sharing the experance

INCIDENT: - Cat -3, HMV incident near Mumbai

TYPE OF INCIDENT:  Roll over

BUSINESS UNIT:  Global Lubricants Supply Chain India

LOCATION OF INCIDENT:  66 KMS from SW of Murtajapur, Maharashtra State (about 550 KM from Mumbai)

DATE OF INCIDENT: 10^th May, 2010

Incident time- 20.45 hours

BRIEF ACCOUNT OF INCIDENT:

A 16 tonner contractor truck (under influence only), carrying finished lubricants packed goods from our Mumbai Central warehouse to our Kolkata warehouse rolled over to its side near Murtajapur ( about 550 Kms from Mumbai)

The incident occurred on a National Highway (NH -6) single carriage dual lane with no shoulders or dividers, when a state transport bus while overtaking came on the way of contractor truck and pushed him to his side resulting in a roll over of contractor vehicle.

State transport bus came on the way of contractor truck as he was obstructed by a trailer which was coming from the opposite side with single head light on (cock eyed).  The oncoming vehicle had its left side (driver Assistant) single light was on.

No injuries to the contractor driver or to the assistant.  .

Both the bus & the trailer had pursued their journey without halting.

The contractor vehicle front tyre (driver assistant side) was busted post the roll over.

The speed of the vehicle captured in GPS was 43 KM/Hr at the time of incident.

Driver:

Driver Name- Addya Yadav (Module -4 trained (14/07/2008))

Age - 38 years.

From the records, it was observed that this driver had driven in our operations at least two dozen times since 2009 and quite familiar to this route with a fair record of safe driving principles.

Driver had reached our depot on 8th of May and had to wait for his load.

On 9th May – driven for 9 hours 36 minutes and covered a distance of 340 kms. He stopped his travel at 20.45 hours

On 10th May – driven for 8 hrs 10 minutes (before the incident) and travelled about 220 kms.  He begun his journey at 7.45 am

He propose to stop in another  20 kms of distance which would have taken 30 to 45 minutes.

Driver had reached Mumbai from Kolkata on 3rd of May since then has been in Mumbai and had done one local movement for Castrol.

Post the incident - eye test was done to the driver and report was shared. He had perfect vision (6/6).

The incident was communicated by the driver to their operational in charge around 22.30 hrs from the nearest local public telephone service.

Key Observations

Width of the road is 7.6 mtrs (24.92 feet). The width of the contractor truck is 3.4 metres (11.15 feet), while the bus which was overtaking the truck is also of same width. The length of contractor truck is 24 feet while the bus which was trying to over take the truck is about 28 feet ( a similar bus measurement was taken).

The oncoming vehicle (trailer) was 30 feet with a width of 3.4 feet (based on the input given by the driver, measurement of similar vehicle was considered).

The distance between the trailer truck & the bus was about 500 metres when the bus came on the way of contractor truck to pave way for the oncoming vehicle.

Contractor driver was driving on his side of the road (extreme left), while the private bus which had to overtake him had to go to the other side (oncoming vehicle side) to overtake the contractor vehicle.

A late reaction from both the vehicle (contractor driver and bus driver) on  recognizing the risk of the oncoming vehicle led to the compulsive action by the bus driver , pushing the contractor to go further left on the soft shoulder and rolled over to its side of about 1.5 feet depth.

As per our journey risk assessment, the said location was a green zone and the speed of the contractor driver was  well below the recommended speed limit. The weather conditions were very hot and dry.

No brake marks observed on the accident spot. From the GPS report, it was observed that there was an attempt made by the contractor driver to reduce the speed.

The contractor vehicle was under the maintenance of OE manufacturer. The tyre burst was shared by the tyre manufacturer post the vehicle rolled over.

WHAT WENT WELL

• Seat Belts were worn by the driver & his assistant
• Transport contractor ‘s active participation in providing assistance and collating the details

WHAT WENT WRONG (CRITICAL FACTORS) :

• CF1 – malfunctioning of head lights (just one light was functioning) of the oncoming vehicle
• CF2-   the bus overtaking the contractor vehicle and coming on the way of the contractor truck

SUMMARY OF IMMEDIATE CAUSES:

CLC Ref No.	Description	Comment
2.3	Use of equipment  of vehicle with known defect	The oncoming trailer vehicle head lights were not functioning. It had just one light (on the driver assistant side) was on, which had mislead both the private bus and contractor vehicle driver were mislead.

System Causes (Organisational factors that allowed the immediate cause to exist)

CLC Ref No.	Description	Comment
11.7	Incorrect judgement	The oncoming  vehicle with single light on had mislead the contractor driver to a two wheeler,  hence did not try to adopt any evasive actions
14.2	Practice of skill not effective	Driver is adequately trained and have been operating for Castrol for considerable period, yet have not perceived the risk and reduced his speed
16.7	Lessons learned not embedded	Driver was aware of similar incidents that had taken on Castrol operations  and   yet failed to  adopt  the learnings.