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: 10th 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.
|
No comments:
Post a Comment