      extinguished.

   3. Access to Fire Fighting Equipment to enable effective fire fighting.

                                     Replicability
       All Locations with railway sidings where rakes are decanted / loaded

                                            126
                                      Caselet– 4

                             Issue under Discussion:
                                  Safety in TLF Area

                            Development of Hazard :
In the morning shift at one Depot before start of TT filling , the Operations Officer in
charge observed a spillage of about 30-40 litres of SKO on the ground.

                            Accident / Problem faced:
Spilled product is a hazard anywhere and more so in the TLF area. If it was not
observed it could have resulted in an accident.

                              Observation of Hazard
The alert & vigilant Operations Officer has the habit of taking a round of the TLF area
before Operations start and this good safety habit made him observe the spilled
product.

                                    Action Taken
The Operations Officer immediately called the staff/contract labour to clean the SKO of
TLF area and sand was spread over this area.


                                   Details of Loss
No loss . However an accident could have occurred had the hazard not been detected
on time.


                          Learnings from the Incident
   1. Ensure excellent housekeeping in the TLF area.

   2. Take a visual round for detecting any spills or other hazards before TT filling
      starts.

   3. TLF is the core operating area in a Depot / Terminal & as such of prime
      importance as far as Safety goes.

                                    Replicability
       All Operations Locations



                                            127
                                     Caselet– 5

                            Issue under Discussion:
                             Safety around Installation

                           Development of Hazard :
Near one Terminal there are adjoining farms where farmers have the practice of burning
their waste vegetation after the harvesting of crop . This burning vegetation poses a
threat to our terminal.

                           Accident / Problem faced:
One fine day a farmer burnt the remaining dry plants and after burning all of it in his
farming area he left. He didn’t realize but the fire aided by wind slowly could spread .
Since it was day time the flames were not that visible and the smoke was not dense too
, since the fire was in small area. But soon fire had reached the boundary wall on the
outer side and since the quantum of vegetation was high the fire increased and the
smoke became dense.

                             Observation of Hazard
The shift officer noticed the smoke from CCTVs in the Control room as well as the
security guards also reported the matter to him..
                                   Action Taken
Location in-charge was informed and called since it happened on Sunday. Meanwhile
the staff along with guards were sent out side with DCPs and sand in order to contain
the fire and simultaneously in the terminal area hoses were connected with the
hydrant system and water was sprayed on the boundary wall and other side .Thus the
fire was extinguished.


                                  Details of Loss
No loss . However an accident could have occurred had the hazard not been detected
on time.
                          Learnings from the Incident

   1. Vigilance of fire hazards even outside our premises.

   2. Equipments and fire protection items should be readily available.

        3. Awareness and education to nearly households farmers and industries.

                                   Replicability
      All Operations Locations

                                          128
                                      Caselet– 6

                             Issue under Discussion:
         Safety Hazard due to pilferage by TT driver during TT filling

                            Development of Hazard :
At one location one TT driver stole some MS in a can and kept it in the cabin of his TT.

                            Accident / Problem faced:
 After filling the TT he came down from Tank truck and entered in the cabin of tank
truck and started the TT, due to spark generated from loose wire of battery the cabin of
the tank truck caught fire.



                              Observation of Mishap
The Operations Officer noticed this mishap and immediately took action.

                                    Action Taken
He and staff immediately mobilized DCP FE’s & extinguished the fire in the TT.


                                   Details of Loss
Minor property loss by way of burnt cabin.


                          Learnings from the Incident
From this incident it is learnt that stealing of product TT crew and keeping it in the TT
cabin is a major safety hazard and it should be stopped by vigilant officers and staff
doing duty at TLF as well check the Tank driver cabin and all safety fittings as per
norms

                                    Replicability
       All Operations Locations




.

                                             129
                                     Caselet– 7

                            Issue under Discussion:
                      Safety Precaution during Mixed Loads

                            Development of Hazard :
At one terminal during Mixed loading an accident was prevented by a cautious
Operations Officer.

                           Accident / Problem faced:
One of the TT crew was assigned a mix load bay by automation. It had to fill HSD in
tank lorry. But TT crew put the loading arm of MS inside the chamber and showed card
at the bay for HSD filling. They were about to start filling but an officer noticed the
mistake and stopped the TT crew to do so. Had it not been seen, there would have
been a huge product loss.

                             Observation of Mishap
The vigilant Operations Officer at TLF noticed the mistake by the TT crew.

                                    Action Taken
The Operations Officer at TLF noticed this mishap and immediately stopped the filling.


                                  Details of Loss
Nil. But was a safety hazard .


                           Learnings from the Incident
Whenever supplies to such new TT crews are to be released they should be manually
allotted dedicated bays of specific product.

Every one going inside terminals should be well trained and if there is a new practice or
new workmen comes it should be under strict supervision


                                   Replicability
All Operations Locations




                                           130
                                     .Caselet–    8

                            Issue under Discussion:
                Safety Hazard due to Non Maintenance of Pumps

                           Development of Hazard :
During the operation of SKO pump at one location, the coupling of pump got detached
while the pump was in running condition.

                           Accident / Problem faced:
During the operation of SKO pump at one location, the coupling of pump got detached
while the pump was in running condition, and it flew through the pump house manifold
area breaking the roof of shed.


                             Observation of Mishap
An operator observed this occurrence and took corrective action.

                                   Action Taken
The vigilant operator immediately switched of the pump thus averting further damage.


                                  Details of Loss
No major loss but this incident could have resulted in fire due to spark generated in
falling of coupling in structures of Pumphouse manifold or could have hit nearby
workers.



                          Learnings from the Incident

Scheduled maintenance of rotating equipments must be carried out and nuts and bolts
tightening and alignment must be checked.



                                    Replicability
All Locations




                                           131
                                          Caselet– 9

                                Issue under Discussion:
                            Safety Precaution during Hotwork

                               Development of Hazard :
Pipeline augmentation work was going on at pump house at one depot . A few pipelines
laid from Railway siding was to be joined with an existing MS pipeline in the manifold.
Hotwork was being carried out under supervision of 2 officers.
                              Accident / Problem faced:
In order to match the levels of the 2 pipelines to be joined. The old pipeline (emptied
and degassed earlier to the extent possible) was raised a little by loosening it from a
flange joint further away. Under instruction from the officer, one person was asked to
continuously take explosimeter reading at the loosened up open end of existing pipeline .
                                 Observation of Mishap
Hardly had the fit-up completed and root run of welding started, the explosimeter reading started
to go up from zero.
                                        Action Taken
As soon as the explosimeter reading started to go up , immediately welding was stopped and
further flushing done on the existing line before further hot work started. Before the start of the
hot work and issue of permit, explosimeter reading was zero and it continued to be zero even
during fit up.


                                       Details of Loss
Nil. Had the explosimeter reading not taken continuously, as advised by the supervising officer,
the explosive mixture of MS emanating from the loosened pipelines and would have caught fire
coming in contact with the spark of welding.


                             Learnings from the Incident
Continuous monitoring of flammable vapour during any hot work on existing product
line.


                                        Replicability
All Operations Locations




                                                132
                                         Caselet– 10

                                Issue under Discussion:
                            Safety Precaution during Hotwork

                               Development of Hazard :
Pipeline augmentation work was going on at pump house at one depot . A few pipelines
laid from Railway siding was to be joined with an existing MS pipeline in the manifold.
Hotwork was being carried out under supervision of 2 officers.
                               Accident / Problem faced:
In order to match the levels of the 2 pipelines to be joined. The old pipeline (emptied
and degassed earlier to the extent possible) was raised a little by loosening it from a
flange joint further away. Under instruction from the officer, one person was asked to
continuously take explosimeter reading at the loosened up open end of existing pipeline .
                                 Observation of Mishap
Hardly had the fit-up completed and root run of welding started, the explosimeter reading started
to go up from zero.
                                        Action Taken
As soon as the explosimeter reading started to go up , immediately welding was stopped and
further flushing done on the existing line before further hot work started. Before the start of the
hot work and issue of permit, explosimeter reading was zero and it continued to be zero even
during fit up.


                                       Details of Loss
Nil. Had the explosimeter reading not taken continuously, as advised by the supervising officer,
the explosive mixture of MS emanating from the loosened pipelines and would have caught fire
coming in contact with the spark of welding.


                             Learnings from the Incident
Continuous monitoring of flammable vapour during any hot work on existing product
line.


                                        Replicability
All Operations Locations




                                                133
.
                                     Caselet– 11

                             Issue under Discussion:
                        Safety through Good Housekeeping

                                       Problem :
Waste material, Rags, etc are a fire hazard providing the flammable material in a
location. It is of utmost importance that good housekeeping is ensured to reduce risk of
fire.


                            Accident / Problem faced:
Not Applicable .
                              Observation of Mishap
Not Applicable.
                             Solution / Action Taken
At one location a format was prepared in which the entire area of the terminal was
divided and put under the charge of a particular officer . The payment of haulage
contractor was done only if the particular officer would certify the satisfactory upkeep of
his area.

                                   Details of Loss
Not Applicable.


                      Learnings from the Good Practice
Making an Officer Responsible for a particular area as well as linking pyment to
certification by officer resulted in effective and good housekeeping which greatly
reduces fire risk.


                                    Replicability
All Operations Locations




                                            134
                                      Caselet– 12

                             Issue under Discussion:
                               Safety of DCP type FE’s

                                Accident / Problem :
CO2 cartridges were received from CIP of a Region. They were fitted in FEs. Within a
day 3 cartridges burst out from seal side like bullet on their own. Prima facie the CO2
cartridge filling was not properly done & were very old stock. Immediately all cartridges
were collected in open space & covered with net so that their impact could be contained
and damage prevented. The matter was reported to Regional Safety with photographs
& the whole lot was replaced. The vendor was blacklisted
.
                              Solution / Action Taken
Immediately all cartridges were collected in open space & covered with net so that their
impact could be contained and damage prevented. The matter was reported to Regional
Safety with photographs & the whole lot was replaced. The vendor was blacklisted



                                    Details of Loss
Nil. But could have led to injury & loss of property


                           Learnings from the incident
CO2 cartridges should be received with certificates & Manufacturing & refill date should
be checked .Physical checking of all CO2 to be done religiously and regularly.

                                     Replicability
All Locations




                                            135
                                       Caselet– 13

                              Issue under Discussion:
                   Safety during Loading at automated locations

          Development of Hazard / Accident/ Problem faced :
One day, during loading of TTs on the TLF one of the batch controller suddenly stopped working
.



                               Observation of Mishap

         The TT driver noticed this and quickly informed the Operations Officer.


                                      Action Taken
The OO ‘s response was to try to immediately stop loading at that particular bay and then
analyse the cause to rectify the problem. Options were 1) to remove earthing, 2) press stop
button 3) Close the audco valve.
The earthing was removed but since it did not stop the loading , the OO closed the
audco valve and it stopped the loading


                                     Details of Loss
Nil.

                            Learnings from the Incident
  The same may happen at other automated location & closing the audco valve of the
                      loading arm is most reliable option.



                                      Replicability
All automated Operations Locations




                                              136
                                        Caselet– 14

                               Issue under Discussion:
                         Safe & Right height for Foam Pourer

           Development of Hazard / Accident/ Problem faced :
Foam pourer systems were installed on tanks as & when the tanks were emptied for
cleaning. However on HSD tank no 1 the foam pourer was drilled under the safe height
of the tank. While receiving an HSD parcel at 1930 hrs , the product was spilled from
the 4 foam pourers and around 800 litres of HSD was spilled & any spark in the vicinity
could have created a havoc.



                     Observation of Mishap / Action taken
Receipt section staff who were present swung into action, they opened the valves of
another HSD tank to accommodate the HSD flowing in the pipeline and closed the
valves on receipt side of overflowing HSD tank no 1. Meanwhile control room officer
arranged for fire fighting facilities to handle any exigency . Spilled over HSD was
collected in barrels.



                                      Details of Loss
Nil.But could have resulted in a major location.


                             Learnings from the Incident
The height of foam pourer on all tanks is to be checked & they should be placed above
                 the safe height of the tank to avoid to avoid any spill.


                                       Replicability
All Operations Locations




                                               137
                                      Caselet– 15

                             Issue under Discussion:
                    Safe & Correct Operation of DCP type FE

         Development of Hazard / Accident/ Problem faced :
      During a fire drill at a location one employee due to lack of proper care operated the
      DCP FE pointing the nozzle on his face.



                    Observation of Mishap / Action taken
      The entire powder came on to his face with full force ad he would have sustained
      serious injury had not one employee acted swiftly & taken the FE from him.



                                    Details of Loss
       Minor injury . But could have resulted in a major injury

                           Learnings from the Incident
Always remember to start a DCP type FE with care. The pin is to be punctured keeping
   it away from the face & the nozzle should also be firmly held away from the face.




                                     Replicability
All Operations Locations




                                             138
                                       Caselet– 16

                                Issue under Discussion:
                             Safe job to be done at flange joint

           Development of Hazard / Accident/ Problem faced :
At one location an HSD pipeline was extended from Bay 18 to Bay 25. The connection
at Bay 18 was done using flange joint at night when adequate light was not there.



                      Observation of Mishap / Action taken
In the morning when the shift started and line was pressurized it was found that there
was leakage from the flange joint. This led to disruption in filling .



                                     Details of Loss
Nil.Disruption in filling.

                              Learnings from the Incident
  Such a job like linking through flange joints should be done in daylight so that gasket
 could hae been appropriately placed and the loss of product & unsafe conditions could
                                    have been avoided.




                                      Replicability
All Operations Locations




                                            139
                                      Caselet– 17

                             Issue under Discussion:
                  Safety Precautions during degassing of Tank

          Development of Hazard / Accident/ Problem faced :
A Naptha tank had been opened for cleaning & left for degassing. The contractor
supervisor was advised to fill some quantity of water into tank and flush out for early
degassing of tank. Contractor supervisor instructed the labour to fill water into the tank
and left from the site. The labour entered into the tank with hydrant hose connected to
hydrant line and started putting water into the tank to remove sludge from bottom of the
tank. His intention was to clean the tank without putting manual labour in tank cleaning.

                    Observation of Mishap / Action taken
The officer who was present there observed the man in the tank which was left for
degassing. The officer shouted and asked the labour to come out immediately. He came
out and was feeling giddy & out of breath. After some 15 minutes he could regain his
normal composure. Had he been in the tank for some more time the Naptha vapours
would have made him unconscious.


                                    Details of Loss
Nil. But it could have resulted in a life threatening situation for the labor concerned.

                           Learnings from the Incident
An experienced Supervisor must be available at the site especially when crucuial M&R
work is to be carried out. While putting the man on the job, especially where risk is
available he should be familiarized with the precautions to be taken while doing the job.



                                     Replicability
All Operations Locations




                                            140
                                   Caselet– 18

                            Issue under Discussion:
                                Safety in TT Filling

         Development of Hazard / Accident/ Problem faced :
During filling of HSD in TT, TT crew wrongly inserted 4KL loading arm in 2 KL
compartment. This resulted in spillage of 200 litres of HSD on the ground..

                     Observation of Mishap / Action taken
The OO immediately got the RIT closed and then made the TT crew to mop up the
spilled HSD with foam soaker & sand was dispersed on the remaining product left on
the ground.



                                  Details of Loss
200 litres of HSD.


                           Learnings from the Incident
Remain vigilant against wrong filling of compartments & be ready to take action to
prevent spillage and unsafe conditions


                                   Replicability
All Operations Locations




                                          141
                                   Caselet– 19

                              Issue under Discussion:
                                  Safety at PMCC

          Development of Hazard / Accident/ Problem faced :
At one location Air Compressor in PMCC was to be checked . As soon as the electrician
tried to open the screws, the screw driver touched the live bus bar panel & a short
circuit was caused.


                    Observation of Mishap / Action taken
Immediately CO2 FE was discharged & Fire extinguished. Electrician suffered minor
burn injuries on hands.




                                  Details of Loss
Minor burns to Electrician.

                          Learnings from the Incident
 All panels & busbars to be positively isolated prior to any Maintenance jobs on PMCC
                                          panels




                                   Replicability
All Locations




                                         142
                                    Caselet– 20

                           Issue under Discussion:
                             Safety at Railway Siding

         Development of Hazard / Accident/ Problem faced :
One MS BTPN rake was decanted during night shift and in the morning about 7 AM
Railway shunting staff came along with Engine to remove the rake. They just attached
the engine with the first wagon and started pulling the rake.


                   Observation of Mishap / Action taken
Operations Officer was watching the rake being pulled out and he observed that wheels
of one wagon were not moving and the dragging was causing a lot of sparks. It was
because railway staff had not de-vacuumed all the wagons. The OO immediately
contacted the security guard posted at the railway siding on walkie talkie and told him
about the problem .
The shunting man with Red flag was informed and he got the rake stopped. The
vacuum was released and then the rake was shunted out safely.


                                   Details of Loss
Nil.But could have caused a major accident.

                         Learnings from the Incident
 It should be ensured that the shunting man must check all the wagons and only then
                   give the green signal for rake to be shunted out.



                                   Replicability
All Locations with TW operations




                                          143
                                    Caselet– 21

                           Issue under Discussion:
                             Safety at Railway Siding

         Development of Hazard / Accident/ Problem faced :
One MS BTPN rake was decanted during night shift and in the morning about 7 AM
Railway shunting staff came along with Engine to remove the rake. They just attached
the engine with the first wagon and started pulling the rake.


                   Observation of Mishap / Action taken
Operations Officer was watching the rake being pulled out and he observed that wheels
of one wagon were not moving and the dragging was causing a lot of sparks. It was
because railway staff had not de-vacuumed all the wagons. The OO immediately
contacted the security guard posted at the railway siding on walkie talkie and told him
about the problem .
The shunting man with Red flag was informed and he got the rake stopped. The
vacuum was released and then the rake was shunted out safely.


                                   Details of Loss
Nil.But could have caused a major accident.

                         Learnings from the Incident
 It should be ensured that the shunting man must check all the wagons and only then
                   give the green signal for rake to be shunted out.



                                   Replicability
All Locations with TW operations




                                          144
                                      Caselet– 22

                              Issue under Discussion:
                          Safety during pipeline Operations

          Development of Hazard / Accident/ Problem faced :
In pipeline receipt section there is working round the clock. At one Terminal in 2 nd shift
there was a message that Pipeline division will start pumping product at 8.00 pm in the
HSD tank. ‘B’ Shift officer made the line through at 06.30 PM. It was practice that staff
made the line through. Staff confirmed that line of HSD through including manhole to
receive the product. In 2nd shift P/L division could not start delivery. 2nd shift officer left
with the remark that line of HSD tank is through and pipeline will start delivery in ‘C’
shift including bay. But line is to be again checked by ‘C’ Shift.



                    Observation of Mishap / Action taken
In the start of ‘C’ shift two staff sent to check the line. By mistake one staff who went to
check tank manifold, he closed the line. But line from main manifold was through.
When at 1100 PM when delivery started , line automatically got shut down due to
pressure increase at pipeline location . Immediately, line was checked and got through
to take delivery.A practice was started to check the receipt line twice at the gap of 10
minutes by different staff


                                    Details of Loss
Only 20 to 30 litres over flow from their top up valve.But could have caused a major
accident.


                           Learnings from the Incident
Line through operation is also be supervised by control room officer most of the time.



                                      Replicability
All Locations with PLT operations




                                             145
                                     Caselet– 23

                             Issue under Discussion:
                             Safety in TT Parking Area

          Development of Hazard / Accident/ Problem faced :
One day at around 7 pm in the evening one security guard at a location informed the
location in charge about a fire in the cabin of a TT . The TT crew was cooking their food
in the TT parking area & the cloth hanging outside the helper’s side caught fire.

                    Observation of Mishap / Action taken
About 35-40 loaded TTs were parked in the vicinity and thus it could have resulted in a
huge disaster.

The TT crew & Security guard immediately operated the DCPFE’s and managed to
extinguish the fire.

                                   Details of Loss
Only the cloth outside the TT got burnt but had the fire spread it could have resulted in
a catastrophe.


                           Learnings from the Incident
We should earmark an area where the crew can cook their food and a strict control to
be maintained on not allowing TT crew to cook near TTs..



                                    Replicability
All Operations Locations




                                           146
                                     Caselet– 24

                             Issue under Discussion:
                              Safety in Tank Farm Area

          Development of Hazard / Accident/ Problem faced :
On a holiday there was a call from shift officer that a major spillage of MS has occurred
near the new tank farm area.
The gasket of a blind flange had give way and MS was leaking with pressure. Almost 50
sq m of area was surrounded by MS spillage.

                    Observation of Mishap / Action taken
The leakage was observed by a patrolling security guard .action was taken by way of
depressurizing the line & changing the gasket. Sand was spread on the spillage to soak
the product.

                                   Details of Loss
Pillage in an area of 50 sqm which if continued could have been disastrous.


                           Learnings from the Incident
Regular and vigilant patrolling of tank farm area s well as regularly depressurizing the
lines especially during hot weather when product expands.



                                    Replicability
All Operations Locations




                                           147
                                     Caselet– 25

                            Issue under Discussion:
                             Safety in Tank Farm Area

          Development of Hazard / Accident/ Problem faced :
On a holiday there was a call from shift officer that a major spillage of MS has occurred
near the new tank farm area.
The gasket of a blind flange had give way and MS was leaking with pressure. Almost 50
sq m of area was surrounded by MS spillage.

                    Observation of Mishap / Action taken
The leakage was observed by a patrolling security guard .action was taken by way of
depressurizing the line & changing the gasket. Sand was spread on the spillage to soak
the product.

                                   Details of Loss
Pillage in an area of 50 sqm which if continued could have been disastrous.


                           Learnings from the Incident
Regular and vigilant patrolling of tank farm area as well as regularly depressurizing the
lines especially during hot weather when product expands.



                                    Replicability
All Operations Locations




                                           148
                                     Caselet– 26

                             Issue under Discussion:
                    Safety in TT Filling-Loading arm handling

          Development of Hazard / Accident/ Problem faced :
An Operations Officer noticed a splash of HSD coming out o loading arm on an adjacent
bay.


                    Observation of Mishap / Action taken
The OO ran towards the TT and stopped the loading by pressing the Stop button. The
helper of the TT was moaning in pain. On enquiring it was found that the helper was
putting the loading arm in the ill pipe of the TT and as he was about to chin the arm to
the TT, the driver started the loading. The sudden surge caused the arm to come out
with great pressure and hit the helper on the side of his head.




                                   Details of Loss
500 litres of HSD . Minor injury to helper . But spillage could have caused a fire.


                          Learnings from the Incident
Proper training to TT crew as far as TT filling is concerned.



                                    Replicability
All automated Operations Locations




                                            149
                                     Caselet– 27

                             Issue under Discussion:
                             Safety in Tank Topping Up

          Development of Hazard / Accident/ Problem faced :
During tank top up, suddenly the officer in charge tank farm ops found that one FR tank
was getting topped up gradually and it was already above the safe filling height


                    Observation of Mishap / Action taken
The OO observed it from the TFMS display and hurriedly informed the location in
charge. The location in charge immediately rushed to the Tank farm Area and as the
product in the tank was still within gross level height , immediate inter tank transfer was
started into another tank.

The incidenc happened due to wrong lining up the tank for TLF at PH manifold.


                                   Details of Loss
Nil . But overflow of MS would have happened and the FR could have been damaged /
overturned causing huge damage / fire.

                          Learnings from the Incident
Proper training to TT crew as far as TT filling is concerned.



                                    Replicability
All automated Operations Locations




                                            150
                                     Caselet– 28

                             Issue under Discussion:
                             Safety in Pipe Line Transfer

          Development of Hazard / Accident/ Problem faced :

It was around 19.30 hrs and a PLT of MS was planned to BPCL . During the sealing of
our MS tanks by BPCL workmen , they noticed a leakage in MS tank along with our
patrolling guard. This security guard immediately informed to control room by walkie-
talkie. Control room officer took the assistance of BPC officer and went to the spot. It
was leakage of MS product through the body expansion valve. Actually packing from
tank side was damaged and due to this product was coming like anything with large
pressure. The officer informed the CTM and other officers who were at their home by
phone.


                    Observation of Mishap / Action taken
The leakage was not controllable and all attempts to stop were failing. The only thing
which could be done was taking the product in a big tray and from their into the drums.

When other officers reached along with M&R team, they decided further line of action.
As the product height was above 10 meters in the MS tank , product was coming with
very high pressure and so it was decided to take the product as much as possible to
other MS tank. Taking permission from CTM, and started Inter Tank transfer to
adjoining MS tank .

By this time we had taken all the safety precautions with the help security guards and
pipeline assistance. Team was ready with 75 Kg DCP, 10 KG DCP and hydrant line
with connected hoses. When the level of product got down we again tried to replace the
packing. But due to lack of space and high vapour present in that spot we could not get
success to replace the packing.
Our CTM suggested not to take further risk because it was midnight so we continued
with taking leak product in drums with all safety precautions . ITT continued till the
morning when level of product came down we took again a safety measure by filling
this MS tank by 2 meter of water so that whole vapour gets out of the area.

After that the faulty packing was replaced.

                                   Details of Loss
Spilled Product. A bigger spill would resulted in a big accident.




                                            151
                         Learnings from the Incident

   1. Regular checking of packing in body expansion valves.
   2. Never panic in event of leak
   3. Take all safety precautions and reduce stop leakage by the right strategy.

        Replicability
All Operations Locations where PLT operations are done




                                          152
                                   Caselet– 29

                            Issue under Discussion:
                            Safety in TW decantation
                       ( Avoiding Product Contamination )

         Development of Hazard / Accident/ Problem faced :
A rake was placed for unloading at a depot in 1995 having product mix of MS/HSD/
SKO on IOC & IBP A/c. As per standard practices those prepare were connected to
pump as per labels provided / pasted on T/ wagon. ( Audco Valves & TW bottom valve
were not opened). The OO started checking T/W by opening top cover, visually and
taking density & temp. As per practice/guidelines at that time density of every 7 th T/W
was to be checked.


                   Observation of Mishap / Action taken
While checking density/ visual checking the OO saw a hose pipe connected to the
HSD pumps as per label on that particular T/W. While passing near that T/W the officer
smelt MS and got opened the Top of the T/W and drew the sample and was surprised
to see that the T/W contain ,MS not HSD as labeled on both sides & docket label of
Railway.
Immediately the OO took out the label from the both sides of T/W along with Railway
docket label and reported the matter to Depot Manager who immediately talked to
Kandla., the loading point . After checking  I got changed the hose pipe line canged
from HSD to MS . Hence possible product mixing was avoided.


                                  Details of Loss
Nil . But mixing of MS into HSD would have resulted in loss as well as accident hazard.

                         Learnings from the Incident
The dispatching location should take utmost care in labeling the TWs for the right
product as well as the receiving location should ensure sampling and avoid product
mixing.



                                   Replicability

                                          153
All Operations Locations




                           154
                                   Caselet– 30

                            Issue under Discussion:
                            Safety in TW decantation
                       ( Avoiding Product Contamination )

         Development of Hazard / Accident/ Problem faced :
A rake was placed for unloading at a depot in 1995 having product mix of MS/HSD/
SKO on IOC & IBP A/c. As per standard practices those prepare were connected to
pump as per labels provided / pasted on T/ wagon. ( Audco Valves & TW bottom valve
were not opened). The OO started checking T/W by opening top cover, visually and
taking density & temp. As per practice/guidelines at that time density of every 7th T/W
was to be checked.

                   Observation of Mishap / Action taken
While checking density/ visual checking the OO saw a hose pipe connected to the HSD
pumps as per label on that particular T/W. While passing near that T/W the officer
smelt MS and got opened the Top of the T/W and drew the sample and was surprised
to see that the T/W contain ,MS not HSD as labeled on both sides & docket label of
Railway.
Immediately the OO took out the label from the both sides of T/W along with Railway
docket label and reported the matter to Depot Manager who immediately talked to
Kandla., the loading point . After checking   I got changed the hose pipe line canged
from HSD to MS . Hence possible product mixing was avoided.

                                  Details of Loss
Nil . But mixing of MS into HSD would have resulted in loss as well as accident hazard.

                           Learnings from the Incident

The dispatching location should take utmost care in labeling the TWs for the right
product as well as the receiving location should ensure sampling and avoid product
mixing.

      Replicability
All Operations Locations




                                          155
                                     Caselet– 31

                            Issue under Discussion:
                     Safety during M&R of Sprinkler System

         Development of Hazard / Accident/ Problem faced :
At railway siding , M&R group at one location operated the sprinkler system for
inspection of nozzles etc. Due to this, lot of water entered in SDV’s & flow meter
devices.

                   Observation of Mishap / Action taken

During subsequent rake loding t round 14ro hrs in one block TIT, Gantry Operator
observed a lot of smoke coming out of flowmeter SDV.

He spread message through pager system. Immediately CR/Gantry Officers along with
all operators / security staff rushed to the site carrying CO2 FEs & operated on affected
SDVs till it was controlled completely.

                                  Details of Loss
Nil . But fire could spread and a major accident caused.

                          Learnings from the Incident

   1. M&R Group was advised that before operating sprinkler nozzle systems at Rail
      gantry , all relevant SDVs / Flow meter electronic devices must be covered with a
      plastic sheet.
   2. All flame proof / intrinsically safe electronic devices must be brought to flame
      poof conditions after due maintenance / repair jobs.


                                   Replicability
All Operations Locations with Rail Siding




                                            156
                                     Caselet– 32

                            Issue under Discussion:
                      Safety during Driving inside Terminal

         Development of Hazard / Accident/ Problem faced :

At one Terminal , one day one TT after getting loaded was coming out of the licensed
area gate . It was driven around 8-10 kmph and hit the barrier pole and cracked it.

                   Observation of Mishap / Action taken

The Security staff observed the mishap & informed the location in charge. The TT
driver said that he was temporarily blinded nd s such hit the pole. However it ws

                                  Details of Loss

Nil . But fire could spread and a major accident caused.

                          Learnings from the Incident
   1. M&R Group was advised that before operating sprinkler nozzle systems at Rail
      gantry , all relevant SDVs / Flow meter electronic devices must be covered with a
      plastic sheet.
   2. All flame proof / intrinsically safe electronic devices must be brought to flame
      poof conditions after due maintenance / repair jobs.



                                   Replicability
All Operations Locations with Rail Siding




                                            157
                                  General Operations
                                      Caselet–33
   ________________________________________________________________

                                Experience shared by

                       Shri Pallav Kumar, Dy Manager(S & D)/ER

INCIDENT:

During pipeline transfer of MS from one of our refinery to one of the location, it was
observed from the manifold sample that the incoming MS is not meeting the criteria of
higher limit of density. Immediately, the charge-man in field reported the matter to
concerned shift officer over walkie-talkie and without waiting for a second the shift
officer rushed to the spot, re-checked the density and found the observance of field
person correct. The officer consulted his refinery counterpart and advised him to stop
the product transfer immediately. During all the process, around 300 KL of product was
already taken into the tank so the officer on duty collected all level sample of product
from tanks and found the result same as it was with manifold product. Since the tank
was containing before receipt product also, so it was assumed that the entire product
has become off-spec now. Immediately, a local level committee was formed, comprising
of both officers from Marketing and Refinery. Different samples from different places
were collected, all the registers were verified, and record of the routing and circulation
process of the product in refinery tanks was verified. In the meantime, an operator
reported that, now the sample density is matching with the original density given by
Refinery. All the team went to the spot, again collected the sample and density was
checked, off the utter surprise to all the density was well with specification and it was
matching with the original density (as per mother tank density).After close observation, it
was found that the hydrometer, which was being used previously is not working and a
faulty one. By mistake the faulty hydrometer was kept along with the other hydrometer
and charge-man on duty picked the wrong one.

Results:
   1. So many man-hour was lost for un-productive work
   2. Supply to market was kept on hold for whole day


Lessons learnt:
   1. There should be periodic calibration of the instruments with master one.
   2. The faulty instrument should be destroyed immediately with a noting in the register.
   3. The instrument to be used in field should be handed over to field-level personnel by shift
      in-charge.



                                             158
                                        Caselet–34
   ________________________________________________________________

                                 Experience shared by

                       Shri Pallav Kumar, Dy Manager(S & D)/ER

INCIDENT:
 At one of the location, during regular mock fire drill, an employee was standing near
empty hose and watching the proceeding. The drill was completed and the Govt fire
tender was moving out. During the process the fire tender crossed the idle lying hose
and as a result the nozzle connected to the hose took off from the ground position and
hit severely to one of the employee.

Lessons learnt:
   1. It is to be ensured that after mock fire drill all fire-fighting equipment should be collected
      and placed back to original place.
   2. During the proceeding of mock fire drill, all involved should be careful of their own safety.




                                               159
                                      Caselet–35
    ________________________________________________________________

                                Experience shared by

                      Shri Pallav Kumar, Dy Manager(S & D)/ER

INCIDENT:
At one of the location, TT belonging to one of the transporter reached the TT parking
area and the driver went to S&D building in hurry to collect the loading slip. In the
meanwhile, after getting down from the TT, the helper went behind the TT for urination
near the rear left side of the vehicle. After collecting the loading slip the driver came and
started to reverse the TT. The attention of the driver was on his rear i.e. the rear right
side and could not see the helper behind the TT on left side. The helper was hit very
badly by the reversing TT.

Lessons learnt:
   1. Movement of truck in TT parking area should be always under direction of helper or
      security personal.
   2. Training to be imparted to TT crew as regard to safe practices of driving.




                                            160
                                     Caselet–36
   ________________________________________________________________

                               Experience shared by

                      Shri Pallav Kumar, Dy Manager(S & D)/ER

INCIDENT:
At one of the location, working in two shift, there were huge no. of indents still pending
and second shift was about to close. The day was last date of the month and everyone
was interested in clearing all the indents on that date only. Many TTs were still under
loading in gantry and shift timing was running out. As standard practice and guideline
the invoices should be prepared after completion of loading only. But it would have
taken much time to complete all the operations and documentations within the shift
time. So, in order to save the time and complete the activities within shift timing the
concerned officer decided to complete all the documentation before filling of the TTs.
But unfortunately due to some electrical problem in loading gantry the loading
operations stopped mid-way and it was not possible to rectify the problem on that date.
Finally, it was decided to keep all half loaded TTs inside the terminal in sealed condition
but since invoices against all those TTs were already prepared and the S&D officer was
not having authority to cancel the invoice in SAP and he could not contact the person
having the authority for that. Next day also SAP did not allow canceling the document
because of change of month. As a result, wrong sales figure was reflected in SAP and
explanation was sought from the concerned officer for his act.

Lessons learnt:
   1. Always follow the standard guideline and manual instruction for any documentation
      practice.
   2. In case of any deviation from manual or standard practice approval from competent
      authority should be obtained in advance.




                                           161
   3.

                                      Caselet–37
    ________________________________________________________________

                                Experience shared by

                      Shri Sudipto Roy, Dy Manager(Ops)/WBSO

Mismatch of receipt and tanker dispatch quantities
It happened in one of the port location which is equipped with all modern type of
technology and automated facility at the operating area.

On a day a time chartered tanker loaded with High-speed Diesel loaded from one of the
Refineries berthed at the quay at the afternoon. The tanker is having centre type tanks
and was to discharge almost 20 TMT in this first port of call and then it was being
planned to go to other destination. After completion of all initial operating formalities the
tanker started her discharging in such a manner that all the operation will be completed
by next day afternoon and she will be on her way to the next port of call. The planning
was made in such a way because the port was not having the night navigation.
There was the boarding officer at the tanker and a shore office in the control room who
were connected through VHF so that the discharge and the receipt quantity along with
the density can be tallied every hourly as per the Manual instruction. The shore tank
was nominated in such a way that it has the sufficient ullage to accommodate the
discharged quantity.

Through out the whole night figure were exchanged between them and it was all within
the permissible limit. Since everything was under control and smooth both the shore
and the on board officers were relaxed in their job.

An unpredicted trouble popped up in the next day. All of a sudden it was noticed that the
difference between the discharge and the receipt figure cropped up. The difference
went on increasing at the early afternoon when the tanker informed that they are almost
at the verge of completion of the discharge program.

Since the difference was more than some few hundred KL the operation was
immediately suspended and it was asked to take the ullage of all tanker tanks including
the slop tanks and cofferdam.
The matter was immediately informed to all including the location in charge and other
operation head of the state office. In the mean time it was asked by the shore officer to
gauger to take the dip of the receiving tank.

After an hour taking all the ullages of individual tanks, calculating minutely considering
the trim and list of the Tanker, the discharge figure was found to be matching with the
initial figure as declared by the tanker while operation and thus the difference prevailed.

                                            162
The discharge line connected between jetty and tank manifold was checked thoroughly
and was not found anything, which will incur such huge loss.
All of a sudden the Location in charge along with the shore officer went up to the tank to
take the dip physically and after gauging it was found that the dip provided by the
gauger is not matching with the dip taken by them. On enquiring it was found that the
gauging system attached at the tanks was giving the erratic figure at the high level.

This could have been ascertained if the dips were taken physically and this unwanted
time and financial loss a would have been avoided, over and about due to this delay in
operation the tanker was not able to go to the next port of call on that day and was
released in the next morning.


Result:
   1. Unwanted time loss incurring the huge financial loss to the corporation.
   2. Detention of the tanker incurring recurring loss of time and delay in operation.

Lesson learnt:
   1. To take every hourly dip of the shore tank and tallying the figure with the tanker.
   2. Apart from taking dip of the shore tank through the gauging system it is required to take
      physical dip time to time for rechecking the installed system




                                              163
   3.

                                    Caselet–38
   ________________________________________________________________

                               Experience shared by

                   Shri R.Bandyopadhyay, Sr Manager (T & D)/ER

INCIDENT:
In one of the Terminals I was working, brass caps of 10 kg DCP fire extinguishers (FE)
used to be regularly stolen.

One day, I heard a bursting sound from the TLF shed. When rushed there, found that
one of the caps of 10 kg DCP fire extinguishers had gone up in great speed and pierced
the asbestos sheet (hence the sound) of the TLF shed.

On investigation, it was realized that one person (was he the regular pilferer? This could
not be established beyond doubt…) was fiddling with the brass cap of that FE. In the
process, the cap had become loose. The clip of the FE was missing. And since
accidentally and unknowingly the hand was pressed over the plunger, the cartridge
inside burst and with the great pressure of gas, blew the loose cap fitted above away
from the FE and ultimately pierced the AC-sheet above. Luckily, nobody was injured.

Lessons learnt:
   1. It is extremely important to ensure that only adequately trained employees are
      allowed to handle fire extinguishers. Nobody should operate it with his/her head
      above it.

   2. It must be ensured that clip is there at the slot so that even if somebody tries to
      press the plunger of the FE accidentally or unknowingly, the cartridge inside
      would not be pierced.




                                           164
   3.

                                     Caselet–39
   ________________________________________________________________

                               Experience shared by

                   Shri R.Bandyopadhyay, Sr Manager (T & D)/ER

INCIDENT:
An above-ground cone-roof tank in a Terminal was found to be in a tilted/bent condition
on one ‘fine morning’. On investigation it was found that the free vents at the top of the
tank were having lot of bird-nests which were clearly making it difficult for the tanks to
breathe. This resulted in pressure-differential in the tank (outside pressure more than
inside) which led to tilting/bending of the tank.

Not knowing what to do about the situation, SOS was sent to Regional M & I group.
After inspecting the tank, the visiting official advised to pump water into the tank. After
water was pumped into the tank upto about 60% capacity, the tank became straight
without any visible deformity.

Lessons learnt:

   1. The critical importance of keeping the vents clean.
   2. There may be simple solutions available to complex-looking problem.




                                           165
   3.

                                   Caselet–40
   ________________________________________________________________

                             Experience shared by

                              Shri Aryil Ray Chaudhari
                                    COM – TNSO


Issues under discussion:
NRMTM – CBMT: 2004 – 2005
Sudden increase in evacuation rate/ products handled – HSD, SKO, NAPHTHA, MS
(bridged from other supply locations) and LSHS

Abbreviations used:
NRMTM – Narimanam Terminal
CBMT – Cauvery Basin Marketing Terminal
CBR – Cauvery Basin Refinery

Background/ Problems/ Solution:
   1) Delay in full-fledged commissioning of CTMPL due to certain unforeseen factors.
   2) Improvement in crude receipt position at CBR.
   3) Deferment in commencement of construction work of the dockline from CBMT to Nagore
       Jetty, initially/ predominantly envisaged for evacuation of NAPHTHA.

In a meeting attended by the then top brasses of IOC and IBP, held at NRMTM, it was
clearly indicated that owing to the above mentioned factors, there was no other option
left than CBMT shouldering the responsibility of increased evacuation, on a sustained
basis, single-handed.

On an average, we, at CBMT, used to fill 160 TTs per day. With the additional demand,
we were expected to load, on an average, 260 – 280 TTs daily. Later, as found, on
some occasions, the total number TTs filled on a day, even crossed the mark of 300+.
There was no increase in manpower, nor any scope for augmentation of infrastructural
facilities, either at NRMTM or CBR.

However, the team rose the occasion and took on the challenge frontally. In the
process, some new/ practical ideas were implemented. From general shift starting at
08:00 hours, commencement time of operations activities were pushed to 06:00 hours.
The closing hours were also stretched much beyond the normal 17:15 hours. With
limited manpower, we planned and executed the concept of rational distribution of
working hours.



                                         166
For working from 06:00 hours and beyond 17:15 hours, we went for rotation amongst
officers and employees. We also implemented the idea of calling officers from other
locations, who would be on tour to CBMT, working as relieving officers to keep the
NRMTM-based officers fit to carry on, on a sustainable basis. As a result of all these,
we could cater to the need of the hour. We acted as a homogeneous team and solved
the problem.

Lessons Learnt:

In this particular case, it was not anybody’s fault that led to the situation of crisis.
However, more frequent and close coordination with higher offices and refinery,
perhaps, could have given a better view of the situation a little earlier.
Any critical situation can be handled, provided we work as a team and conceive/
execute innovative and realistic solutions.




                                          167
                                     Caselet–41
   ________________________________________________________________


Issues under discussion:
NRMTM – CBMT: 2006 – 2007
Intermittent disruptions in operations due to adoption of unfair tactics by TT crew/
owners.

Abbreviations used:
NRMTM – Narimanam Terminal
CBMT – Cauvery Basin Marketing Terminal

Background/ Problems:
Like many other locations, at NRMTM also, there was emergence of a class of TT crew
members turned into owners. In order to have a formal/ political status, they joined the
association of TT Owners’ Association of CBMT. However, because of the very nature
of its origin, a substantial part of its membership was represented by traditional TT
owners’ group.
However, this group of TT crews, turned TT owners, from time to time, used to come up
with a lot of unjustified demands. Any refusal to accede to their irrational claims used to
lead to break-out of flash strikes, seriously affecting the normal operations.

Solutions/ Lessons Learnt:
At the increase of such menace, we started thinking of some strategy for crushing them,
once and for all. As a counter measure, we started building up, very discreetly, good
relationship with the strong office bearers and members, all of whom were from the
traditional transporters’ group.

Further, we discussed and could convince them that such a vandalism-oriented
irresponsible action not only disturbed our functioning but also sometimes would affect
the interests of the original transporters’ group quite adversely. We waited for an
opportunity. It came with their demand for parking their vehicles not from a particular/
stipulated time, as earlier decided mutually, but at any time that they would please. On a
Sunday, we were working for combating product crisis. This faction of trouble-creators
tried to take advantage of the situation and started parking their vehicles from early
hours of the day, not for any loading purpose, but to prove their point of might is right.

At this juncture, we immediately contacted the office bearers of the Association and
appraised them of the situation. They rushed to the spot. We, jointly, countered the
move of the delinquent TT crew members, quite overtly.

As a result, they were forced to take all such illegally parked vehicles out of the parking
slots. This took place in front of all other members of the TT crew. Therefore, it had a



                                           168
solid demonstrative impact on all others. The sporadic disturbances of any kind came to
a permanent halt.

It was found that by proper thinking and effective boundary management, a lot of such
undesirable developments can be tackled successfully.




                                         169
                                    Caselet–42
   ________________________________________________________________



Incident:Fire/flame travel in P/L

A 300 m straight P/L 24’. Jetty to land was water flushed and water drained some P/L
was empty disconnected with the main line, by opening the plange and hot work was to
be taken up at the jelly end for connecting sample, expansion line and welding one
leak.
The line was checked by exposure meter near the jelly end. There are four people
including the welder man at jethy end, and there are four people including some IOC
employee (officer & staff) were standing near the free end on store, near the open end
and the pipe.
When the leak welding shared a sudden gush of flame started near the jethy end,
rushed along the pipe line and escaped from the open end. It was just one burst.
Luckily as no one was very near to the open end, no one was burn/ injured.

Lesson :

   1. Pockers gas in P/L cannot be ruled out even direct water flush. Flame rushes to
      the open end quickly and one has to be careful, nor be present near the opening,
      even it is far away from the welding spot.




                                         170
   2.
                                      Caselet–43
    ________________________________________________________________

Incident: Fire in a tank during repairs inside after tank cleaning.

Situation:
A class A product tank was opened up for tank cleaning, product evacuated, water
flushed and emphed. Tank cleaning was taken up more than 10 to 12 days had elapsed
and mind not work was done both inside and outside on the shall of the tank without any
mishaps.

What happened?
A bottom plate welding was to be done. The site of the welding required was close to
me rool leg. A welder and two/three people were inside the tank holding there are one
officer .When the welding started the bottom weld; there was a sudden burst of flame
from near the leg of the FRVT.

Since DCP extinguisher was there the small fire was immediately put only.

Danger: The danger was in the surprise flames were anticipated as several hot work
was already done in the tank although at shell plates.Although flames were small,
possibility of injury to welder, due to his not anticipating the flame could have taken
place.

Reasons for fire:

All legs of FRVT are blocked pipes. There is a small hole in the bottom of the leg from
which any oil that enters the bottom portion of the leg during usage can drain out.
In this case, that hole was blocked and MS in the leg portion had not immediately
drained. During the subsequent days after cleaning the blockage was allowing seapage
and MS from the bottom portion of the leg had separate out, leading to the fire, when
the welder applied the flame near the leg resting place.




                                            171
                                      Caselet–44
    ________________________________________________________________



Category: Free due to P/L leak during ranker discharge. (20 years back)

Background:

Tanker was discharging HSD there 3 km P/L 24 inches. The P/L was in an isolated area
of the port and entry into terminal was directly from part. The location was coastal line
was always kept with sea water, as water flush was taken and life period the P/L was
normally 3 years.

By 2nd year, P/L had several holes which were normally clamped. Once above 30 h 35
clamps were in place, line was decommissioned and welding was undertaken. Line was
generally in use for 25 days in a month. Discharge rate was 500 to 700 km/hr or
presume the 5 kgkm2.

HSD was discharged on P/L had – 7 to 8 clamps on the line. A new leak developed and
oil came up in a stream. How it caught fire was not determined but probably due to a
stray man smoking.

The fire/flame rose 4 to 6 feet high. The patrolling team immediately informed terminal
and the port fire fighting team with fire engine. The fire was midway from jetly to
terminal. Since area was inside port and isolated no other person were there.
Immediately on the fire being noticed. Tanker stopped the pumping operation. Similarly
afraid then the fire with travel the P/L, shore terminal shut all the tank valves.
Then the tanker lined up in water flush and water flush started to everybody’s surprise
the fire did not subside desperate the fire engine continuously fighting the fire from the
next 5 to 7 meters.

It was then realized that although terminal was informed by boarding officer about water
flushing being started. The same was not conveyed to the chayeman and tank valves in
removal were not open.

The same was corrected, tank valves opened and within 5 minutes. When water
reached the site the fire died down. As the tanker always gives water flush with its
bypass values opened, presume did not build up in the p/L during the initial phase when
tank valves were closed.

Conclusion:
Sequence action is very critical especially in the confusion that arises when a fire starts.


                                            172
                                    Caselet–45
   ________________________________________________________________

                              Experience shared by

                                    Shri P.P.Adhia
                                    CRC Jamnagar.

Practice followed at Ahmedabad during my previous tenure:

In our locations due to high ambient temperature locations falling under middle part of
India and locations falling under Gujarat state where ambient temperature rises up to 46
to 47oc in summer at that time ‘0’ zone area of our locations heated vary badly and
there us chance to possibilities of mis fire. Generally we use to cool down ‘0’ zone area
like TLF/TANK FARM/ RLY. SDG/ PUMP HOUSE etc. by using after monitor through
fire pump.

We observe that this type of conflicts sometimes create unbearable atmosphere effect
to the employees/tt crew/ contract labours who are in their work place. Due to high
atmospheric temp there is a chance of fire particularly at TLF area where vapours exist
due to loading operation.

At our location we have started the practice of operating fire Hydrant System by
operating Monitors in TLF area during the lunch break hours so that, will reduce
atmospheric temperature in TLF area, also will reduce vapour and also clean TLF area
which will give comfort to all persons working in the area.

Issue under Discussion:
FR tank-Roof tilting

Background/ Incidence:
Somewhere around Yr 2000,at Pakni dep. Reported for tilting of FR roof while loading
TW. Roof got stacked on all side from dif hatch pipe from welded joint.

Solution/ Lessons Learned:
   1. Roof got raised by draining welder from top of the tank by fire hoses pushing
      upward, made in floating cardibian.
   2. Reason for getting roof stuck: welded dip hatch pipe in FR tank. Now guideline
      charged to have single dif hatch pipe without any welding tank.




                                          173
                                   Caselet–46
   ________________________________________________________________

Issue under discussion:

Fire caught in TT, while welding work for first time trail basis security system in TT.
Somewhere during (somewhere outside TL area) 2000 (vashi somewhere outside area)

Background/ Incidence:

While welding of TT, immediately fire took place and welder died there only at vashi
outside TL area.

Solution/ Lessons Learning:

While any welding work to be carried out at TT, complete water flushing by overflowing
the TT chamber to be ensured. Also thrice Expl.Meter for vapour content to be checked
and made vapour free.




                                         174
                                    Caselet–47
   ________________________________________________________________

                               Experience shared by

                             B. K. Jha, Ch. Mgr (OPS), DSO

Background/ Incidence:

1.Fire at TW siding during hot work

Leakage in pipeline of MS at TW siding was observed after hydro-testing of pipeline.

After flushing of pipeline, Hot work permit was issued to the contractor under
supervision of location incharge and maintenance in charge. Earth work was completed
to make the space for welding. DCP was kept at the site for any consequences.

After readiness of everything, a spark was shown at the site, immediately fire took place
by the vapour coming out of pores of the soil, which was not actually envisaged.
Immediately DCP was discharged and fire was killed. But this saved the life of welder,
supervisor and other officer standing at site for supervisor.

   -   While excavation of the pipelines a bigger surface was exported.
   -   Oil was soaked through the pores of sand and sufficient vapour was present
       inside which immediately start coming out as soon as flame was shown.

Lesson :While doing such hot work coating of fresh to be done to close the pores to
avoid opening otherwise this may lead big incident.

2.Sinking of floating roof

At Kanpur Terminal during 1995 while commissioning of Naptha Tank oil came out of
roof and roof start sinking.We thought initially that water may not be present in the roof
drain and water was procured from top but nothing happened.

It was decided that since vapour is present during mid day roof should be inspected in
the early morning by maintenance group.As planned maintenance staff and
undersigned went on the roof through monkey ladder available.

Staff immediately reacted that there is enough vapour on the roof and breathing is not
possible. Undersigned also went on the roof but soon realized that there is enough
vapour and it was suffocating and feeling unconscious.


                                           175
Any how we could manage to escape we realized as under:

Solution / Lessons learnt:
   - Explosive meter/ oxygen meter was not used to check in such case before going
      on roof top in case when oil is present on roof.
   - Petroleum vapour is highly toxic and within few minutes one can be victimized.
   - Similar precaution must be taken while entering into vessel or doing any hot work
      inside storage tank.
   - This small violation or negligence can lead a disaster.




                                         176
                                     Caselet–48
   ________________________________________________________________

                               Experience shared by


Issue under discussion : Operational Problems –Ingress of MS in SKo tank during
pipeline receipt


Background/Incident:

In morning hours in a Terminal operating in general shift, SKO delivery to market
through TT was to start. The lab staff was absent on the day. LIC asked DM(ops) to
check flash point before release . DM(ops) reported that thermometer seems to be
wrong as FP is coming as 18 deg C, the atmospheric temp on that day. LIC than went
to lab to check the same and flash could be seen instantaneously.

All actions were than taken to reverify the fact & the matter was reported . Tank was
kept isolated and correction took 3 months.


Solution / Lessons learnt: It had all the possibilities of releasing SKO as rutine when
lab assistant did not report for duty. No shortcuts in practice as it may short cut life of
how many, we do not know.




                                           177
                                    Caselet–49
   ________________________________________________________________

                              Experience shared by


Issue under discussion : Safety & operation related


Background/Incident:
It was noticed on the morning safety round that a portion of grass has dried up and
there were marks on the drain wall. It could immediately be seen that a flange joint in
MS receipt line has developed leak.


Solution:
Immediate action was taken to empty out the line and by the time it was started the joint
gave way but as all line up was done there was no loss of product or other serious
situation .One can visualise the impact if it would have gone unnoticed.




                                          178
                                     Caselet–50
   ________________________________________________________________

                               Experience shared by

                      Shri A.R.Shakri, COM, Bihar State Office

Background/Incident:
1.
A Tank Truck loaded with 6kl MS & 6kl HSD arrived at a RO for decantation. After
checking the TT, hose connection was done for unloading. 2 chambers of MS was
unloaded. While unloading 2nd chamber the TT caught fire. The driver of the TT
immediately drove the vehicle out of ROO premises & park the same at road side. The
TT kept on burning till Fire Tender arrived and extinguished the fire.

Reason : Overlooking SOP

When the hose was connected to TT & Under ground tank. The helper found that the
hose is sagging. He then passed the hose over a metallic tin kept above a plastic chair.
While decantation there was minor leak from the tt manifold. During the unloading
stormy hot wind started blowing resulting in the metallic tin fell down, sparked & caught
fire.

Remedy :
  1. Camlock coupling to be used at RO for decantation.

   2. Metallic tin, plastic chair etc must not be around decantion site.

   3. Crew members to be educated enough.

   4. RO staff to be present at the decantation site & no unloading without camlock
      coupling.



Background/Incident:
2.
A truck loaded with 12 kl of HSD was released after completing all formalities from an
automated location. After travelling around 170 km the TT arrived at RO for decantation.
The lock etc was found to be perfectly alright. While taking sample, it was observed that
one of chamber is empty.

Reason : Negligence


                                           179
Though the location is automated , the check has been bye-passed at least three
instances :
    1. At control room

   2. At TLF.

   3. At S&D, while preparing the invoice.

Besides, Exit barrier gate has malfunctioned. The crew member did not check the TT
while they have signed the invoice accepting 12 kl of product.

Remedy :

   1. Checks must not be bye-passed at any level in automated location.

   2. Crews must be educated to check each chamber of the TT before locking.

Background/Incident:
3.
A rake loaded with HSD & Naptha was placed at a location. After checking, sampling of
the wagons the supervisor advised contract workers to connect the hoses for
decantation. After connection etc the supervisor advised to start decantation & pump
was started. Then, he went to admin office which is almost ¾ km. There he felt uneasy
& requested his superior & in-charge of the TW activities to send another supervisor for
time being.

He was briefed by the earlier officer about the composition of rake being decanted.
While checking the TWs for rate of decantation, he found that one of LDO tw is
connected to Naptha line & the same is already decanted.

Reason : Sabotage / Lack of supervision
All the hoses were not connected in presence of supervisor. Even after connection the
same were not checked before starting of the pump.

Remedy :
  1. Dependency on contract labors has got its own limitation.

   2. Hose connection/ Sample checking is very sensitive, must be well supervised. A
      slight lapse leads to unseen consequences.




                                          180
                                   Caselet–51
   ________________________________________________________________

                             Experience shared by

                             SHRI SUBHRANGSU DAS
                                  CM (O), MPSO


ISSUE UNDER DISCUSSION:

On 20.08.2010 at Gwalior Depot the loading of TT No. MP31HA-0605 was in progress
by inserting the loading arms in TT Compartments. The loading of Comp. no. 1, 2 & 3
was completed successfully but the loading arm was not reaching the Comp. no. 4 as it
was a 20 KL TT. The driver of the TT then started the TT for moving slightly ahead and
helper was holding the loading arm, while standing above the TT. Due to unbalance of
helper his one leg slipped from Tank of TT. He hold the pipe railing near by and saved
himself. There was no injury in the incident.


LESSONS LEARNT:

Proper training should be imparted to TT Crew for loading of 20 KL TT at TLF. The
present design of loading arm is for normal length of TT (12 KL). Some TLF Bays
should also be designed for TTs having more length.




                                         181
                                    Caselet–52
   ________________________________________________________________

                              Experience shared by

                              SHRI SUBHRANGSU DAS
                                   CM (O), MPSO

ISSUE UNDER DISCUSSION:

On 28.07.2010 at Itarsi Depot, demonstration on use of Fire Extinguisher was in
progress. All the SOP’s including movement of FE, checking of wind direction, removal
of clip, pressing the nozzle keeping safe distance from the centre of FE to the person
was explained. The driver of TT No. MP05 H 0144 was ready to demonstrate use of FE
and subsequently the threaded cap of FE went into air and fell at a distance of 10 m
away. Since he followed the proper procedure, the threaded cap of FE flew away
without hitting the face of the driver or near by personnel.

LESSONS LEARNT:

To tighten the cap of Fire Extinguisher as a matter of practice.Following SOP on use of
Fire Extinguisher.Proper training to TT Crew on use of Fire Extinguishers.




                                          182
                                       Caselet–53
   ________________________________________________________________

                                Experience shared by

                                GIRJA SHANKER
                       CHIEF MANAGER (OPERATIONS), UPSO-I

ISSUE UNDER DISCUSSION:

Frequent running of jockey pumps to maintain pressure in hydrant line

BACKGROUND/ INCIDENT:

Hydrant System has been provided in all the Terminals/ Depots which are to be kept
under pressure (7 Kg/ Sq. Cm) on auto mode. The function of jockey pump is to
maintain pressure in the system & take care of small leakages. The operation of jockey
pump is controlled thru a pressure setting switch (say 5.5-7.0 Kg/SqCM) . In normal
course when the hydrant system is maintained in good condition, the running frequency
of jockey pump is after every 30 -40 minutes for 1-2 minutes to maintain the required
pressure in the system.

As per the instructions of M&I, return line in the hydrant system was provided at the
installation to periodically flush out the stagnated water from the hydrant system into the
above ground Fire water storage tanks to control corrosion in the hydrant lines.

PROBLEM FACED:

During the round of the location & interaction with staff on duty at Fire water pump
house, it was discovered that frequency of jockey has increased for past few days & it
get starts at every 5-6 minutes. He also informed that no significant leakage is being
observed in the field inspite of that frequency of running of Jockey is not coming to
original level.
After interaction with Staff & officers two possibilities suspected.
   (i) Sweating or dripping in the underground portion of hydrant lines.
   (ii) Bye –passing of gate valve provided in the return line.

SOLUTION / LESSION LEARNT:
A blind was placed after the valves of return line towards tank side to check passing of
valves & it was discovered that Gate valve provided in the return line was not able to
hold the hydrant line pressure & water was passing thru valve into Fire water tank.
Ultimately a hammer blind was provided between return line valve & tank body valve
which resolved the problem & frequency of running of jockey improved to original level.


                                              183
                                     Caselet–54
    ________________________________________________________________

                               Experience shared by

                               GIRJA SHANKER
                      CHIEF MANAGER (OPERATIONS), UPSO-I

ISSUE UNDER DISCUSSION:

Foam pourer system in above ground tanks at Terminal/Depots

BACKGROUND/ INCIDENT:

Foam pourers are being provided in some above ground tanks at locations in line with
OISD requirement & these pourers are to be tested at every 6 months for observing its
satisfactory performance. Normally testing facility are provided in such a manner that
while testing is done the foam does not inter into the tank & fall outside so as to see the
performance of these foam pourers. The location does not have proper testing
arrangement as a design defect. Whenever testing was being done, the foam pourer
use to be rotated at 90 degree by opening/ re-fixing 10-12 nuts bolts to see the
performance.

PROBLEM FACED:
In one of the above ground tank, testing was done accordingly by maintenance staff by
rotating foam pourer but after completion of the same it was not brought to its original
position after completing the testing. This tank was also lined up for pipe line receipt
next day. The receipt was about to be completed in this tank & pipe line / marketing staff
were on the job for change over of tank for continuing the receipt in another tank but at
the same time they found the overflow of product from the foam injection point.
Immediately pipe line shut down was taken & within few minutes the changeover was
also affected & pipe line receipt was resumed.

SOLUTION / LESSION LEARNT:
The officer on duty informed that the product level in the tank is still below safe capacity
of this tank & it is not under stood as to how the product has over flown from the tank.
Further study revealed that safe capacity of tank was not revised after installation of
foam pourer system which was done 4-5 years back. Other tanks were also checked &
it was found that all tanks have similar problem. Safe capacity of all tanks were revised
                                            184
/ reduced in consultation with Engg/ Operation & a gap of atleast 300 MM was
maintained in all tanks between the safe height & bottom side of foam pourer.
    (i) Changes in the system to be made considering all safety/ operational related
            aspects & it should be shared with all concerned to reduce risk.
    (ii) Proper testing facility to be provided right from inception wherever testing is
            required to be carried out at certain interval.


                                    Caselet–55
   ________________________________________________________________

                              Experience shared by

                                  Shri N.S.Bajirao
                            Chief Manager (Claims),WRO

ISSUE UNDER DISCUSSION:
During summer days one day around 12.00 noon at one of the port location , Terminal
manager received a phone call from pipeline division officer that, there is heavy MS
smell is coming from pump house. Immediately then he alerted to maintenance team
and control room and advise them to visit to site and he him self also rushed to the
site. Product was spilled in quite large quantity across the pump house manifold area
and they observed MS was leaking from joint over header pipeline. The situation was
very very dangerous and catastrophic. Matter was then immediately reported to state
office . Before beginning of salvage operation first one team was instructed to keep
fire fighting system ready, in case of any eventuality and Positioned two DCP fire
extinguisher and 75 kg DCP fire extinguisher near to the site. After ensuring fire system
is ready , instructed another maintenance team to use portable fire monitor and spread
foam over the surface of leaked MS by using fire water. After spreading of foam
solution on leaked MS surface then salvage operation was started. Then to begin with,
tried to suck back content of header into MS tank by operating pump, so that leakage
from joint gets minimised. After ensuring header is slightly empty, then nut bolts of
joints opened and changed the packing of joints. Changing of packing took almost 1.5
hour. There after entire spilled product salvaged in drums with the help of aluminium
bucket and cleaned the pump house. It took around three hours. Entire day was gone
into this operation. Nature was quite helpful as there is always heavy breeze in this
particular port location , which has diluted the vapours spread in atmosphere and
prevented the formation of dangerous inflammable mixture of air & hydrocarbon.

REASON AND SOLUTION:
Then reason of bursting of packing of joint was investigated and analyzed. The reason
established was that, expansion lines provided on header were not kept open caused
                                          185
increase in pressure in the header due to expansion of product with temperature rising .
The weakest portion in pipeline was gasket packing in joint , which got burst due to built
up of pressure. Expansion lines were kept closed to avoid the migration of BS-II MS to
BSIII MS, as delivery lines of both tanks are meeting over there on same manifold.
After detail study, system was formulated that, expansion line will be made through and
should be given in the tank, whichever grade of MS is handled.

LESSON LEARNT:
Maintenance officer as well control room officers were explained about the problem and
importance of monitoring of manifold valve in pump house. They were advised to
monitor strictly manifold as well valves and joints over other pipelines specially in noon,
when ambient temperature is high. As a location in charge was also frequently
monitoring this aspect during his round of terminal. Thereafter no such incidence
recurred.

ISSUE UNDER DISCUSSION:
After commissioning of one of the Depot , during first monsoon one day, there was a
heavy rain in night. Next day morning when operator went for gauging, after climbing
on MS tank, he immediately came down and came rushing to office building and
informed to Depot Manger that, there is a MS spilled on the roof of the tank. Then Depot
Manger himself alongwith colleague officer I went over the MS tank and observed that,
roof of the tank is tilted and some MS has spread over the roof of the tank. Team of
Depot was not very familiar with functioning and handling of floating roof tank. So it was
decided to report the matter to higher office and reported accordingly incharge of higher
office. Higher office sent a team officer who are experienced in floating roof tank
immediately. After arrival at Depot team along with Depot manger went over to MS tank
and observed the situation. One member of team who was operating personnel
instructed to check all pontoons by opening cover on it. One of the pontoon chamber
was found full of rain water, which has caused roof to tilt and tilting caused
displacement of MS, which was surfaced over the roof of the tank. Team advised to
remove the water from pontoon, which was filled with water. After evacuation of
pontoon, then team looked for reason of ingrace of rain water into the pontoon.

REASON AND SOLUTION:
 The reason found that, around 10” welding on roof joint was not done properly and also
central water drain was found clogged with construction material. The reason of
entering water in pontoon was that, when there was raining, due to central water drain
clogged, water level rised and reached upto the open welding joint and water in-graced
through that. As product was already received into the tank, team advised to block the
open welding joint by plugging it with M-seal and keep on watching the tank. In next
cleaning the same may be get repaired by hot work. Tilted roof was straightened and
made at even level by pumping some product into this tank from other MS tank.

LESSON LEARNT:
Team advised to follow the manualised procedure of checking floating roof tank. There
after strict checking of floating roof tank was implemented and tank was thoroughly

                                           186
checked as per check list and record maintained. This was a lesson learning about
operating aspect of floating roof through near miss and never been forgotten.




                                      187
                                    Caselet–56
   ________________________________________________________________

                              Experience shared by

                               Shri Surinder Kumar
                              Chief Manager (RC),PMC

ISSUE UNDER DISCUSSION:
Rake was placed for loading ATF at 1140 Hrs on 12.07.10 at the Gantry no.1. During
the rake loading at around 1900 Hrs, strong wind with rain started and rake was moved
about two to three feet on one direction. The movement was stopped and immediately
small stone was placed under the wheel of TW at the end of the rake. The movement of
rake under loading would have caused serious accident/damage to the loading arms
inserted inside the TWs. In-fact the loading arms have prevented the movement of rake.

REASON AND SOLUTION:
The rake was placed without wheel Jammed placed under the TW wheel. Also the
braking system was not applied by the Railways after the rake placement. Stormy
weather/ wind initiated the movement of the rake.

This is a Railway matter, which has been taken up with them at local level as well as at
Sr DOM/ DRM level. Meanwhile; the wheel jammer have been procured by TXR and
provided to the Rly operating staff for use.

LESSON LEARNT:
To ensure that the rake is placed with jammer or stopper under the wheel of last TWs
on either side to prevent any movement during rake.




                                          188
                                      Caselet–57
    ________________________________________________________________

                                Experience shared by

                                 Shri Surinder Kumar
                                Chief Manager (RC),PMC

ISSUE UNDER DISCUSSION:
One TW noticed overflowing while loading HSD at gantry, which was stopped by
stopping the loading. The only gantry officer for two gantries was called and TW was
decanted partly to bring it at the correct level. Meanwhile; out of six operators, only
three operators were found at the gantry and other three in the rest room. The staffs for
this particular TW was not available at the gantry while on query, he told it was to be
looked after by other operator to whom he has nominated for the time being.

REASON AND SOLUTION:
The workers missing from his work place and resting in canteen/rest room is a common
practice experienced at locations like LPG/Terminals. Few staff members only remain at
the work place while other nominating their work to them. On query, they argued for
going on the work and practices because of which work/operation monitoring/
supervision cannot be ensured by officers alone, that too always less than the required
strength. The situation is really common and risky for unattended routine ongoing
operations. This has become so in the name of maintaining good IR. The officers of the
gantry & control conveyed that making documents and reports of such incidents are
waste of time and taking risk /conflict, till some authority for direct action is visible from
the Loc I/C.
The allotted duties of the staff can be ensured only if officers are having the admin
controls according to the responsibility they have. Even shifting the work station of staff,
within the location, deployment is by the union, where as principle of ‘responsibilities’ is
to have corresponding ‘authorities’. The occupier (Loc-in-charge) must be disciplinary
authority for the staff working at the location may be the solution.

LESSON LEARNT:
The staff must be made accountable for the jobs assigned to them and officers can be
responsible if corresponding authority is vested for getting the assigned job done.
Otherwise, those should be held responsible who are having the authorities for staff
handling and such unsafe acts at the locations.




                                             189
                                     Caselet–58
    ________________________________________________________________

                               Experience shared by

                                    Shri R R PRASAD

                                      Incident No:1

Incident Narration:

Andhra Pradesh has product pipeline connecting Vizag HPC refinery to Hyderabad a
distance of around 700 KM .Enroute IOC had constructed three TOP’s ie at
Rajamundry(Gokavaram),Vijayawada(Kondappailli) and Hyderabad(Cherlapall)iOne of
these pipeline terminals(TOP) on Vizag – Hyderabad pipeline was ready for
commissioning.

The acceptance/inspection team            instructed that fire hydrant system to be
demonstrated for its effectiveness. The location personnel including the location in
charge demonstrated various monitors, foam nozzles. Meanwhile a team of three
connected the fire-hose to the hydrant and was trying to display the effectiveness .The
person operating the control valve suddenly increased the water pressure. The person
holding the fire hose could not control the sudden jerk and lost the grip of the hose and
it went out of control. Immediately the person at the control of the fire-hydrant hose
rushed to help the person holding the hose. This did not help in any manner in stopping
the uncontrollable jerking circular motion of the fire-hose. Meanwhile one of the
personnel rushed to the control valve at the fire-hydrant monitor station and closed it.
This stopped the flow of water and brought the hose under control.

Causes of accident:Do not increase water pressure suddenly resulting in jerky
flow.while operating fire hoses.

Conclusion.:1

Fire drill to be taken seriously as accident can occur during firedrill also.2.Each person
constituting/operating the fire control equipment should be thoroughly trained and
should know the do’s and don’t’s.




                                            190
                                     Caselet–59
   ________________________________________________________________

                               Experience shared by

                                   Shri R R PRASAD

                                      Incident No.2

Incident narration:

Santacruz AFS was storing Avgas100LL during 1983-85 in underground tanks. Product
receipt was through Tank truck . Tank truck decantation was under process. The
opening dip of receipt tank was recorded in the decantation register was recorded. After
checking the tank truck containing Avgas for quantity and quality decantation process
was commenced. Finally the decantation was over and post unloading checks were in
process.

During this process the officer on TT unloading duty was sent for aircraft refueling .After
completing the refueling the designated officer came back and advised the staff
assisting him in the unloading .

To bring the closing dip meanwhile the officer was checking the emptiness of the tank
truck. Since lot of time had elapsed for unloading the tank truck the truck and due
pressure from the tank truck for delay the decantation officer after convincing himself of
emptiness of tank truck released the truck without reconciliation of the quantity as per
challan with the quantity received in the tank. The final/closing dip quantity calculated
for quantity of product received it was found that around four KL loss was resulting for
receipt of 12 KL product. Immediately efforts were made to find out the whereabouts of
the TT for rechecking the emptiness.

Luckily the tank truck was traced and brought back to AFS for rechecking .It was found
empty. So the designated officer for TT decantation again took the closing dip of the
designated which was under his supervision. When the revised quantity was quality the
quantity received in the tank was tally with the quantity shipped as per challan.




                                           191
On finding out the reasons for this variation it was informed by the dipping crew that the
intial closing dip was of the underground avgas tank was carried out from the wrong
hatch which resulted in erroneous readings.
Lessons learnt:

1.Do not carryout simultaneous operations which results in errors.

2.All operations to be supervised physically


                                           Caselet–60
     ________________________________________________________________


                         FIRST INFORMATION REPORT OF ACCIDENT



1.     Name of the Location

       FORESHORE TERMINAL CHENNAI


2.     Site of Accident

       In front of the Main Gate of Terminal “A” and CPT container corridor road
       between “A” and “B” terminal


3.     Date and Time of Accident

       20.05.2010 at 1050 hrs

4.     Brief of Events including status at the time of reporting actions being taken,
       potential hazards (if any)

       The tower light structure (Steel Truss Structure) collapsed half way to the
       Chennai Port Trust Container Corridor Road. NO CASUALITIES. Our compound
       wall, a motorcycle and a tricycle damaged.
5.     Probable reason(s) of Accidents


       HIGHLY CORRODED STRUCTURE unable to withstand the load



6.     No. of casualty (if any) - Own employees
        - Others

                                                  192
      NIL


7.    No. of injured persons - Own employees
        - Others

      NIL

8.    Extent of damage to Plant/Machinery, structures/buildings/public property

      1. Structure collapsed to compound wall damaging the barbed wire fencing and
         a portion of the wall.
      2. Motorcycle and tricycle parked outside the gate has been damaged

9.    Impact on operations

      The debris has BLOCKED THE VEHICULAR TRAFFIC ON THE CHENNAI
      PORT CONTAINER CORRIDOR ROAD.

10.   Assistance (if required)

      Matter to be taken up with competent authorities to phase out the existing 10
      numbers of highly corroded tower light structures and installing 4 numbers of
      High Mast towers.




                                         193
                              Caselet–61
  ________________________________________________________________

                         Experience shared by

                           K.KISHORE KUMAR
                            SR.MANAGER(T)
                                VIZAG (T)

ISSUE UNDER DISCUSSION : APPLICATION OF FOAM.

BACKGROUND / INCIDENT :
DURING ONE OF THE FIRE DRILLS FOAM WAS NOT COMING OUT WHILE
OPERATING FOAM MONITOR. FOAM WAS COMING WHEN DIFFERENT FOAM
CAN WAS USED.

CAUSE :
ON CHECKING FOR THE REASONS ,IT WAS OBSERVED THAT THE FOAM CAN
CONTAINS WATER INSTEAD OF FOAM.

POSSIBLE EFFECT :

  1. FIRES CAN NOT BE EXTINGUISHED.
  2. MAY LEAD TO CONFUSION AMONG THE TEAM MEMBERS.
  3. FIRE MAY SPREAD TO ADJECENT FACILITIES DUE TO LOSS OF TIME.

SOLUTION / LESSONS LEARNT :

  1. CHECKING THE SEALS OF THE FOAM TINS SHOULD ENSURED AT ONE
     MONTH FREQUENCY.
  2. USED FOAM TINS SHOULD NOT BE LOCATED AT THE PLACES WHERE
     FOAM TINS ARE TO BE POSITIONED.




                                   194
                                     Caselet–62
   ________________________________________________________________



FAILURE OF ONE MS STORAGE TANK AT KANDLA
MAIN TERMINAL IN 1993
While passing through the trauma on and after disastrous fire at Jaipur Terminal, one of
the all time worst accident in the history of petroleum industry, I feel or believe , how
lucky we were, when a similar leakage or worse than that at Kandla , could have
caused, perhaps with more deadly impact , had there been any fire.

The tentative date was 26.10.93. I was In-charge of 2nd Shift at Kandla Main Terminal.
After completion of MS discharge from one tanker through flushing line (16"Ø) into tank
No. 8, water flushing was on. I was in the field busy in checking the line sample. After
ensuring the line sample as pure water at around 06:20 pm, I switched over flow of
water into Interceptor. I advised one of our employees to close the tank body valve and
came back to shift office to intimate boarding officer for stoppage of flushing.

The same employee came back shouting even before I could reach the shift office. “ sir
, water is coming out from tank shell like fountain”. Immediately, I rushed to the spot and
found even worse than I could imagine .

It was water jet coming out with enormous speed from T-joint of 1st strake shell and it
appeared to be opening towards bottom weld joint. This was having clear indication that
the bottom shell would be opened fully or partly and entire MS would come out of tank
no 8.

Understanding gravity of the situation, I send message to our colleagues who were
staying in colony , opposite to our office. I tried to get CTM, Shri OP Salampuria, who
went to attend one marriage ceremony at Gandhidham along with two DGMs from HO,
through VHF. Since he was not responding, one car was sent to him for immediate
information and guidance. Also, SOS was sent to adjacent Army camp, BPC, HPC and
Kandla Fire Brigade.

Till such time the colleagues and Army arrived at the Terminal, we, with the available
staff started boxing up one empty tank (tank No. 13), so that some qty of product could
be transferred from tank no. 8 to 13. The relevant materials like nuts &bolts , packing
materials etc. were available inside a locked cabin controlled by Shri Mangal Singh
Jadeja, the then Union leader at Kandla. Since there was hardly any time and Shri

                                           195
Managal Singh was not available, I instructed to break open the cabin door to get the
required materials.
With unbelievable speed both the manhole covers of the empty tank were closed. There
was no connection to main line. With 8’’Ø tanker handling hose, the empty tank( tank
no.13) was connected to the manifold. Within 40 minutes, transfer of water/product
started from tank no 8 to 13. Since water flushing was taken in tank No 8, bottom half of
the tank was having water and balance 2000 kl was MS.

Within 10/15 min our colleagues and army came to the spot . BPC & HPC also came
within 30 min with foam and extinguishers. Initially, army tried to tie the bottom shell with
ropes to prevent anticipated lateral failure. That effort, however,                remained
unsuccessful. The tank bottom shell weld joint continued to open further and MS
leakage started along with water.

Army cordoned off the entire area. Surrounding IOC staff & officer colonies and were
evacuated even before MS leakage were started. BPC has helped us by arranging food
and shelter to our families during odd hours at their Guest House at Adipur.

Apart from inter tank transfer from 8 to 13, we got ourselves in different groups
consisting IOC Staff, & Officers, HPC, BPC & army personnel and engaged in
salvaging spilled product in another tank ( tank No. 11) which was almost empty.
Meanwhile, leakage and smell was so much, it was difficult to stand inside the tank farm
area.

We saw one by one , around seven army personnel fell unconscious due to strong
vapor. They were rescued by fellow colleagues. Mr. Teckwani, the then Manager (T) fell
unconscious on my shoulder. He was rescued by me.

Some time we were in knee-dip product in the tank farm area to salvage product
physically. Then we used to move out of the area to take fresh air. Another group used
to work then. At 10 pm Shri Mangal Singh union leader came and took away all IOC
staff who were doing excellent job during crisis. Shri Singh, perhaps, was upset by
seeing his cabin broken.

Inter tank transfer from 8 to 13 was stopped at 11:30 pm. However, salvaging leaked
product in the tank farm continued till 10 am of next day. The bottom shell weld joint of
tank No 8 was found fully opened and 2nd shell 16 mm dia Mild Steel plate was torn
apart by 4 inches due huge pressure during leakage.The area was declared safe on
next day at around 10:30 pm.

Total leaked MS Qty. from tank No 8 was about 2000 kl, out of which 600 kl was
transferred neatly in tank no 13. Balance qty was dirty/contaminated and was salvaged
entirely in tank no. 11.

 We still feel lucky and thank to God for protecting us, our families, neighboring area
from a possible disaster. The size of Kandla Main Terminal was less than 10 acres and

                                            196
within this small area there were 13 big tanks with close vicinity. Fire in one tank could
have caused fire in all tanks.
It was a matter of luck that 2 DGMs were present by default during that leakage. Almost
entire period of operations they were available.

 The best part is , however, definitely there was no fire. Action by us , like boxing up of
tank No. 13, connecting the same with manifold and transfer of product , was
spontaneous and effective even before arrival of CTM & DGMs.

The action by Army and support by BPC & HPC were commendable & beyond any
appreciation.




                                      Caselet–63
    ________________________________________________________________

                                Experience shared by
                                  Experience Shared By

                                        P.P. Adhia
                                      CRC Jamnagar

Issue Under Discussion:

Fight caught in TT while welding work for first time. Trial basis security locking system in
TT (somewhere during 2000, Vashi

Background/Incident:

While welding of TT, immediately fire took place and welder died there only at Vashi
outside TL area.

Soultion/Lesson Learnt:

While any welding work to be carried out on TT, complete water flushing by over flowing
the TT chambers could be ensured. Also, thrice EXPL. Meter for vapor content to be
checked and made vapor free.




                                            197
                           Consumer-Sales
                                    Caselet–1
   ________________________________________________________________

                              Experience shared by

                                           Shri Dipak Basu, SDCSM/ Kolkata DO

      LDO BUSINESS OF KOLAGHAT THERMAL POWER PLANT, E.MIDNAPORE.

This is a real story about how we snatched LDO-business of WBPDCL , Kolaghat from
HPCL.

BACKGROUND :
WBPDCL , Kolaghat , Distt : East Midnapore was commissioned in the year 1984. The
installed production capacity is (210 MW x 6 Units) and normal annual requirement of
LDO is 6000- 7000 KL PA. M/s HPCL was the traditional supplier of LDO to Kolaghat
Thermal Power Station for the last 20 years by conventional rakes ex-Vizag. The
business was a strong bastion of HPCL …nearly invincible for us for long a time.


INITIATIVES TAKEN
We had taken up the challenge for making entry in this stronghold business since last 2
years by initiating persuasion , follow up, & constant interaction.


Customer was taking conventional rakes ex-Vizag from HPC on inter-state basis
against CST. To commensurate with their landed price , our only option was to provide
inter-state supply ex-Bongaigaon against concessional sales tax. But, at BRPL only
BTPN loading was available. Hence, we had to turn back on the Customer for
modification of their entire unloading facility to accommodate BTPN rake.


Firstly , we won over the Customer with our endeavor for placing order of BTPN rake
by emphasizing on our superior logistics , speedy execution of indent , incomparable
technical support & lastly & importantly , our relationship building .


Kolaghat Thermal was initially hesitant to accept BTPN supply due to existing MOU with
HPCL , restriction of ullage & as the same implies more financial outgo at a time .

                                          198
However, we received unexpected ‘help’ from nature at that time as there was severe
flood in the state of AP and southern parts of Orrisa resulting in disturbance of rail
movement through SE Rly. Obviously there was a restriction of rake movement by Rail
as HPCL’s supply point was Vizag.


Ultimately the party realized the obvious advantage of choosing IOCL as their LDO-
supplier.


So success was ours !! BTPN modification job was completed in Dec ’08 & the first
breakthrough was made in Dec ’08 by procurement of order.


From Dec‘08 – March ’09 , we have supplied 7778 KL and in May ’09 we have supplied
3500 KL to Kolaghat Thermal Power Station .


The outcome of the above and our success in gaining this age old business of HPCL
has given us self motivation and inspiration for our further efforts to leap forward.


Lessons learnt:


1. Grab the slightest opportunity at right moment.

2. Encash our logistic strength to the fullest extent.




                                             199
                                     Caselet–2
   ________________________________________________________________
                              Experience shared by

                                                     Shri D.Basu, SDCSM/Kolkata DO

         Restricting discount to M/s Suryachakra Power Corporation Ltd

Background
Suryachakra Power Corporation Ltd, Andaman is one of our major customers,
consuming around 2000 – 2200 KL HSD per month. We had executed Fuel Supply
Agreement with the customer for supply of their 100 % requirement of HSD Ex Port
Blair Terminal on 31st January’2000 for 15 years, and extendable for further period of 10
years by mutual consent.
During 2006-07, the customer had been facing severe financial crunch and sales
volume was falling drastically due to irregular payment. To overcome the situation, 30
days’ Interest bearing ( @ 7% PLR of SBI) credit facility against BG of Rs. 8.00 crores
had been extended with effect from 01.04.07 after obtaining approval from the
Competent Authority, which was valid upto 31.03.09 .

Subsequent Development
However, around 2008, when crude price was soaring to record levels, we felt, that it
was the need of the hour, to come out of the credit exposure in view of our huge
financial crunch. We initiated discussions with the customer to convert to 100 %
advance payment as well as to switch over to Xtramile Diesel Super. Initially the
customer was not at all inclined for making advance payment and insisted for
continuation of credit supply. But there were a few occasions, when they had defaulted
in payment within due date. Our target was to make the customer’s outstanding nil by
31st July’08 and we were in constant persuasion with M/s Surychakra for realization of
the outstanding amount.

The Success
There was an outstanding of around Rs. 5.7 crores an a/c of Suryachakra as on
30.07.08. Finally we realized the amount from the Banker by encashing their BG on
31.07.08 with prior consent of the customer.
From the month of August’08, we have not only made them agreeable to lift HSD
against advance payment, we have also been able to convince the customer to switch
over to Xtramile Diesel Super from normal HSD.

Benefit
Tangible benefit of Rs. 9.0 lacs per month for withdrawal of credit exposure of 8.0
crores for 30 days and also extra revenue earned on a/c of sale of 100% xtramile in lieu
of normal diesel. Also the important lesson learnt out of this exercise was that we can


                                          200
achieve almost anything which looks normally impossible with sincere and constant
persuasion with our valued customers.

                                    Caselet–3
   ________________________________________________________________
                              Experience shared by

                                          Shri V.K.Handa, Chief Marine Manager/ER

                Debunkering of FO at Haldia from MT Jag Prakash

Background
a) 200 MT Bunker FO Bonded nomination for Haldia was received on 14.7.2010 from
   IOC ,Western Region in respect of customer M/s Great Eastern Shipping Co.

b) Based on the nomination ER Marine placed the order vide S/M/17/237 dated
   14.07.2010 to IOC Haldia Installation. Haldia Installation loaded FO 190.863 MT
   from Haldia Refinery Tank no 905 on 14.07.10 and executed the Bunker on
   15.07.2010 at Haldia Oil Jetty. Invoice no 640502302 dated 15.07.2010 was raised
   for an amount of Rs 4674362.00.

c) ER Marine received a complaint from Customer M/s Great Eastern Shipping that
   the Aluminium + Silica (Al+Si) contents from the Bunker stock of 15.7.10 are
   significantly exceeded as per testing carried out by independent Testing Labs DNV
   Fujairah & FOBAS Fujairah of ship’s onboard sample as per details tabulated below.
   The Testing Laboratory also recommended to the customer that this fuel should not
   be used since the testing indicates the presence of very dangerous levels of
   abrasive catalytic fines which may damage Ship’s engine.

 Name of    Customer     Date of    HR     Al+Si      Test      place of   Customer
  Vessel     Name        supply    TANK   content   result by    supply      Lab
                                    NO      Test    customer
                                          Report
                                           at the
                                          time of
                                          bunker
 MT JAG       Great     15.07.10   905    38 PPM    192 PPM     HALDIA       DNV
PRAKASH      Eastern                                                       FUJAIRAH
             Shipping                               164 PPM                 FOBAS
                                                    MIDDLE                 FUJAIRAH
                                                    211 PPM                 FOBAS
                                                    BOTTOM                 FUJAIRAH
 The Testing Lab (DNV) also circulated a Bunker Alert on their website stating that the
vessels should be careful in sourcing Bunker FO from Haldia as testing of FO sample

                                          201
by them has indicated presence of dangerous levels of abrasive catalytic fines ( Al+ Si)
which may damage Ship’s engine.

Action taken
The matter was analysed and it was found that Al + Si reported in the Test Report as 38
ppm with Test Method D 5185 while the ISO 8217:2005 mentions testing of Al + Si
parameter with Test method IP 501.
a) The matter was taken up with Haldia Refinery to investigate the customer’s
   complaint. Haldia Refinery confirmed that FO supplied to customer was conforming
   to DG Grade spec IS 1593 :1982 and not as per ISO Bunker FO spec ISO 8217:
   2005.

b) The issue was discussed with HO Marine also and a decision was taken in
   consultation with customer’s representative, Mumbai to jointly test the retained
   sample for this Bunker at an independent testing laboratory.

c) Retained sample was sent to Mumbai from Haldia Installation for Testing at
   independent Lab SGS,Mumbai which was jointly witnessed by Customer and IOC
   Reps on 19.08.10 where result for Al+Si was observed as 189 ppm which is beyond
   the limits(80 ppm) mentioned in the Bunker FO spec ISO 8217: 2005.

d) The customer informed that they have already segregated the suspected fuel on
   board MT JAGPRAKASH and requested IOC to debunker the same during the
   vessel’s next call at Haldia.

e) IOC agreed to the customer’s request in view of the long term business relationship
   and to avoid any potential claims for damages.

Action Plan For Debunkering at Haldia

Debunkering Action Plan for of MT Jag Prakash was finalised with Haldia Installation,
Haldia Refinery and Great Eastern Shipping in order to facilitate the smooth execution
of this operation.

Issues on Debunkering at Haldia

a) The FO to be debunkered was supplied earlier as Bonded due to foreign run status
   of MT Jag Prakash.

b) Because of the Bonded status of the product , Excise & Customs clearance was
   required for the debunkering operation.

c) The debunkering involved the hiring of Black Oil Barge , deployment of Surveyor and
   arrangement of documentation by CHA for this operation.


                                          202
d) The Debunkering involved the following cost as tabulated below:

      S.No     Item                                                Amount ( Rs)

      1        Barge Hiring charges                                268886.00

      2        Surveyor – charges                                  16545.00

      3        CHA – expenses                                      3529.00

                                                            Total 288960.00


Debunkering / Operational Issues

a) IOC Contracted Black Oil barge Nand Kiran was used for this Debunkering purpose.
b) 4x1lt sample was drawn and tested promptly on arrival of MT Jag Prakash by Haldia
   Refinery.
c) The Debunkering exercise started on 29.09.2010 on arrival of the vessel at Haldia
   by utilizing onboard pump for loading the proposed FO into barge from Jag
   Prakash. The Debunkering required around 10-12 hrs to pump back the FO qty
   meant for Debunkering into barge.
d) Jag Prakash kept their system ready including onboard pump and related pipelines
   on its arrival at Haldia Oil Jetty.
e) The Debunker FO loaded into the Barge was pumped back to designated Refinery
   Tank.
f) Thereafter , fresh Bunker quality FO produced by Haldia Refinery was pumped from
   the Barge into the Bunkering pipeline to displace the Debunker FO Pipeline
   contents.
g) The Debunkering exercise was completed on 30.09.10.

Lessons learnt

a) Regular production and availability of Bunker quality FO conforming to ISO
   8217:2005 by Haldia Refinery and bunker of this quality fuel to all Marine vessels
   instead of DG Grade FO.
b) Haldia Refinery Laboratory should have facilities for testing Al + Si parameter as per
   ISO Test method IP 501 instead of Test Method             D 5184 being currently used
   by Haldia Laboratory for testing / Certifying Bunker quality FO since the customers
   are insisting for supply of Bunker FO conforming to ISO Specifications.
c) Corrective action as above will lead to meeting properly the demand of Quality
   Bunker Fuels by Marine customers and avoiding any complaints and any potential
   claims for damages from these customers.
                                          203
d) The customers complaints are to be avoided since any instance of customer
   complaints regarding quality of Bunker Fuels also leads to circulation of Bunker
   Alerts on the internet which gives a bad name to IOC and consequently leads to
   reduction in Bunker enquiries from customers which ultimately affects our Bunker
   business volumes.


                                     Caselet–3
   ________________________________________________________________
                              Experience shared by

                                            Shri Saibal Das, Chief Marine (CS)/WBSO

CUSTOMER              -      A major Naphtha consuming petrochemical consumer
ISSUE                 -      47 Nos of Cheques bounced consecutively.
AMOUINT               -      300 Cr
As per policy, we are supposed to issue notice to the party first and if the payment dues
are not met, we are supposed to go to court. As soon as we go to court, arrest warrant
will be issued against the Board of Directors. Board of directors of that state
government-sponsored company included Secretary, Industries, and other many other
important persons from industry. This would naturally have huge ramifications and IOC
local Management would be under severe pressure. A note was initiated mentioning the
implications of the above situation and its impact on IOC as an Organization. It was
recommended not to go as per policy which means not to lodge case.
On the other hand, the officers dealing with the consumer (and not concerned with the
relation of IOC & state Govt) were concerned about the departmental proceedings
against them in the event of nonpayment of our dues. So they were eager to lodge the
case, as per policy, to save their skin.
Our recommendation was turned down by Management. With this turned down
proposal, these officers handling the consumer, went to the then consumer-head to
finally apprise him before lodging the case.
The HOD took the copy of mail that adviced us to take ‘suitable action as per policy’,
and wrote on the body of the note ‘I am taking decision not to go ahead with Court case
considering the overall situation’.
This decision was a master stroke and showed his foresightedness. The party came out
its bad times in the next 8 months and our relationship with them and Govt of WB
remained unaffected. The party still is our single biggest Pvt Customer and our present
annual transaction with them is around 2000 cr. His action also absolved his junior
officers of any lapse on their part.
The Managerial decision was taken with calculated risk which is the job of a
Manager which resulted in a WIN – WIN Situation while going strictly by books
and as per policy could have been a disaster.



                                          204
                                 Finance
                                 Caselet—1

                                             Contributed by: Shri T.Murali, CFM/ER

Accounting Treatment
Issue:
    Lease rental for the year 2008-09 was paid to BSNL in the month of Mar’08.
    The same was charged off in the year 2007-08 to Revenue.
    Demand of Lease Rentals for the year 2009-10 was received in the month of
       July’09.
    Location was not able to pay the same for want of budget.

Reasons:
   No expenditure was booked in the year 2008-09 as payment to BSNL for the
     year 2008-09 was charged off in the year of payment itself i.e 2007-08.
   Revenue Budget is allotted on the basis of previous year’s actual expenditure.
   Hence budget allocation for the year 2009-10 was Nil.

Correct treatment:
    Payment of Lease Rental made in Mar’08 for the year 2008-09 should have been
      booked as Prepaid Expenses in the year 2007-08 and the same should have
      been charged off to Revenue in the year 2008-09.




                                       205
                                         Caselet—2

                                              Contributed by: S/Shri T.K.Basak & Manju
                                                           Gupta, CFM/ER

Issue:

Truckload of LPG Cylinders (14.2 kg) (Product Code: M00056) are dispatched from
Bongaigaon BP (Loc code 2472) to Bhutan Consumer TASHI COMM CORP (Payer :
182185) during November 2010.

Pricing was last updated in SAP on 20.09.10 as Rs. 47299.15 (ZAVL-Assessable
Value) per 1000Kg. And at this Rate Challan was prepared for the period from
01.11.2010 to 18.11.2010. Pricing has changed from November/2010 which was not
updated in SAP in October/2010 end.

Further, this product was sold at a subsidized rate to Bhutan and the subsidized amount
was recovered from Ministry of External Affairs . Because of above non-updation, the
subsidy amount of Rs. 379.14 applicable to October/2010 sale has continued in SAP till
18.11.2010.Subsidy applicable for November/2010 was Rs. 403.27 per Cylinder.

As a result, there was under-billing for 2142 cylinders to this customer.

Corrective Action:

   a) Eastern Region Pricing noted the anomaly and brought it to the notice of
      NEISO/Pricing. It was on 19.11.2010, the correct Pricing of Rs. 48931.28 (ZAVL)
      per 1000 kg was uploaded for the period from 01.11.2010 to 30.11.2010 and
      Subsidy amount was also corrected.
   b) Eastern Region has advised to Finance/BNG BP and Area Office & NEISO to
      raise necessary Debit Note on the party.

Lessons:

   a) Pricing Section should be ensure timely ZAVL updation & check for any un-
      updated records at each price revision thru yvr320.
   b) Location must verify the Invoice Price with Price Circular sent by SO/ HO
      Circular
   c) State Office must run ZEDA Rate checking Master.

SAP INTERFACE:

Relevant T-Code for viewing Price Master with date of updation: YVC244.


                                            206
                                    Caselet—3

                                        Contributed by: Shri S.G.Majumdar, CFM/ER

                 Customer outstanding lying in suspense GL code

Two Retail Outlets of AOD Division namely Joy Santoshi Ma under WBSO & Shivam
Janki Ser Stn under BSO made payment towards supplies amounting to Rs 28 lacs
during Year 2007. The cash receipts were prepared in SAP customer codes under
Company codes WBSO & BSO.

The customers were under SAP System, both under AOD & MD Company codes. AOD
Division raised a control account advice on MD Division & debited Rs 28 lacs to ERO
suspense Gl code during the time of closing of books in 2007 instead of debiting the
customer code in MD Division. The credit generated out of this was posted in customer
code in AOD Company code.

 In order to meet the closing target dates without analyzing in detail, the amount was
transferred to Debtors’ suspense account. This resulted in double credit in customer
accounts once in MD Division & again in AOD Division.

Subsequently during 2008 , MD Division transferred the credit balance from individual
customer codes in WBSO & BSO to AOD Division in the same customer account.

The suspense debit lying in ER books was analyzed in year 2009 & mail was given
AOD to provide details of debit. Initially there was resistance from AOD Finance & Sales
Group. After much scrutiny of the data & analysis, the debit was sent back to AOD.

On taking up with Retail Outlet they accepted that they had received excess credit &
enjoyed over the period. However they pleaded for installment payment due to
insufficiency of fund with them. Interest bearing installment was fixed & recovery done
for the above customer.

Results:
1. Loss due to blockage of Fund for almost two years.

2. Loss of man hours to clear the debit suspense at a subsequent date.

Lessons:
1. No suspense codes should be used when regular code exists for transfer of fund.

2. Debits lying in suspense codes should be analyzed & cleared.

3. Scrutinize your GL balances regularly & ask questions for balances.


                                          207
                                    Caselet—4

                                        Contributed by: Shri S.G.Majumdar, CFM/ER

                   Cheque dishonor by IAG Glass Company Ltd.

During 2004, M/s IAG Glass Company, Hazaribagh Ltd made a payment of Rs 42 lacs
to IOCL against supply of petroleum products by IOCL. The cheques got bounced for
want of fund. Money suit was filed in Hazaribagh District Court. The Company did not
make payment & supplies were stopped. On the insistence of Auditors, the dues of IOC
was classified as doubtful & transferred to doubtful GL code. Provision was created in
IOC books against the outstanding.

Repeated time petitions were filed by customer & the money suit could not be enforced.
In year 2010 after a gap of six years the ownership of the Company IAG Glass
changed. IAG started uplifting petroleum payment against advance payments to IOC.
The old outstanding was informed & discussed with the customer. The customer made
verbal commitments of honoring the old outstanding. However no payment towards old
outstanding was coming from the customer.

The Finance Department of IOCL was watching the case closely. One day an advance
payment of Rs 8 lacs by IAG was adjusted towards the old outstanding after taking the
Functional Group into confidence. The customer stopped taking supplies from IOCL &
started uplifting products from M/s BPC on advance payment basis. Immediately IOC
Sales Group took up the matter with Other Oil Marketing Company during their monthly
Joint Meeting.

With lot of discussion & good understanding with OMC it was agreed by OMC that for
30 days period they will not make any supply to IAG Glass. IOC should settle their
books during this period of 30 days. This understanding of one month with OMC was
not known to M/s IAG.

The new IAG Management wanted to revive the plant. The stopping of supplies by OMC
forced IAG to enter into an agreement with IOC to settle the dues on monthly
installment basis.

The Finance, in close co-ordination with the Sales Force, started allocating part of the
advance payment towards settlement of old dues. By this way, over a period of time, the
doubtful outstanding could be recovered from the customer. Interest on dues is still due
& is being recovered from advance payment by customer.

The credit terms of customer is maintained as advance payment against supply.



                                          208
Results:
  1. Blockage of Fund for six years.

   2. Unnecessary litigation costs.

Lessons:
     1. Proper credit analysis should be done for credit supply.

       2. Maintaining a close watch on customer credit worthiness during supply
          period.

       3. Maintaining good liaison with competitors.

       4. Close coordination between Functional Groups.

Trigger point for recovery: Adjustment of advance payment of Rs 8 lacs from
customer account.




                                          209
                                     Caselet—5

                                         Contributed by: Shri S.G.Majumdar, CFM/ER

                           Customer case of Rs 412 crores

During the year 1998-2001, Kerosene used to be imported for PDS(Public Distribution
System) with nil customs duty.

This was decanted at Haldia & was pumped to several Tap off points in the HBK(Haldia
Barauni Kanpur) pipeline & HMR (Haldia, Mourigram, Rajbandh) pipeline. The supplies
(sales) were done from various Locations situated along this pipelines.

In the year 2003, Calcutta Customs Department raised questions on utilization (PDS)
for assessing duty free import. They wanted to see the utilization of imported SKO.

The matter could not be settled at the initial stage & Authorities were not satisfied with
IOC’s contention. Ultimately, this led to demand of Rs 412 crores by Customer
Authorities along with similar amount for interest & penalty.

The case lodged by Authorities was for facts & not on Law. Getting COD(Committee on
Disputes) permission to take up the case to Court of Law could not be obtained & at
point one it was almost certain that IOC had to make payment of the amount.

However due to proper co-ordination of Senior IOC Officials, COD permission was
obtained for re-quantification of the demand amount in the year 2007.

All the old records were arranged from the Locations involved along the HBK & HMR
pipeline. Lot of man hours were put in to prepare complete account of utilization. Daily
visits to Department for a period of more than two years were done to convince the
Authorities that imported Kerosene was used for PDS purpose only. Copy of sales
invoice, reconciliation, Location wise sales quantity, dealer wise sales figures, PDS
quota sanctions by District Administrations were produced. This was a mammoth job &
Senior IOC Officials had to visit on regular basis to convince Authorities involved in re-
quantification.

Ultimately, the Custom Authorities accepted IOC contention that the sales were done for
PDS purpose only. However for the line fill quantity, no rebate was given in re-
quantification.

The Authorities submitted their report on re-quantification to COD with a claim of around
4 crores for duty on line fill quantity.




                                           210
Results:
 Loss of lot of man hours of IOC Officials

   Unnecessary litigation costs.

 Lessons:
 Proper maintenance of books/records for review by Statutory Authorities.

   Settling the case at the initial stage prior to issue of show cause.




                                             211
                                     Case-let—6

                                              Contributed by: Shri T.K.Basak, CFM/ER

                           An unusual finance concurrence.

In one of the locations of Eastern Part of India, a unit of IOC has been installed for
supply of fuels mainly to Government & other parties. The location is remote and due to
local insurgency problems, the Location –in-Charge was finding it difficult to appoint
handling contractor. In case of public tendering there was no response. In case of
Limited Tendering, all the insurgency group came and demanded for placing their
people in handling job at a high & uniform rate. Under the circumstances, it was difficult
to appoint any party on Single Tendering or Limited Tendering basis. On reasonable
estimates, the yearly financial implication was approximately was Rs. 6 lacs. The
location confronted with the following problems:
    a. When Limited Tendering was pursued, all the groups had tendered the same
       rates which were almost the double of the estimate. If Single Tendering would
       have been done to recommended person of local govt. authority then contractor
       had expressed its inability to furnish credential/Statutory papers. Due to this
       impasse, operation was stopped and Army flights did not get due load and there
       was hue and cry from Headquarters.
    b. Another issue was that all the parties including the local one had expressed that
       they should be paid only in cash for disbursement to their worker. As per the
       provision of Income Tax Act. Payment exceeding Rs. 20000.00 cannot be paid in
       cash to contractor, whereas in this case, the Approx. monthly payment would be
       Rs. 50,000.00.

       Location was in fix about how to deal with the issue whereas it was an urgent
       necessity to appoint handling contractors to run daily business since the location
       was manned by one officer and one blue collar worker of IOC only.

Solution: In this case, the requirement is not one time, but it is a continuous contract for
one year. It deserves to be proceeded as per the condition of Limited Tender. However,
if it cannot be done, then it must be clearly recorded in the note with facts and figures
as for which reason it is impossible, citing the double rate and other vagaries. It is also
to be recorded that the nominated person of the local government, if appointed without
Tendering s, will help in maintaining peace and order by assistance from police/local
protection forces. It is to be made transparent & clear that departure from the spirit of
the policy is required under the forced condition of maintaining law and order and for
ensuring reasonable rate, avoidance of stoppage of operation. Administrative Approval
is to be taken under DOA 8.03(b). Further, since limit is more that 5 lacs, proposal

                                            212
should be sent to HO for approval under D.O.A.9.02 for Rs. 6 lacs on Without Tendering
basis.


Regarding second item of payment by cash, firstly D.O.A.2.04 is to be complied.
Secondly, it is to be cleared in note sheet that under the given circumstances, it is not
possible to pay by cheque as no party is willing to accept payment except by way of
cash. Exceptionality of the situation should be vividly described; else the peace and
safety of the location would be hampered. However, tax to be deducted at source and
effort should be continued to pursue the contractor for opening a Bank A/c.




                                            213
                        General Engineering
                                     Caselet—1

                               Contributed by: Shri B.K.Jha, AM(Engineering)/WBSO

  DIFFICULTIES FACED DURING THE EXECUTION OF THE CONSTRUCTION OF
                   TANKS AT RONGPO DEPOT, SIKKIM

Additional Tankage work Rangpo Depot is constructed during 2010 . The job was
challenging due to the difficult terrain (Hilly) and the sub-soil condition was difficult as
mainly hard rock was faced. Some of the hurdles during the job execution are
mentioned.
     Getting permission from the forest department took almost two month time, &
        that too, the permission was obtained after our regular follow up with the forest
        department top officials and finally giving them undertaking for plantation of
        several no of trees with brick work tree guards at a designated area marked by
        forest department.
     Starting of earth work excavation of the site for 200KL underground tanks, was
        delayed due to fouling of part of the area with the existing permanent lube oil
        store building.
     There was problem faced in disposal of the debris generated during the earth
        work excavation as getting clearance for the identified area which was under the
        State Forest department took unnecessary long time.
     Lot of problem faced for transporting the required materials from Kolkata / Haldia
        to Rongpo site due to frequent blockade of national high way by the Gorkha
        Land agitators.
     The Rangpo Depot is operated covering a small area where installation of the
        new tanks are to be carried out with bare minimum statutory distances. Many
        additional safety precautions are to be adhered to as the depot is under full
        swing operation, which also affected the progress of the work. The entire
        fabrication work at site had to be stopped whenever there was unloading /
        loading of MS tanker at the Rongpo Depot which takes almost two hrs duration
        and the frequency of the same was almost every alternate day.
     There were unusual big size boulders scattered deep in the sand pad foundation
        area which had to broken & leveled in order to accommodate the foundation.
               As the adjacent tanks filled with liquid hydrocarbons are very close, it was
       not permissible to adopt dynamite blasting method for the hard rock removal. We
       also consulted the explosive experts from Indian Explosives Limited who also
       visited the site and suggested to try for cold explosives which also was
       unsuccessful. Under this circumstance there were no other alternative but to
       adhere to manual breaking process.


                                            214
           In spite of deploying 2 nos. heavy duty pneumatic hammer, 1 no electric
             driven hammer and two gangs of manual rock breakers (each group
             consists of 4 skilled & semi skilled labours), it took about four months time
             after the removal of the trees fouling the sand pad foundations.
           The earth work excavation for the 200 KL under ground tanks took undue
             extra time due to fouling of big sizes of hard rock boulders which could
             not be extracted even with the help of JCB & Proklin. Finally the same
             had to be done by manual breaking of these hard boulders which took
             time beyond estimation.
           During the earth work excavation of the 200KL tanks, the excavation work
             had to be abundant half way & refilled the pit as a precautionary measure
             against land slide due the rains. This has caused a delay of about one
             month time.

Lesson learnt:
   1. Statuary clearances for the project should be taken before or during the
      conceptualization of the project to avoid delay and bottlenecks during execution
      stage. This will also help for minimization of execution time and hence cost.
   2. For site located in hilly area, an advance survey method to be adopted for getting
      the clear and accurate picture of sub soil strata for the better control on part of
      management during project. This will also help in planning for better utilization of
      resources like material, manpower & tools.
   3. During the planning stage of project, the external factors which are uncontrollable
      should be factored in.
   4. Essential tool mechanism for project coordination and reporting at appropriate
      level to be ensured for talking site specific hindrances during execution.
   5. Project team must consist of some person from local vicinity who has better
      understanding over local issue like political, environmental and social factors.




                                           215
                           Human Resources
                                     Case-let – 1

                             Contributed by: Shri P.K.Srivastava Dy Manager(HR)/ER

            EMPLOYEE DISCHARGING DUTY IN INTOXICATED CONDITION

Incident:

At one of the AFS, one of our workmen (driver of one of the dispensers) during night
shift operation while refueling an international flight was found to be in inebriated state
and dashed one refueller while going out for refueling of the said international flight and
after reaching the tarmac also was unable to control and park the dispenser at
appropriate place. The Field Officers vide their report have also mentioned that the said
workmen being in drunken state was not being able to control the dispenser and was
circling the same between two bays causing threat of collision with the engine of the
aircraft. The Filed Officer tried to marshal the dispenser for its proper positioning on the
starboard side of the aircraft but the driver being in drunken position could not follow his
instruction and failed to park the dispenser.

The entire incident was being witnessed by the AME and other officials along with the
ground staff also of the said airlines. The airline’s Ground Engineering Crew on
observing that the driver of the said dispenser in drunken state was not being able to
control the dispenser, hence in order to avoid any accident or damage to the aircraft
immediately advised the Field Officer to remove him from the apron otherwise they will
have to call the CISF personnel. Subsequently the Field Officer contacted the Shift in-
charge and sought replacement of the driving hand.

In view of the above the other Field Officer and other crew members who were refueling
other flights at other bays were advised by the Shift In-charge to manage the refueling
of all the flights (including the subject airlines) and remove the driver away from the
apron. Subsequently, the said driver was sent back to AFS by other dispenser after
refueling of other aircrafts. The shift in-charge also vide his report has stated that from
the gestures and postures of the said driver it was quite clear that he was intoxicated
and when criticised about the same he maintained his stand in blurred speech that he
was fit enough to carry out refueling.

As the entire incident was also being witnessed by the officials and ground staff of the
said airlines they condemned the conduct of the driver and mentioned the same on AV-
7 (Aircraft Delivery Receipt) as under:
“DRIVER WAS COMPLETELY DRUNKEN. NO CONTROL OVER THE VEHICLE.
COMPLAIN FOLLOW UP. TAKE SERIOUS ACTION.”

                                            216
Apart from the reporting on AV-7, the officials of the said airlines vide their mail dt.
09.03.2009 addressed to Regional Head of Aviation department has condemned the
entire incident and have asked for reply and action taken against the erring employees.
In view of the above incident the location in-charge had to tender apology to the Station
Manager of the said international airlines.

Subsequently, the said workman was suspended and charge sheeted for his
misconducts. The allegations of rash driving, insubordination were proved but the
allegation with regard to driving in intoxicated condition was not proved in the absence
of any medical report.

Consequences:
 The Field Officers along with other workmen had to face an embarrassing situation
before the airlines officials.
   1. Major accident could have taken place in case of collision of the dispenser with
       the aircraft.
   2. The higher management had to tender apology to the airlines officials.
   3. The threat of loss of business.

Lessons Learnt:
   1. Strict vigil on the workmen in field is required to avoid such embarrassing
      situations and avoid loss of business.
   2. The officials at AFS should have immediately taken the said workman to a
      medical practitioner and should have taken a medical report with regard to him
      being under influence of alcohol, which would have been utilized during
      disciplinary proceedings against him.




                                          217
                                     Case-let - 2
                            Contributed by: Shri P.K.Srivastava Dy Manager(HR)/ER

ISSUANCE OF WARRANT IN THE NAME OF DIRECTOR (M) AND OTHER OFFICER
FOR VIOLATION OF PROVISIONS OF FACTORIES ACT 1948 AT ONE OF THE
LOCATIONS

Incident:

As per the provisions of the Factories Act, the Director of any organization is the
occupier of the locations of the organization. However, in one of the cases against one
of our locations we have got relief from Hon’ble Supreme Court of India and a judgment
was awarded in our favour wherein our stand that the Director not being present at the
location, the location in-charge will be occupier of the particular location was upheld and
it was directed that the notification in this respect has to be issued by MOP&NG.

The Inspector of Factories after inspection of one of our locations issued a notice in the
name of Director (M) and one of the Managers of that particular location considering
them the occupier and Manager for compliance of the violations observed by him during
his inspection. After the compliance report was submitted to the Inspector of Factories
by the location in-charge, the inspecting authorities didn’t agree for the same and
sanctioned prosecution against Director (M). The same was neither conveyed to the
location nor to any of the offices of IOCL.

Thus in absence of any information in this regard no one could appear before the court
to defend our case. In view of non appearance of any official of IOCL or any advocate
on our behalf, summons was issued in the name of Director (M) which was not received
by any of the offices of IOCL. Again after issuance of summons also when no one
appeared before the Court a warrant was issued in the name of Director (M), which was
again not received by any of the offices of IOCL.

After around 6 months of issuance of warrant in the name of Director (M), the in-charge
of local P.S of that particular location called the location in-charge and discussed
regarding the warrant lying at his end and asked him to whom to approach for execution
of the warrant. The location in-charge requested him to not to proceed further and give
him some time to look into it. The P.S. in-charge in view of good rapport with the
location in-charge accepted his requested.

The location in-charge without any delay immediately informed the same to HR: ERO
and Law Deptt.: BSO which in turn was conveyed to HO. The lawyers were engaged to
get relief in the matter. Subsequently, vide an interim order the stay was awarded on
execution of the warrant and Factories Department was also issued notice for
submitting their clarification and they are yet to respond.


                                           218
Consequences:

  1. Delayed action on the part of Emp. Relations: ER and Law Deptt.: BSO after
     getting informed regarding issuance of warrant against Director (M) could have
     been resulted into his arrest or being declared as absconding.


Lesson Learnt:

  1. The location after submitting the compliance report to Factories Department
     should have ensured that the matter is dropped and a communication in this
     regard should have been obtained from them.
  2. The location should have apprised the inspecting authorities at the time of
     inspection that the location in-charge is the occupier and not the Director (M).
  3. The location should have consulted State HR/ Emp. Relations: ER before
     submitting the compliance report to avoid what happened subsequently.




                                        219
          LPG
         2010-11




 TRAINING & DEVELOPMENT
    NORTHERN REGION

Experience Sharing Caselets




            220
                                   Caselet– 1
                             Issue under Discussion:

                            Supervision during Breakdown

                        Development of Problem faced:
At a plant conveyor was running and loading / unloading was being one by contract
labour. Suddenly the conveyor chain broke and the motor was stopped by the operator
for repairing the conveyor chain and he was standing on the motor switch.

                   Observation of Occurrence / Action Taken
 Contract labour was changing the conveyor chain clip. A few other labour crowded
around him. One labour wearing sport shoes was standing on the platform.
Unintentionally one labour started the chain motor switch and this labour’ one leg got
caught and was cut into two pieces. He was rushed to the hospital , where his leg had
to amputated below the knee to save his life.

                           Learnings from the Incident
All repair work should be done under Supervision and no unnecessary persons should
be allowed to crowd around.


                                       Replicability
All LPG Plants




                                         221
                                      Caselet– 2

                               Issue under Discussion:

                                 Safety during LPG Filling

                          Development of Problem faced:

During LPG cylinder bottling on input chain conveyor near carousel , there ws shortage
of cylinder. Some under weight cylinders were lying near the the Carousel. To fill the
gap which came in thru input chain in order to avoid bottling loss due to empty chain.


                    Observation of Occurrence / Action Taken

During line fill one under weight cylinder was put on the cable by a labour. The cable
came out at from the running motor junction box with spark but luckily there was no fire.


                             Learnings from the Incident

By putting iron jali on the motor the risk can be averted.


                                          Replicability
All LPG Plants




                                            222
                                    Caselet– 3
                             Issue under Discussion:

                       Safety through lubrication of Equipment

                         Development of Problem faced:
Due to inaccessibility of greasing point , greasing could not be applied regularly to a
vapour extraction unit ( blower ) in one LPG plant , due to which friction resulted in
bearings become red hot.

                   Observation of Occurrence / Action Taken
This was observed and corrective action taken.

                           Learnings from the Incident
Lubrication point for any equipment should be accessible and regular maintenance /
lubrication should be carried out .

                               Replicability
      All LPG Plants




                                         223
                                     Caselet– 4
                              Issue under Discussion:

                                  Safety through PPE

                         Development of Problem faced:
At one plant during the operation of carousel one employees leg got stuck on it .

                   Observation of Occurrence / Action Taken
 A Vigilant noticed and quickly stopped the carousel thus saving the employee
concerned who escaped with minor injuries. He was also not wearing safety shoes.

                            Learnings from the Incident
All employees on the Floor should compulsorily wear PPE for their own safety .

                                Replicability
      All LPG Plants




                                          224
                             Caselet-5
               on Learning experience in LPG Function
                                Experience shared by

                                     S.Baskaran
                                  Sr.Plant Manager
                                     Quilon BP


                                Topic of Discussion:
                     Crisis situations that were effectively handled
                                            &
                LPG leakage/Fire, unsafe situations effectively handled.


                             Earlier system/ Incident:

                    Bullet Truck accident with or without LPG leak
                (Accident at Kollam Town on 17.10.2009 & 19.08.2009)

Without LPG leak – Lifting of overturned Bullet truck using Chain Pulley block or Crane

   With LPG leak – 1) Transfer of product from accident bullet to other depressurized
             bullets using LPG hose using Pressure Differential Method.
                   2) Transfer of product from accident bullet to other depressurized
                   Bullets using Emergency Rescue Vehicle (ERV).

                             Problem faced/ handled:

A Bullet truck loaded with 17.85 MT of bulk LPG from MLIF, Mangalore to Quilon
Bottling Plant met with an accident near Karunagapalli in NH-47 (approximately 55 Km
from Quilon BP). It was reported that the above Bullet Truck had collision with a Maruti
Wagon-R car coming from the opposite direction around 04:00 hrs. on 31/12/09. This
has resulted in gas leak and further a message was received about the fire around
05:15 hrs.
On getting the message around 04:45 hrs, rescue team from Quilon BP reached the fire
spot at 05:45 hrs. On arrival they noticed that the flame was more than 15 mtrs high and
around 20 shops, 10 to 12 bikes, few houses on one side of the road were found
damaged. A police jeep was found to be fully burnt about 20 mtrs away.

    Source of Ignition -The vapour cloud around the accident bullet got fire while the
     police jeep was started.

                                          225
 Continuous cooling was carried out to avoid BLEVE using the Fire and Rescue
  services.
 People were evacuated to a safe distance with the help of District administration.
 EB was asked to cut the power supply to the area as well as to the transformer
  which was very closer to the accident bullet.
 We asked the Fire tenders not to throw the jet towards the flame to ensure that
  the flame is not put off.
 Around 32 fire tenders were used for carrying out the continuous cooling
  operation all around the bullet for 6 hours as any stoppage may lead to a major
  explosion. Fire tenders of mutual aid member, M/s Kerala Minerals & Metals Ltd.
  also reported for fire fighting.
 The degassing of bullet was carried out using fire tenders.
 Lifting of the bullet to the side of the road was carried out using the crane
  provided by our mutual aid member, M/s Kerala Minerals & Metals Ltd.

                    Solution suggested / Implemented:

 Immediate dispersion of accumulated LPG using fire tenders.
 Vehicles coming for rescue operations should be parked at a safe distance and
  use of spark arrestors should be enforced.
 Source of ignition should be completely eliminated at the accident site.




                                      226
                                LPG-Operations

                                    Case-let – 6
                             Contributed by: Shri K.Saha, Manager(LPG-Ops)/WBSO

In one of the BPs, it so happened once that the Fire Engine was running and a fire
broke out (presumably due to electrical short circuit) in the fire pump-house room itself.
The entire room was engulfed in thick smoke and as a result visibility was also poor.
This situation resulted in complete inaccessibility for any person to reach the spot and
stop the engine. [It was later discovered that fuel was leaking from the fire-engine which
made it even more important to stop the engine. However, the stop-switch of the fire-
engine was located near the engine itself.]

Ultimately, this fire was fought with DCP fire-extinguishers but with great difficulty in
view of the poor accessibility of the spot.

This incident led the location-team to install a remote stop-switch at a different
prominent place for stopping the fire-engine in case of any eventuality.


                                     Case-let - 7
                             Contributed by: Shri K.Saha, Manager(LPG-Ops)/WBSO

In one LPG bottling plant while TLD operation is going on, suddenly LPG leakage
started from failure of LPG unloading hose. Combating operation started immediately.
After 20-25 minutes, the leakage could be arrested. By that time, surrounding area
including loading point of packed trucks are also covered with spilled LPG. One packed
truck crew sensing the leakage wanted to move out his truck to delicensed area. Once
he started the truck, it caught fire.

Reason- failure of EFCV in bulk tanker and wrong practice of starting a truck (without
clearance) for creating ignition.




                                           227
                                    Case-let – 8
                            Contributed by: Shri K.Saha, Manager(LPG-Ops)/WBSO

One air compressor being used for process air, started giving noise. So maintenance
personnel planned for a Sunday routine maintenance and they could detect that its
piston rod needs servicing including replacement of piston rings. They have dismantled
the piston, serviced and assembled the same. Next day, when the operator started air
compressor; the piston blew off the compressor head.
Luckily nobody was physically injured but it damaged the machinery and hampered
production.

Reason- Incorrect marking of piston rod with its holding piece


                                    Case-let – 9
                            Contributed by: Shri K.Saha, Manager(LPG-Ops)/WBSO

While acknowledging empty cylinders at Plants, tally operators count and reconcile the
cylinders received. Also missing safety caps need to be booked in ERV (equipment
return voucher). While the safety cap consumption in plant is a KRA (key result area)
target and is upto 4.5% of total bottling, the same is not known to the tally operators.
This was resulting in huge non-booking of safety caps and failure on KRA.

Reason- Non-dissemination of important facts to key persons.




                                          228
                                     Case-let – 10
         Contributed by: Shri A.K.Chattopadhyay, Dy Manager (Safety)/Kalyani BP

In Budge-Budge BP, the work of fabrication of new Pipeline was on. Work was carried
out throughout the day on Sunday and the work continued in night shift. As the
shutdown was upto 6 AM next day, the target was to connect 10 Deluge valves of filling
shed to the main line.

At around 4:30 AM, the supervisor site engineer took the round of the pipeline to see
whether any un-welded part in these and at that point of time welding was on in Deluge
Valve. At 5:30 AM, water was forced in the new pipeline and as the air came out of the
empty pipeline (new), he heard a slight sound and the checked the Deluge Valves and
found that one small part was not welded properly.

The same was done immediately before water injecting, as otherwise there could have
been loss of production.

The work could be completed by 6 AM and the Plant started in time.

The Lesson learnt is that the person supervising the work should be vigilant at all
times and must be at the site so that the problem can be taken care of and any loss to
the Corporation is avoided.


                                     Case-let – 11
                Contributed by: Shri T.K.Roy, Dy Manager (Safety)/BudgeBudge BP

Operator was punching tare wt. of cylinder s. Suddenly, huge leakage was found from
the gun. The operator got down from his seat and paused the filling gun. Since visibility
was poor due to presence of huge amount of LPG vapour, to stop the filling the hand of
the operator got stuck between the gun shaft and reflector strip. As he pressed the
pause button the gun went up with the hand of the operator. The shed officer rushed to
him and pressed the ‘enter’ button to bring the gun down and thus the operator was
saved. Otherwise there was a possibility of dislocation of hand from the shoulder of the
operator as the carousal was on the running position.

Lesson: In this sort of situation, it is better to stop the carousal at the first place. Also
one needs to be very cautious while operating the ‘pause’ button.




                                            229
                                   Case-let – 12
                                Contributed by: Shri S.Chackraborty, SPM/Patna BP

INCIDENT: During receipt of Bulk LPG the same is taken in Horton Spheres / Bullets as
per ullage available in respective storage vessels. These vessels are provided with
remote operated valve as a first valve from the Tank and Glove valves connecting to the
Manifold. The remote operated valves are interlocked with the level gauge so that in
case the level reaches 85% of the storage vessel capacity, the ROV automatically
closes restricting further intake of Bulk LPG into the particular vessel.

This is to ensure safe filling capacity of a particular vessel as per laid down rules of
Chief Controller Of Explosives. The ROV is fitted with an actuator which is operated
through a Solenoid Valve which receives the signal from High level alarm of the vessel
as well as an electrical control panel to operate the same during normal operating
condition as well as emergency.

During receipt of Bulk in one such vessel in a particular day, the Pump house operator
overlooked the Gauge reading and suddenly it was found that Liquid LPG has entered
into an LPG Vapour Compressor through Vapour line which is taken from Top of the
Storage vessel. As a result of the same the LPG compressor broke down consequent
upon failure of Valves as LPG Vapour Compressors are not designed to handle Liquid
LPG which acts as a solid block if it enters LPG Vapour Compressor.

Immediately the Pump house operator called upon the duty officer who rushed with the
operator to close down the remote operated valve as well as the Manifold valve
manually.

It was further observed that though the Vessel has been overfilled but there was no
indication for the High level alarm and consequently the ROV failed to close
automatically. The liquid level of the subject vessel was brought down within safe limit
by taking the same into bottling. On further investigation, it was found that the micro
switch which actuates the High level alarm was stuck as open condition due to sulphate
formation in its contact tips. The same was cleaned with carbon tetra-chloride and was
found to be operative again.

Results: 1. Break down of Vapour Compressor causing high replacement cost of its
suction and discharge valves. 2. Unsafe operating condition due to overfilling of
Storage vessel.

Lessons learnt: 1. The Pump house operator should be attentive at all points of time.
2. The precision electrical parts of the High level alarm should be periodically cleaned
and maintained.
3. The High level alarm should be checked for its functioning periodically to ensure
safety of the system.

                                          230
                                   LPG (Sales)
                                     Caselet-13
                       Contributed by: Smt Dipa Bishayi, SM(Plant)/Jamshedpur BP

                Investigating diversion…improving 19 kg LPG sales

Despite high incremental sales volume during February and March’07, it was observed
that backlog with two of the distributors in the Area Office Head Quarter town was still
persisting. We have been receiving regular complaints from the customers regarding
delay in getting refills. Despite adequate supply from bottling plant, backlog with those
distributors was not abating. Backlog was found to be a perennial problem mainly with
two of these distributors.

It was then decided to scrutinize the above distributors’ records for a certain period as a
test case. During scrutiny of records, quite a large no. of malpractices was established
against these distributors.

Based on the market information, we had anticipated that diversion of domestic cylinder
by the above distributors in particular and other distributors in general are a deep-rooted
problem, and quite a substantial quantity of cylinders was getting diverted by various
means.

In view of this, it was decided to carry out thorough customer-survey of the above
distributorship on door to door basis through an outside agency because it was felt that
such type of survey for detection of diversion would have impact on the distributors’
community as a whole, and would further alert them about the consequence of
diversion. The outcome of the survey for a particular distributorship may also be utilized
as reference for computation of actual demand of the others.

   Scope of survey was primarily
   a) To ascertain exact number of bonafide domestic customers in existence.
   b) To ascertain customer wise consumption pattern.
   c) To assess quantum of cylinders issued against bogus customers.
   And secondarily
   a) To detect multiple connections.
   b) To observe kitchen safety.
   c) To collect data for creation of customer database.

The survey team had a bank of 22570 nos. of households , who were customers of
these two distributors. The findings were :-

                                           231
       Irregularities observed                                 Total
       Customer is not found at the registered address         1886
       TV/TTV already issued but customers existing in
                                                               275
       BLAZE (hence also in INDSOFT)
       Address not found                                        41
       Connection is used by unauthorised persons               53
       Total                                                   2255


It was observed that around 1200 nos. of refills were supplied to these
unauthorized/non-existent customers within a very short period of six months by these
two distributors.


Actions taken:


1. Penal action against the distributor for diversion of domestic cylinders as per
   provision of MDG. It is pertinent to mention that we have not faced any resistance in
   collecting the penalty amount.
2. Updation of records of the customers who have changed address without informing
   the distributor.
3. The report submitted by the survey team was cross-checked by the A.O. from time
   to time for its correctness.
4. Those customers were blocked in INDSOFT.

It is needless to mention that after this exercise, sales volume of 19 kg cylinders for the
Area Office (as well as in all distributors) has increased threefold.

Recommendation:
1. Success of the entire exercise depends on the efficiency and professional integrity of
   the survey team. The report submitted by the team should be cross-checked on
   random sample basis before acceptance. Hence it is recommended that this tool can
   be explored only if a reputed local agency is available.

Customer survey of large number of distributorship by outside agency as routine
assignment may result in resentment among the distributors. Therefore it is
recommended that survey may be done in phased manner for limited number of
selected distributorship where no significant improvement is observed even after
initiation of penal action against diversion.




                                            232
                                      Caselet-14
                          Contributed by: Shri P.K.Ray, Manager (LPG-Sales)/WBSO

                 Not attending telephone calls on part of distributors

Not attending telephone calls by distributors is one of the most common problems being
faced by the customers. Customers need to contact the distributor for the purpose of
refill booking, leakage complaints and for other service-related matters, since it is not
always possible for the customers to visit the show room of the distributors for this
purpose.

While it is a fact that around 80% of refill booking is being done through telephone only,
but customers are not satisfied with the facility as they are finally successful to contact
the distributor after repeated attempts/efforts only. Most of the time, telephone facility
available with the distributor found either engaged or found ringing.

Having not been able to contact the distributor for the purpose of booking refills or
lodging leakage complaint calls, such customers need to rush to the distributorship to
resolve their problem. It is also a fact that customers are not aware about the alternate
telephone number available with the distributors.

As per policy of the Corporation, distributor needs to provide adequate telephone facility
to cope up the requirement of the customers attached to them. Not getting distributor
over phone is a sheer denial of customer service. We are getting large number of
complaints on this.

In spite of repeated instructions through circulars, counseling and follow up by field
officer, area office etc, hardly any improvement in the services towards this direction is
seen. As a result, customer sufferings continue.

Solution -
 First and foremost thing is, distributor must understand that all ready options are
   made available with the customers for contacting the distributor. It is for the purpose
   of business only.

   Distributor has to provide adequate infrastructure for attending to all calls of the
    customers attached to them. If the facility is not commensurate with the number of
    customers attached, the same has to be augmented.

   All contact telephone numbers of the distributors are to be properly circulated so that
    in case one number is engaged, customer can contact in other number.

   Providing alternate option of contacts with the distributor viz. inter-net, call centre
    etc.

                                            233
   Effective monitoring by field officers through surprise checks, mock calls etc besides
    training and development to the distributor/distributors personnel.

   Action against erring distributors, etc.




                                               234
                     Lube Institutional Sales
                                    Caselet : 1
                               Contributed by: Shri S.Ganguly, CISM (Lubes)/WBSO

                         Quality complain from a customer

IOC has recently started marketing Transformer Oil under the brand name Servo
Electra. One Transformer Manufacturer had been procuring Transformer Oil from IOC
for the last one year. The product is currently blended at a contract blender, tested at
our end and then marketed. The product is meeting BIS specifications.

The customer has placed an order of 45 barrels of Transformer Oil which was supplied
to them in due course. However, after about a month, the customer complained that on
opening of the 8 barrels of Transformer Oil sent to their Rajasthan site, they have found
that there is 50% water in the barrels.
They immediately lodged a complaint           against IOC and asked for substantial
compensation and take back the barrels. An officer from our Rajasthan State Office was
sent to the site; he also confirmed that the barrels were contaminated with water. The
options available to IOC were:

1) To take back the barrels and agree for compensation
2) To refute their claim with proper justification.

In case of customer complaints, IOC usually takes back product as a gesture of
goodwill. However this case was different as may be understood from the following:

a) At our end we checked the batch test report of the product and found that the same
   is meeting specifications.

b) Product of the same batch sent to other places did not have any complain. We also
   advised the customer to check the balance no. of barrels at their end which they
   found to be in order.

Based on the above, it was concluded by us that this was done by the Transporter and
IOC cannot be blamed for the same. It appeared that the transporter resorted to
pilfering since barrel sealing can be pilfered. Accepting all the claim of the customer
would have meant admission of guilt on IOC’s end for which there was not enough
proof, even though as pointed out earlier, IOC in many case takes back product from
customer as a gesture of goodwill.


                                          235
In this case however we were convinced that since there was no other barrel lying in
any other places contaminated with water, IOC was not at fault. It was felt that if we
take back 8 barrels as a gesture of good will and knowing the nature of the customer, it
was apprehended that they would also lodge claim for compensation for the losses
incurred their end.
We had explained the entire situation to the customer and have politely refused to take
back the contaminated barrels.




                                          236
                                    Caselet : 2
                               Contributed by: Shri S.Ganguly, CISM (Lubes)/WBSO

                       Bearing failure due to improper grease

A Steel Plant customer was using lithium grease from an MNC. Customer informed
IOC that after every seven days the oil from the grease was running out leading to cake
formation and frequent bearing failure.

The customer then approached IOC for offering equivalent grease. We offered our
equivalent grease for the application. It was again seen, that even with our grease after
few days there was bearing failures. The customer was at loss and approached IOC to
solve the problem. Our technical team visited the site and it was found that the grease
was used in the withdrawal motor bearings of continuous casters.

In a Steel Plant steel making is done in the basic oxygen furnace. Molten steel is poured
from the ladle and cast into billets and slabs in the continuous caster. This is a high
temperature zone. The temperature of the billets is almost 1200 deg C and it was found
by using digital thermometer that the bearing temperature was nearing 200 dec c.

It was felt that good quality high temperature grease is required for the application and
ordinary grease will not serve the purpose, although the price of the grease was almost
double the price of the existing grease.

IOC then offered high temperature grease to meet the requirement based on calcium
sulphonate technology which had high drop point of 330 dec c. The product was found
to be excellent and the bearing failures could be eliminated.

Result:
This resulted in savings of approx. Rs.15.00 lacs bearing cost by switching over to
superior quality high temperature grease and also increased the plant productivity.




                                          237
                                 Lube-Retail
                                    Case-let: 1
                        Contributed by: Shri D.Bhattacharjee, SRSM (Lubes)/WBSO

Auto-service Business at Supermarkets
This is a case to establish collaboration as a strategy for auto-service business at
supermarkets.

1. Retail Sector in India
Retail is the one of the fastest growing sectors in the Indian economy. Traditional
markets are being transformed into department stores, hypermarkets, supermarkets
and specialty stores. India has the highest shop density in the world and the present
retail market in India is estimated to be US$ 200 billion of which only 3% is in the
organized Sector. Projections point to a rapid growth of organized retailing at an annual
rate of 25–30 per cent.

2. Auto-service Market in India
The automobile industry in India is growing at a very rapid pace. The Compounded
Annual Growth Rate (CAGR) of production of automobiles during the last ten years has
been 10.6%. The CAGR of production of passenger vehicles and 2-wheelers, which are
the major auto segments visiting supermarkets, are 14.2% and 10.1% respectively. As a
result the service demand has also been growing enormously. According to Auto
Component Manufacturers’ Association (ACMA), the passenger vehicle production is
expected to reach a level of 3 million by 2014-15 with CAGR of 7.8% during 2007-14.
The projection for 2-wheelers production is 24 million by 2014-15.
A survey conducted by Mahindra & Mahindra in 2007 in passenger vehicles segment
reveals that only 40% of this market is estimated to be catered by authorized repairers
and the rest by mainly unorganized sector. The turnout of 1-10 year old vehicles at
OEM authorized workshops for services is shown in the Figure 1. It implies that there is
a huge gap in providing auto-services through organized set-ups.




                                          238
                  Figure 1: Turn out of vehicles at authorized workshops
Due to advancement in vehicle technology the service requirement of vehicles has also
become technology dependent. Demand of highly skilled workers is on the rise. Hence,
there is growing demand for organized service retailing. Many professional groups are
entering into this area to grab this business opportunity by setting up multi-brand service
outlets. Some of the names gathered from the field survey are following.
    CARNATION by ex-CMD of Maruti
    FIRST CHOICE by Mahindra & Mahindra
    ROADWORX by ex-CMD of Skoda
    CAR ZONE by Castrol
From the survey of Mahindra & Mahindra, it is learnt that services other than major
repairs and accidental works account for about 67% of total revenue share of passenger
vehicle service market as shown in Figure 2. These services of minor and routine
nature can be provided easily with minimum investment.




               Figure 2: Revenue contributions of different auto-services

3. Potential Synergy of Retail Sector and Auto-service sector
Considering the growth of 25-30% in the organized retailing through supermarkets and
also the need for organized auto-service retailing due to the rapid growth of auto
industry, it is an ideal platform for marriage of the two sectors. The driving factors for
such synergy are following.
    Middle class is likely to grow from 50 million to 550 million by 2025 (ACMA 2008)
    Growing footfalls in supermarkets at the present rate of 25-30%
    Idling of vehicles of shoppers at supermarkets. In a recent survey made on
       passenger car owners shopping at supermarkets in Kolkata it is revealed that
       18% of the vehicles idle upto 1 hour, 39% idle for 1-2 hours, 25% idle for 3-4
       hours and 18% idle for more than 3 hours.
    Convenience of service at a supermarket while shopping
    Least attention to OEM authorized workshops for minor services, especially at
       the large cities
    Lack of spare time of vehicle owners to visit authorized workshops
    Huge size of auto-service market and its fast growth rate.


                                           239
4. Collaboration as a Strategic Solution
IndianOil approached one of the major retailing giant in India, Pantaloons, to start an
auto service business at one of their malls in Mumbai towards this synergy. The mall
was built up in a very uprising locality of South Mumbai, the mall authority had been
always on the lookout for value additions to the shopping mall to increase footfalls. The
car parking is at the basement and can accommodate only 175 cars at a time. IndianOil
on the other hand is looking for opportunity to showcase its brand of multi-brand auto
service venture and also to promote its lubricants in the brand name SERVO through oil
change facilities and thereby enhancing its image of customer service.

With the above objectives, collaboration was made between the two companies. The
auto service facilities were provided at the basement car parking area occupying a
space of only around 400 sft. A service outlet in the brand name of SERVOXPRESS
was set up and the operation started in April 2007. For operating the facilities a
franchisee was selected by IndianOil. Due to limitation in space, only few facilities like,
check-up services, vacuum cleaning, perfuming, dashboard polishing, tyre polishing, AC
deodorizing, wax polishing, leather polishing etc. were only provided.

A study was conducted for one year from July 2007 to June 2008 and it was observed
that on an average 10 vehicles were serviced per day. The average revenue per car
increased nearly three-fold from an initial level of Rs. 231.00 to Rs. 628.00. With
increase of number of services the figure is likely to go up day by day.

The success resulted in establishing the brand SERVOXPRESS as a chain of
organized service retailing. SERVOXPRESS outlets have been set up at our retail
outlets, shopping malls, workshops etc.




                                           240
          Maintenance & Inspection (M & I)
                              Caselet -1
                                 Contributed by Shri Uttam Nag, SM (M&I)/ER

            FAILURE ANALYSIS OF TK 2 AT PARADEEP TERMINAL

                              BACKGROUND
•   TANK NO. TK 2 OF PARADEEP TERMINAL IS A DOUBLE DECK FR TANK OF 36
    MT DIA X 14 MT HEIGHT, 14000 KL CAPACITY TANK CONSTRUCTED IN THE
    YEAR 1996.
•   THE TANK WAS INSPECTED ON 29/11/2006 BY M&I DEPARTMENT, ER. NO
    MAJOR DEFECTS WERE OBSERVED EXCEPT REPLACEMENT OF FEW TOP
    DECK PLATES THAT WERE HAVING HOLES / PATCH PLATE / DEEP PITTING.
•   PARADEEP WAS EXPERIENCING HEAVY RAIN FROM 16-17/09/2008 ALONG
    WITH HEAVY WIND OF 85-90 Kmph.
•   ON 17/09/2008, 1500 HRS. STM, PARADEEP INFORMED COM, ORSO THAT
    THE ROOF OF THIS TANK HAS CAVED IN.

                          (Some snaps attached)




                                  241
242
243
ACTION TAKEN
  • A FOUR MEMBER COMMITTEE CONSTITUTED TO INVESTIGATE INTO THE
     MATTER.
  • THE COMMITTEE MEMBER COULD ONLY GO UPTO THE TOP OF TANK BUT
     COULD NOT REACH THE DECK SINCE IT WAS INACCEBABLE.
  • THE COMMITTEE SUBMITED THEIR REPORT AFTER GOING THROUGH THE
     DOCUMENTS AND INTEROGATING THE OFFICERS.

  COMMITTEE FINDINGS
  • FROM THE COMMITTEE REPORT IT IS CLEAR THAT DUE TO PRESENCE OF
    HUGE QUANTITY OF WATER INSIDE THE PONTOON CHAMBERS
    (ESPECIALLY AROUND THE CENTRE OF THE DECK THE ROOF BOTTOM
    PLATE GOT DEFLECTED AND THUS 14 NOS OF GUIEDS (AROUND THE
    CENTRAL POSITION) HAVE SHEARED (TOTAL 39 GUIDES). AS A RESULT OF
    SUCH FAILURE THE CENTRAL PORTION OF THE DECK CAVED IN. EXCEPT
    FEW LEGS, MAJORITY OF THE LEGS LOCATED AROUND THE PERIPHERY OF
    THE ROOF WERE FOUND ALMOST INTACT.

  CAUSE OF FAILURE
  THE TANK REMAINED IDLE FOR NEARLY TWO YEARS COVERING TWO
  MONSOON SESSIONS. INGRESS OF WATER INTO THE PONTOON CHAMBERS
  CAN TAKE PLACE EITHER THROUGH OPEN PONTOON COVER OR THROUGH

                                 244
LEAKY CENTRAL DRAIN PIPE. BUT IN ALL SUCH CASE THERE EXISTS
STANDARD INSPECTION PROCEDURE OF ROUTINE CHECK BY THE LOCATION
TO INSPECT THE PONTOON CHAMBERS AFTER RAIN. THE PONTOON
SEPARATION PLATES WERE NOT WATER TIGHT AT THERE VERTICAL AND
HORIZONTAL WELDING JOINTS. MOST PROBABLY THE SAME REMINED UN
ATTENDED THOUGH OFFICIAL RECORD SAYS THAT EVERYTHING WAS OK.
INCIDENTALLY THERE EXISTS ANOTHER TANK TK-1 OF IDENTICAL CAPACITY
AND TYPE BUT THE SAME REMAINED INTACT THOUGH IT WAS FULL OF
PRODUCT.




                               245
                    Caselet - 2
                       Contributed by Shri Uttam Nag, SM (M&I)/ER

ROOF COLLAPSE OF FR TANK NO. 10 at SILIGURI TERMINAL




                        246
247
248
249
OBSERVATION
1. THERE EXISTS ONE EXTRA HOLE IN THE LEG AT A DISTANCE OF 275mm
   FROM THE HOLE MEANT FOR ROOF OPERATING POSITION. THE TOP TWO
   HOLES HAVE EXTRA REINFORCEMENT BUT THE THIRD ONE DOES NOT
   HAVE SUCH REINFORCEMENT.
2. IN TOTAL NINE NOS. OF LEGS ARE PROVIDED WITH 62.5mm SCH 40 PIPES
   INSTEAD
   OF STANDARD 21 NOS WITH SCH 80 PIPES.
3. ALL THE NINE LEG SUPPORT PIPES FOUND BEND FROM ON AND AROUND
   THE
   THIRD EXTRA HOLE PROVIDED IN THE ROOF SUPPORT LEGS
4. MINOR BEND OBSERVED IN THE SHELL NOZZLE (DEFUNCT). NO WELDING
   CRACKS OBSERVED.
5. DECK FOUND FLOATING UP AND DOWN FREELY WITHOUT ANY DAMAGE /
   TOUCHING THE GAUGE WELL PIPE. NO WATER LEAKAGE INTO THE DECK
   OBSERVED.
6. THERE EXISTS ONLY ON AB VENT AND ONE EMERGENCY DRAIN WITHOUT
   WATER SEAL.
7. NO ABNORMAL DENT / DAMAGE OBSERVED IN SHELL PLATE, BOTTOM
   PLATE, ROOF UPPER SIDE / UNDER SIDE.




                                250
RECOMMENDATIONS
  1. ALL THE NINE LEGS ARE TO BE CHANGED TO SCH 80 GRADE PIPE OF
     SAME SIZE. NO NEED TO INCREASE THE NUMBER OF LEGS SINCE THEIR
     LOAD CARRYING CAPACITY IS SUFFICIENT AND SAFE. ADDITIONAL
     REINFORCEMENT IS RECOMMENDED FOR THE TWO HOLES IN THE ROOF
     SUPPORT LEG.
  2. THE DEFUNCT SHELL NOZZLE MAY BE BLANKED FROM INSIDE THE
     TANK.
  3. ADDITIONAL AB VENT AND EMERGENCY DRAIN WITH WATER SEAL TO BE
     PROVIDED.
  4. BOTTOM PLATE TO BE VACCUM TESTED AND SHELL TO BOTTOM JOINT
     TO BE TESTED WITH CHALK KEROSENE.
  5. THE TANK TO BE FILLED UP WITH WATER UP TO SHF BEFORE
     COMMISSIONING.




                               251
                             Quality Control
                                      Caselet-1
                                     Contributed by: Shri S.Bhattacharya, SM(QC)/ER
Incident
After receipt of SKO in two tanks of Patna Terminal from BKPL, the tanks failed in Flash
Point Test, which was carried out during Bath Formation Test at Patna Laboratory. As
flash point for SKO is an important test, product in both tanks was on hold and delivery /
receipt from the tanks were stopped immediately.

Investigation Committee was formed constituting members from QC/ER, Pipeline
Division, Refinery (Barauni) and Operation Deptt. / BSO, to establish the cause of
Product failure.

Investigation
The committee checked all retention samples, records and Pipeline records. All
retention samples of Pipeline division taken from the pipeline failed in Flash Point test
which indicated that the product (SKO) which has gone into the tank was off-spec in
respect of Flash Point.

SKO was pumped from Barauni through BKPL in a 12” line with a certain high pressure
whereas simultaneously MS was also being pumped in another separate line of 20” with
a less pressure then the other line. Both the lines are completely separate at Patna
Station.

To find out the reason for failure, committee had to proceed to Barauni as there was no
other clue.

At Barauni Pumping Station, all retention samples were tested, record book checked
and detailed interaction with Staff and Officers were done. Also tank retention sample
from which SKO was supplied from Barauni Refinery was tested and interesed by the
Committee members.
All samples were clearly passing and were matching with the Refinery tank test result
which meant that Refinery tank as well as Barauni P/L are clear from contamination
area.

However, it was observed that 12” Line & 20” Line were have a common portion.

Why Confusion/Suspicion
At the receiving end of Patna, SKO being pumped through a Pipeline without any
common portion, the product failed while at the other end of the same pipeline the same



                                           252
product passed test! This can’t happen as the pipeline is one. Pipeline puts blame on
marketing division whereas marketing people blames Refinery and Pipeline.

Ray of Light
It was noted that one MS line (separate) was also simultaneously pumping MS to Patna.

      It suddenly occurred to the committee that the sampling point could be at such a
      position where contamination would not affect the sample.

      Committee checked the sampling Point Position. That was much down side the
      common portion where 12” & 20” Line are connected (inside Barauni Pumping
      Station)

      Committee checked the common portion of the SKO/MS Line which was
      connected by a motor operated valve (MOV) and no record was maintained for
      that. Due to shutdown, significant pressure got built up in MS Line and MS was
      leaked into SKO through the MOV. But samples were not affected as the point
      was down side. So contaminated product, even though originated from Barauni,
      was not detected there as the contamination happened after the sampling point.
      But the same was caught at Patna; the sample there failed.

This incident highlights the importance of positive segregation.




                                         253
                                     Caselet -2

                                    Contributed by: Shri S.Bhattacharya, SM(QC)/ER

Incident (during 2004)

MCCPTA was one of the Valuable customers for IOC/Haldia and it took FO. There
were other suppliers like BPC and HPC who were trying to capture the business of
MCCPTA from IOC.

MCCPTA requires FO of stringent quality in 0.2% water only as against a (maximum)
1.0% allowable BIS limit of water Content.

Suddenly one fine morning few T/T Loads of FO were returned /refused by the
customer and complaint of water more than0.2% was lodged.

Similarly next few days all loads were refused not meeting water content requirement.
BPC/HPC they started to enter slowly into the customers area.

Sales-Strategic

Matter reached Regional Office and the cauldron was boiling as HPC/BPC started
supply few loads of T/T.

Matter stood still for about 7 days and lot of pressure generated on the issue.

QC Entry

QC was advised by Sales Group as well Location in Charge/ Haldia to resolve the
issue somehow as the issue related with quality of FO.

On advice from the Regional Office following action were initiated by me –

   (a) Testing of Refinery Tank for water content in Marketing Lab.

   (b) Advised Refinery to produce 0.1% water FO

   (c) Visited MCCPTA Lab along with one Sales Officer and witnessed their testing. It
       was observed that the FO water content is tested as per “Shell Kit” method which
       is not as standard method, as per our MOU.

   (d) The matter was discussed with their representatives who were briefed about the
       MOU between IOC & MCCPTA wherein it was noted that FO would be supplied
       after conforming with BIS.
                                           254
   (e) Their representative was told to test the same sample (for which the result was
       above 0.2%) in our marketing Lab.

   (f) On next day same sample brought by representatives of MCCPTA was tested in
       front of them and result was found to be satisfactory. By this way, they were
       convinced.

In the mean time Refinery also brought down their FO production with only 0.1% water
which was very good and this satisfied our high value customer.

It was shown to MCCPTA representative that the sample which was showing >0.2%
water was actually incorrect and correct result was <0.2%.

Customer was convinced and from next day FO supply resumed at Haldia MCC-PTA.

This incident highlights the importance of knowing our MOUs with our major
customers.




                                         255
                                  Caselet -3

                                     Contributed by: Shri N.C.Saha, DGM(QC)/ER
Background

      Patna Terminal receive product through BKPL ex- Barauni Refinery.
      One fine morning when samples of SKO was tested for batch formation test
       after such receipt from BKPL it was found to be very low in Flash Point test in
       350C against the Refinery report of 390C.
      Investigation Committee was formed for such deviation in quality and
       Committee started to investigate the matter at Barauni Refinery end.

Case

      Committee checked all the details of PLC rendered during pipeline receipt.
       Other relevant records were checked.
      SKO was pumped ex T-110 of Barauni Refinery.
      SKO was having interface with MS preceding it which was accommodated in
       MS tank 10.
      There was shutdown in the pipeline on two occasions on 5.1.11 & 7.1.11 due
       to ullage constraints at Patna.
      From the PLC data of Barauni Pipeline Station it was noted that there was a
       downward t trend of density for about 5 mins after stabilization w.r.t SKO
       pumping.
      During the pumping of SKO from Refinery, it was noted that the booster pump
       was used for pumping the SKO batch.
      Before using MS booster pump is SKO, flushing of the accessories were not
       done in the Refinery.
      Interface has been generated more than the normal expectation which may
       be due to 2 shutdown.
      This increase of interface was not apprehended at Patna end which might
       have lead to wrong interface cutting.
      As per log book of BKPL, Patna interface cutting was proper but wrongly
       switched over to TK-3.

Actual cause of failure
    Mismanagement of interface at BKPL, Patna caused the deviation of flash
      point, as interface is a mixture of MS-SKO (wrongly taken in TK-3).
    Use of MS booster pump at Refinery without water flushing before its use in
      SKO.




                                       256
Lesson Learnt

During interface-cutting, the concerned officer should be alert enough to identify the
starting and end point of interface so that the whole quantity of the same interface is
taken in the appropriate tank as per manualised instruction.



                                      Caselet -4
                                     Contributed by: Shri S.Bhattacharya, SM(QC)/ER

Background
Before T/T loaded with SKO is released from Depot/ Terminal, one sample from the TT
nozzle is required to be tested in Lab for flash point. The T/Ts are released only after
the nozzle sample passes test in flash point. This is done as per a circular from QC/ER
after Kota fine incident.

The Episode
   In one such testing of nozzle sample from T/T delivery point at Haldia Lab, the result
    was found to be 36/37°C against a specified limit of 38°C. Matter was informed to
    SRC/Haldia who advised repeat sample & testing. The subsequent sample also
    failed in Flash Point as it was found to be only 36.5°C.

    Supply was stopped and Refinery Haldia was informed.
   Immediately Haldia Refinery OM&S Deptt. conferred with laboratory and informed
    that the tank was certified and the sample cannot fail. After sometime, Haldia
    Refinery Lab and many others started informing that the tank is certified and hence
    Flash Point is passing. They even forwarded one sample drawn by them to
    marketing Lab.

   On testing this sample, the result was found to be 37°C; this was informed to
    SRC/Haldia.

   Later on to keep the market supply of SKO, if was decided by the Terminal to load
    T/T from BPC Terminals.

   The issue was literally challenged by Refinery on Flash Point Testing. However,
    marketing division stressed upon testing of the sample drawn from the same delivery
    nozzle.

   Later on Haldia Refinery drew sample of their tank and tested.


                                            257
   Supply from BPC terminal continued for next 2-3 days.

   On the 4th day Refinery made available another tank and sent sample for testing to
    Marketing Lab; the result of trash was 42°C. Supply then resumes from Refinery
    tank.

   Later on it was understood that Refinery tank which was initially given for supplying
    SKO was later on detected to have a flash point of 37°C only.

Lessons learnt: It is important to stick to manualised procedures. On products of mass
consumption like SKO, one simply can’t take any chance.




                                           258
                                          Caselet -5

                                        Contributed by: Shri S.Bhattacharya, SM (QC)/ER
Background


Reliving duty for Patna Lab was assigned to Siliguri Lab during 1987-88.
During one such relieving duty at Patna Lab, following episode took place.


Episode
      One sample in Plastic Container was brought to Patna Laboratory wherein one
       paper, containing the information on sample/product /date of sampling /type of
       sample/drawn by etc. sample was pasted. The sample was drawn from a RO.
      The sample was not sealed.
      When the sample arrived, immediately STM/Patna summarized Lab-in-Charge
       and advised testing of the sample.
      Lab-in-charge/Patna who was on temporary duty informed that there is no policy
       for testing of outside sample; without the consent of QC deptt; and hence QC
       clearance is required.
      In the meantime the Lab-in-Charge went through the files available in the
       Laboratory and found that the same sample was tested one month before and
       found that it failed in Distillation test.
      CDM / Patna came into the picture, and advised immediate testing of the sample
       and again the Lab-in-Charge stuck to the earlier stance that without          QC
       clearance, sample can’t be tested and further that the sample is already failure
       case.
      During those years, telephone faicility was not easily available like nowadays and
       only one telephone available was in STM’s Chamber.
      Ultimately STM/Patna agreed on the issue and informed QC that Lab Officer is
       not Testing sample since the same was not advised to him by Regional QC.

                                                259
       QC/ER wanted to hear it from the Lab officer.       On hearing the whole story,
        QC/ER ultimately advised not to test the sample as the sample once failed.
After few days there was Policy/Guideline issued by QC/ER on testing of such type
outside sample. It helped to aver similar situations in future.



                                      Caselet -6

                                          Contributed by: Shri N.C.Saha, DGM(QC)/ER

                        Contamination between HFHSD & HSD

One of the depots in ER received HSD & HFHSD from a Port Terminal through tank
wagons on a Friday. At about 16:00hrs on that day it was informed telephonically by
Depot Manager to QC dept/ER that substantial quantity of stock loss in HFHSD and
similar amount of gain in HSD was observed. QC/ER advised Depot to quarantine HSD
tank and send the samples of HSD for test. Subsequently the sample failed in Sulphur.

Meanwhile Depot has supplied some quantity of HSD from the same tank without
waiting for the test result.


The Episode

Next day when sample of HSD tank was re-tested, it found to be failing in Sulphur in its
lower and middle layers. Surmounting pressure for product correction from all corners
gained momentum due to following reasons :

   1.   Non availability of HSD in Depot sales area,
   2.   Depot did not have sufficient stock of HSD in other tanks for supply.
   3.   Before disposal Investigation is also required to be completed.
   4.   The next day being Sunday there will be no operation.

For correction of product in HSD tank, good low sulphur HSD is required to be mixed
with it according to the mixing ratio. On Saturday afternoon it was informed by the Depot
that on Sunday there will be rake loaded from same Port terminal for the Depot with
HSD wagons in it. Immediately on Saturday evening following actions were taken:

   1. Depot was advised to rush 2x2 lts. of failed HSD samples to Port Terminal Lab.
   2. Port Terminal was advised to use HSD tank having lowest Sulphur for loading
      wagons of Depot.
   3. Port Terminal Lab was advised to ascertain mixing ratio of failed product with the
      HSD tank of Port Terminal from which the wagons to be loaded.
   4. Constituted Investigation Committee to find out the cause of failure.

                                            260
This action saved lot of time against the time required in ascertaining mixing ratio of
failed HSD sample with the wagon sample drawn at Port Terminal itself.


Findings of the Investigation

A Committee reached Depot for investigation and found out the following as cause of
failure :

   1. MOV between HSD & HFHSD lines at pump-house was malfunctioning, thereby
      mixing some HFHSD containing high Sulphur into HSD containing low Sulphur,
   2. Lack of proper positive segregation of lines,
   3. Lack of product knowledge of Officers of the Depot as initially confusion mis-
      leaded into supply of product from failed HSD tank.

Product Correction

Before the TWs reached Depot, the mixing ratio was already in place. The Committee
advised disposal action and to unload HSD according to the determined mixing ratio in
the failed tank. After unloading, samples were tested for batch formation test at Lab and
passed in sulphur test and subsequently supply resumed.

Remarks:This is the quickest product disposal action advised by ER/QC to meet
market demand.




                                          261
                                      Retail
                                    Case-let: 1
                                Contributed by: Shri D.Goswami, CRSM/Kolkata DO

               Successful handling of fire incidence at an RO at KDO

PERSPECTIVE:
The devastating fire incidence at our Jaipur Terminal shocked everybody, especially
people across oil sector. As an aftermath, we started relooking in the fire incidence per
se, as it may take place in any Retail Outlet. After series of gruelling brainstorming
sessions and discussion at Kolkata Divisional Office, we dissected the various possible
options of fire incidence and chalked out the means to plug the gaps.

VULNERABLE PLACES / TIMES OF FIRE
We found that the most vulnerable places or times for possible fire incidents are:
1. TT Decantation
2. DU Management including leakage in handling, electrical joints etc.
3. Electrical Rooms / fittings etc.
4. Forecourt (General non observation of basic rules such as No-Smoking, No-Mobile,
   Not switching off vehicle engines etc.)

PLAN OF ACTION
We planned a three-pronged strategy to overcome the problems / short-comings:
  A. Extensive awareness programs across ROs including
      a. Dealers’ Training / Sensitization program imparted directly by KDO,
         including hands-on training of maintenance and operation of firefighting
         equipment
      b. Frequent Field level training of managers and pump attendants across ROs,
         including demonstration of operation of equipment, showing video footage and
         staging mock fire drills.
  B. Placing of adequate RO-wise firefighting equipment and making sure that the RO
      personnel can use them.
  C. Placing of several display items, Dos & Don’ts boards, Safety posters, stickers on
      DUs etc. to make sure that the safety messages get spread to all concerned
      such as the customers, pump attendants, etc.




                                          262
INCIDENTS
While all the above efforts were on, a flash fire broke out at our RO M/S Super Avenue
Service Station, Shyam Bazar on 09.04.2010 at about 1:30 pm while unloading MS.
The pump attendant Sri Abhijit Ghosh, while doing pre-decantation density checks, first
noticed it and shouted “Fire, Fire”. He promptly took guard and charged the first DCP
fire extinguisher. Other pump attendants immediately rushed to the spot with fire
extinguishers available at nearby work stations. Sri Ghosh effectively discharged six
consecutive fire extinguishers to bring the fire under control. In the meanwhile, the
driver of the TT promptly closed the unloading valve of the TT manifold, which
prevented the fire from going into the TT chamber.

The fire was put out completely within seconds, much before help arrived from the local
fire brigade and police station.

Next day the largest circulating English daily of Kolkata, The Telegraph, came out with a
positive coverage of the incident stating that the fire were effectively doused by the
pump personnel.

Later, both the pump attendant and the TT driver were felicitated for their efforts.

POST MORTEM
Detailed analysis was carried out subsequently and the following were found:

   1. The particular day was extremely hot which indeed led to accumulation of MS
      vapour in the decantation area, which appeared to have caught fire.
   2. After probing all possible reasons for the cause of the spark, it was established
      that the spark was caused by the mild steel cover over the unloading point which
      is housed on a mild steel frame. In case of removal of the cover by sliding over
      the frame, this may have generated spark. This has also partly been caused by
      the elevation of the tank sump cover by about five inches to accommodate
      automation probes into the tank, leading to a steep slope between the top of the
      angle frame and the rest of the paved driveway. This steep slope leads to scope
      to the partially open metallic sump cover hitting the floor if someone accidentally
      gets to stand on the cover, leading to generation of spark.
      The pump attendant observing pre decantation density was the first to spot the
      fire.




                                            263
LESSONS LEARNT
  i. The continuous training imparted towards maintenance and operation of
      firefighting equipment really came handy in the time of need. Repeated training
      not only made the personnel learn the processes, but also made them not to
      panic during crisis time and effectively discharge their duty.

   ii. The abrupt elevation of the tank sump covers should be avoided in case of
        automation / other rectification.

   iii. Small windows should be provided for unloading point and dip hatch to avoid
        handling of the entire heavy steel plate during decantation.

       If at all required, the plate has to be removed completely and smoothly with the
      help of adequate manpower.




                                         264
                                      Case-let: 2
                              Contributed by: Shri Navin Charan, SDRSM/Siliguri DO

    EFFECT OF PROPER BOUNDARY MANAGEMENT WITH ADMINISTARTION

Background:
On 05-Nov-2010 the TT Drivers and Helpers Union based at NJP have gone for Flash
Strike owing to the reason that one of their Member (Driver) was arrested by the Local
Police as per the complaint lodged by the concerned Owner / Contractor of a TT
attached to NRL (BPC’s) TOP at Rangapani. The reason behind the above was that the
Driver had a perennial habit of stealing the product from the TT and of late he used to
even steal and sell Tyres, Battery & other major parts of the TT. This resulted in the
arrest of the Driver as the Owner had no other option but to take the legal recourse by
lodging an FIR in the local Police Station.

Problems Faced:
In view of the said flash strike no TT reported to NJP Terminal on 5th, 6th& 7th Nov, 2011
as the above Union have put forward the demands of Unconditional Apology by the TT
Owner, Immediate release of the Driver, Monetary Compensation during the strike days,
no high handedness / harassment by TT Owners for which the OMCs to take the
responsibility etc., which ofcousre are far from acceptance & reality. As the entire
Supply Chain of POL was paralysed in N Bengal including Sikkim, there were series of
tripartite Negotiations during the above days by OMCs, TT Owners & Union, where I
was also a part in couple of such meetings. The Union was in no mood to accept our
request to start the loading operation as many ROs have started reporting of dry-outs
and public at large were put to undue inconvenience over such a issue and advised
them not to take the public for ransom, was of no effect.

Action Initiated:
By observing above and as the undersigned had felt that the situation has gone out of
control and will further deteriorate if the POL supplies are not affected from 8th Nov
2011, I have personally contacted Sri Ranvir Kumar, IPS, IG - N Bengal Region, with
whom I have an excellent rapport to the extent that I can even walk into his Chamber
without any prior appointment. After listening to the entire episode he got re-confirmed
regarding any other reasons for the Union Members to act in such an irrational manner.
After getting the confirmation on the above, he called the concerned DSP & CPI and
instructed them to call the main leaders of the Union and explain them “in their own way
& style” stating that the said strike is illegal and if they do not report to the Terminal on
8th Nov 2011, action will be initiated against them as per prevalent Laws / Rules &
Regulations (@).

Result / Lessons Learnt: The result was mindboggling as on the next day i.e., 8th-Nov-
2010 (Monday) without any noise from the above Union, all the TTs started reporting to
S&D Section, sharp at 8.30 AM. Entire Local Industry was pleasantly surprised as they
expected that the turmoil would further continue. Therefore having excellent rapport
                                            265
&maintaining adequate PR with the local Administration is the essence of success
behind this story.

(@)PS: The above activity was done without involving any other Officials / Persons from
OMCs or otherwise and till date it remains as mystery that how such a serious strike
was called-off without any further dialogue / demand with / from the Union.




                                         266
267
                                SHIPPING,HO
                                    Case-let 1
                               Experience shared by

                       Shri Arnab Nandi, Sr. Mgr(S&D), ERO


                              Issue under discussion

                       Berthing of vessels at Haldia Jetty No. 1

                                   Earlier System

Haldia Jetty No. 1 is generally used for berthing small vessels which include POL
vessels, Paraxylene, Ammonia and other Chemicals line Butene, Butadiene etc .
Vessels are taken in berth as per seniority of arrival at Sandheads. Paraxylene and
Ammonia vessels are accorded priority after 24 hrs of arrival.

                         New idea/methods implemented

By collecting ETA timings of other vessels from various external sources like Agents,
Port Authority, Receivers etc, sometimes we can make our POL vessels speed up and
reach Sandheads ahead of the other company’s vessels thereby getting ahead in the
queue.

                                       Savings

One day berthing in advance can result in savings of Rs. 10 lacs approx.      It also
improves turnaround/performance at the next port.


REPLICABILITY – All Port locations.




                                         268
                                  Case-let 2
                              Experience shared by

                    Shri Lalit Manral, MNM, WRPL, Vadinar


                             Issue under discussion

                         Type of vessels being chartered

                               PROBLEM FACED

 MT Devsi came recently from Panna field to IOCl, Vadinar to unload 84000 MT of
  crude Oil. As the vessel arrived in the late evening hours and nigh berthing
  facilities for single point mooring(SPM) are not available with Kandla Port Trust
  (KPT). Thus, KPT advised the vessel to drop anchor in the outer anchorage area.
  Before dropping of anchor, MT Devi’s engine failed & vessel was without its own
  power for any purpose and due to sea currents the vessel started drifting towards
  SIKKA port of Reliance. It reached upto 1.5 miles from where two vessels for
  Reliance were anchored and there was a very real chances of collision of loaded
  vessels. Master of Devsi sent SOS to KPT and KPT inturn sent SOS to Reliance
  SIKKA port and the two vessels which were anchored on way of MT Devsi were
  advised to lift their anchors and move away from there. In the meantime, KPT
  also assigned one Tug to help MT Devsi. Finally the vessel’s engine became
  operational and MT Devsi dropped anchor in SIKKA port area itself.

 After 2 to 3 hours vessel conveyed that it is ready in all respects and tendered
  NOR. Acordingly pilot memo was booked for next date.

 Next day morning when the Pilot (KPT) with IOCL Boarding Officer was going by
  Pilot Launch to board the vessel for berthing, Master of the vessel called on VHF-
  12 that engine of vessel has failed again and it will take 4 to 5 hours to rectify the
  same and by that time, the tide for berthing was over.

 This matter of repeated failures of vessel was taken up with Shipping Dept, RHQ
  as well as with Vessel owner. IOCL, Vadinar advised for rectification of vessel
  again, through a certified reputed agency and only then the inward pilot will be
  rebooked.

 By evening hours VP of Vessel owner informed that the whole incidence was due
  to negligence of vessel personnel and now the problem has been rectified and
  vessel is ready in all respects and requested for booking of pilot. On his
  confirmation pilot was booked for next day.

                                                                                  ….2/-

                                        269
                                           : 2:

    Next while KPT Pilot & IOC Boarding Officer were on the way in Pilot Launch to
     board vessel, again Master of the vessel informed that once again her Engine
     had failed and that she was unable to lift the anchor and berthing was cancelled.

    Now KPT & IOCL, Vadinar took a decision that until or unless vessel equipments
     and accessories are certified by a reputed Agency pilot Memo will not be booked
     and for next date Pilot memo was not booked.

On our consistent demand vessel finally arranged a reputed agency for certification and
finally when the hard copy of survey was made available to IOC and KPT, Vessel’s pilot
memo was booked.

                    TOTAL TIME LOST : - Three and a half days

                       REASON :- Poor equipments of vessels

And finally vessel was berthed on the 4th day.


                                  LESSONS LEARNT

   1. We should carefully charter the vessels taking port performance into
      consideration.
   2. Bad performing vessels like this may always lead to collision with other vessels in
      a congested area like Vadinar where IOC is handling 22 MMTPA, Reliance is
      handling 40 -50 MMTPA, Essar is handling 14 MMTPA of crude apart from
      handling of finished products of Reliance and Essar.
   3. Such vessels also have cascading effect on the berthing prospect of other
      waiting tankers also.




                                          270
                                    Case- let 3
                          EXPERIENCE SHARED BY
                 SHRI MR KULKARNI, AM(PLANT), LBP TROMBAY


                            Issue under discussion
   Leakage at shore end observed at the time of tanker discharge & resultant delay

                                   Problem Faced

Base Oil Discharge was on. Early morning at 0400 hrs, the shore officer noticed
pressure variation and communicated to the Boarding Officer. Immediately, the shore
officer checked the pipeline & suspected leakage in Plant premises. Tanker discharge
was stopped. After pigging operation, the matter was handed over to Engg. Dept. for
pipeline rectification. Discharge stopped at 0700 hrs. Engg. Dept. deployed contractor
& the contract people started the job at 12:30 hrs. After digging out the underground
portion of the pipeline, two pin holes were observed on the pipeline . Engg people tried
to plug the pinholes with clamping but were unable to do the same successfully.

                           Solution suggested/Implemented.

To arrest the leakages, on line application of Devcon Titanium putty was suggested by
me at 15:00 hrs. But local management took 8 hrs to accept the suggestion. After lot of
delay, the local agent of Devcon was called in to arrest online leakages at 23:30 hrs.
The cost of material was 35000/-. Contractor applied the Devcon titanium putty &
dressed the pipeline. Completed at 03:00 hrs & tanker discharge resumed at 05:00 hrs.
We could have avoided delay in implementation of suggestion and saved the time and
demurrage. After implementation of suggested Devcon putty we have unloaded 7
tankers without any leakage in the repair spot.


REPLICABILITY– All costal Locations may be advised to store Devcon Titanium putty
which they will be able to utilize whenever required with minimum loss of time.




                                          271
                                    Case- let 4
                          EXPERIENCE SHARED BY
                 SHRI MR KULKARNI, AM(PLANT), LBP TROMBAY


                             ISSUE UNDER DISCUSSION

                                Tanker sampling & delay


            PROBLEM FACED DURING SAMPLING IN MT EARTH SONG

On arrival of the vessel, sampling for conducting the PD Test was done at 15:10 hrs. At
the time of sampling there was a slight drizzle. Sample was duly tested in the Lab. After
nearly 3 hrs, Lab Officer reported that there is free water found in product. Matter was
discussed with the Master of the vessel . He insisted for appointing P&I Club surveyor.
In the meantime, re-sampling was done by the Lab Officer.

In Re-sampling, no water was found in the product. 4 hours could have been saved if
initial sampling was done more carefully and by observing all manualised guidelines for
doing on-board sampling. The re-sampling also could have been done faster.


REPLICABILITY – All Port locations.




                                          272
                                       Case-let 5

                               Experience Shared By

                                  Ananda Barman
                                   Manager (RC)
                                 Haldia Installation

Issue Under Discussion:
We had faced following problems while unloading MT Jag Pari at Haldia on 15-
16/08/2010:

      After the completion of the discharge, while doing the provisional loss/gain
       calculation by our shore/on-board officers, it was observed that there was loss on
       the higher side (more than 1%). Since it was coastal movement, calculation was
       done at 15 deg. Centigrade.
      And this calculation was done on the basis of shore tank receipt vs. arrival ullage.
      We did not have the copy of the BL from the loading location at the time of
       unloading the vessel. In that case, we could have done the calculation on BL VS
       Shore tank receipt.
      The vessel’s experience factor was positive.
      So it must be giving loss at the disport, but it was on the higher side.
      It happened in the early morning hours. I had been advised thoroughly to inspect
       the vessel along with the Boarding Officer, Shore Officer and the surveyor.
      We checked all like coffee dam, slop, sea chest valve, ballast, over-board valve,
       all the tanks, etc. And we could not observe any deviations.
      We issued protest letter to which the Master replied.
      By the time, the inspection was complete, our shore office received the BL figure
       from the loading location. And it was found that the loss was within the
       permissible limit.




                                           273
Observations:

     Haldia receives coastal vessels from locations like Paeadeep, Chennai (CPCL),
      RIL – Sikka, RIL – Vadiner. In some of the cases Haldia does not get the BL and
      other documents before the vessels arrival. In that case we have to depend on
      the on-board arrival quantity. And Loss/Gain is calculated on the basis of this
      figure.
     In most of the cases, vessel before reaching Haldia part discharge happens in
      between at either Vizag, Chennai, New Mangalore or Paradeep. In that case we
      need the AC-13 from such location for calculation of the loss/gain.
     Because of the non-availability of the BL copy and the AC-13, as the case may
      be, it becomes difficult to ascertain the actual loss/gain. In case of losses on the
      higher side, carrying out investigation takes lot of time. And the vessel might miss
      the scheduled sailing time thereby incurring financial losses.
     As soon as the loading completes and the vessel leaves the loading port, the
      loading location should mail the scan copies of the following documents to the
      disport loactions:
          o BL Copy
          o Load port ullage report
          o AC-13, if any part-discharge happens in between
          o After loading test report




                                          274
                                        Case-let 6

                                Experience Shared By

                                   Rajeswar Prasad

Issue Under Discussion: Conversion factor (VRF) and loss/gain during export of
NAPHTHA

Background:

NAPHTHA: A colorless volatile petroleum distillate usually an intermediate product
between Gasoline and Benzene. This product generally used as a solvent fuel. Approx
more than 2 million MT Naphtha exported per month from Kandla TI.

Issue under Discussion:
Billing of Naphtha Export is done on Mts., hence density plays vital role in calculation of
quantity of Naptha in Mts. Higher the density, more the tonnage calculation and lighter
density less tonnage calculation.

Thus at 3 levels we must analyse our calculations:

Loss/gain

      Before loading ( Very vital as tanks are in filled condition)
      During loading (Reconcilliation)
      After loading ( Accounting)

Based on formula: 1.26 * Temperature Difference * Quantity

Earlier System:
Earlier while shipment loading only half an hour start of lading tanks is gauged, so
during full bright sun we used to get more temperature resulted into low VRF and less
tonnage. When we start gauging the tank in the morning, we started getting low
temperature which resulted into high VRF and more tonnage. This helps us to convert
our loss into gain before loading.

Problems Faced:
Losses beyond target


                                             275
Solutions suggested/implemented:
Earlier when Naphtha tanker was loading, we gauged all the tanks one by one just
before loading the tanker.

Now in the new system, endeavors are made to gauge tanks jointly by surveyor in early
hour. By gauging the tanks in the morning hour, the product temperature is less and
hence density will be more and hence more MT in tanks.




                                         276
                                          Case-let 7

                                 Experience Shared By

          Gladis Nirmala, Dy Mgr., Foreshore Terminal, Chennai

Issue under Discussion:
Leakage found in BPC White Oil-1 line during tanker discharge

Problem Faced
      MT Horizon Theoni was berthed at BD-1 , Chennai Port on 21.07.10 at 0100 Hrs. with
       OBQ tmt BS III MS. Discharge program was planned by BPC White Oil No. 1 line.
      Initial discharge commencement to BPCL, Tondiarpet @ 0525 Hrs and completed @
       0935 Hrs. Product received by BPC was 1967 KL against the pumped quantity of 1997
       KL , loss of 30 KL.
      Next discharge commenced to IOC, Tondiarpet @ 1010 Hrs. and completed @ 1535
       Hrs. Location received 2856 KL against the pumped quantity of 2952 KL, loss of 96 KL.
      In view of the abnormal difference noticed, the discharge was stopped @ 1530 Hrs. and
       IOC was in the process of gauging the shore tanks for correctness.
      In the meantime, the line patrol contract labor of FST who had left the jetty at 1630 Hrs.
       for line patrolling had arrived at the BPC junction point around 1715 Hrs. felt MS smell in
       the air and started inspecting the line thoroughly. Around 1840 Hrs., he had noticed a
       small pool of oil about 100 M long trench, covered with concrete slabs.
      The same was reported by him to CTM/FST @ 1845 Hrs. who had further investigated
       and confirmed suspicion of leakage from the pipeline in the trench portion.

As per BPC, the line was pressure tested to 10.5 kg/sq.cm. during April 10 and as per
the log, the pressure maintained was only 5.0 kg/sq.cm.

The condition of the pipeline was examined and found that the trench was covered by
accumulated mud over a period of time.

An ultrasonic thickness gauging test was taken up by BPC in and around the leaky
portion which established that the leak was due to a localized pitting and corrosion. The
inference is that the leak was due to local pitting caused by local corrosion and
weakening of pipeline in an area of 2.5 sq.cm. where the pipeline which was in touch
with the ground leading to a hole of 12 mm dia.




                                               277
Action Taken:

      AFFF foam on the oil pool, over the area where the PL enters the trench and where it
       leaves the trench.
      A gully sucker was meanwhile called from CPCL refinery and the oil/water/foam mixture
       was sucked.
      A fire tender from port was also kept at the site which was cordoned off for all traffic.
      The pipeline was flushed with water by pumping water from tanker and during water
       flushing, it was noticed that the pool was growing bigger due to oil/water flow from the
       trench, the foam layer was also expanding because of the flow confirming the suspicion
       of the leak.
      The next day, in order to visually examine the pipeline, gaps created at intervals in the
       trench by removing the concrete slabs.
      The pipeline was intensively checked for leakage and it was found that at one place, the
       line had developed a hole at the bottom side about 12mm dia and the same place was
       clamped.
      The line is under repair and maintenance.

The idle time incurred was 16 hrs. and the discharge completed by using the other BPC
line.

Recommendation by the Committee:
      Detailed inspection of pipeline to be carried out as per requirement.
      Hydro static pressure testing to be done as per requirement
      Long term preventive action after intensive inspection to be taken
      Feasibility of retaining product in MS pipeline instead of sea water to be taken up with
       Port Industry basis.
      Any abnormal variation during pipeline transfer or tanker discharge/loading, operation to
       be stopped till valid reason is known.
      Line patrolling is very vital and to be monitored thoroughly.

Idle time: 16 hrs.

Reason:
Poor maintenance of pipeline.




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