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A root cause failure analysis of coal dust explosion disaster – Gaps and lessons learnt
Journal Pre-proofs A Root Cause Failure Analysis of Coal Dust Explosion Disaster - Gaps and Lessons Learnt A.K. Dash, R.M. Bhattacharjee PII: DOI: Reference:
S1350-6307(18)31001-X https://doi.org/10.1016/j.engfailanal.2019.104229 EFA 104229
To appear in:
Engineering Failure Analysis
Received Date: Revised Date: Accepted Date:
11 August 2018 28 September 2019 1 October 2019
Please cite this article as: Dash, A.K., Bhattacharjee, R.M., A Root Cause Failure Analysis of Coal Dust Explosion Disaster - Gaps and Lessons Learnt, Engineering Failure Analysis (2019), doi: https://doi.org/10.1016/ j.engfailanal.2019.104229
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
© 2019 Published by Elsevier Ltd.
A Root Cause Failure Analysis of Coal Dust Explosion Disaster - Gaps and Lessons Learnt A. K. Dash1, R. M. Bhattacharjee2 1
Assistant Professor, 2Professor Department of Mining Engineering 1 National Institute of Technology, Raipur-492010, India 2 Indian Institute of Technology (Indian School of Mines), Dhanbad-826004, India
Highlights ¾ This research paper analysed a 2010 disaster due to explosion that occurred at an underground coal mine in India. ¾ Old mine fire, accumulation of inflammable gas, deposition of coal dust caused the explosion. 14 persons were killed and 5 persons were seriously injured. ¾ Thrust is given in this article for identification of root causes like organizational factors, task conditions, task environment etc. which resulted in to human error or unsafe act leading to failure of the defenses and thereby causing the accident / incident. ¾ Gaps in the existing accident investigation system of Indian mining industry were also highlighted. Abstract Workplace accidents are mostly the result of combined effect of unsafe acts and unsafe conditions which cause ultimate failure of existing defenses in the system. The unsafe act or unsafe conditions, task environment and task conditions are the product of some dormant, passive and latent causes generated from the organizational factors. But in accident prevention strategy at the workplace, the major thrust is often put on human behavior behind the unsafe acts. In this paper, an in-depth analysis of a mining disaster in India, as to “Why” and “How” the accident did happen has been carried out and the sequence of events was shown by Event Sequence Diagram. In this article, efforts have been made to identify the root causes of this accident using accident causation model like Accident Causation Tree (ACT) and Swiss Cheese Model and thereby improving the understanding of the mechanism of the accident. The most important aspect of accident analysis, i.e. the key lessons learned from this accident, has also been identified for the benefit of the industry. Keywords: Disasters; Explosion; Accident analysis; Root cause; Lessons learnt, Accident Causation Tree (ACT)
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S1350-6307(18)31001-X https://doi.org/10.1016/j.engfailanal.2019.104229 EFA 104229
To appear in:
Engineering Failure Analysis
Received Date: Revised Date: Accepted Date:
11 August 2018 28 September 2019 1 October 2019
Please cite this article as: Dash, A.K., Bhattacharjee, R.M., A Root Cause Failure Analysis of Coal Dust Explosion Disaster - Gaps and Lessons Learnt, Engineering Failure Analysis (2019), doi: https://doi.org/10.1016/ j.engfailanal.2019.104229
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
© 2019 Published by Elsevier Ltd.
A Root Cause Failure Analysis of Coal Dust Explosion Disaster - Gaps and Lessons Learnt A. K. Dash1, R. M. Bhattacharjee2 1
Assistant Professor, 2Professor Department of Mining Engineering 1 National Institute of Technology, Raipur-492010, India 2 Indian Institute of Technology (Indian School of Mines), Dhanbad-826004, India
Highlights ¾ This research paper analysed a 2010 disaster due to explosion that occurred at an underground coal mine in India. ¾ Old mine fire, accumulation of inflammable gas, deposition of coal dust caused the explosion. 14 persons were killed and 5 persons were seriously injured. ¾ Thrust is given in this article for identification of root causes like organizational factors, task conditions, task environment etc. which resulted in to human error or unsafe act leading to failure of the defenses and thereby causing the accident / incident. ¾ Gaps in the existing accident investigation system of Indian mining industry were also highlighted. Abstract Workplace accidents are mostly the result of combined effect of unsafe acts and unsafe conditions which cause ultimate failure of existing defenses in the system. The unsafe act or unsafe conditions, task environment and task conditions are the product of some dormant, passive and latent causes generated from the organizational factors. But in accident prevention strategy at the workplace, the major thrust is often put on human behavior behind the unsafe acts. In this paper, an in-depth analysis of a mining disaster in India, as to “Why” and “How” the accident did happen has been carried out and the sequence of events was shown by Event Sequence Diagram. In this article, efforts have been made to identify the root causes of this accident using accident causation model like Accident Causation Tree (ACT) and Swiss Cheese Model and thereby improving the understanding of the mechanism of the accident. The most important aspect of accident analysis, i.e. the key lessons learned from this accident, has also been identified for the benefit of the industry. Keywords: Disasters; Explosion; Accident analysis; Root cause; Lessons learnt, Accident Causation Tree (ACT)
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