Near Miss Incident Report OCL

OCEANLANKA OL/H&S/7/DOC/001/0120
H&S INCIDANT AND ACCIDENT INVESTIGETION REPORT
Report Number NM12

Unacceptable ☐ Near Accident. ☐ Exposure Fire/ ☐ Unacceptable ☐ Safety ☐
Risk ☒miss ☐ Explosion Behavior violation
Release
01. Reported by
Name Thusiths Balasooriya. Employment No 9925
Designation Asst. Manager Health & Safety Report Date 03/05/2019
Signature
02. Report to
Name Dr. Austin Au Designation Managing Director
03. Person involved & incident location

Name(s) & Designation
Employee No(s)
Witnesses K Wasantharaj (10708) Designation M/O
Location/ Inside the printing building. Exit pathway near the loop steamer machine.
Section/
Department
04. Target of this report
Identifying the root cause and intolerable risks related to the act, operation, environment, machine or substance.
Take necessary remedial action to avoid recurrence of same incident. Take necessary disciplinary action against
violators. Raise the productivity of the business by Developing safety culture within the Organization. Protect the
workforce, company plants, buildings, equipment’s and business from the potential endanger.
05. Date of the Incident/Accident 24 04 2019 06. Time 03 45 pm
07. Details of Unacceptable Risk, Incident or Accident
On 24th April 2019 at about 3.45pm part of metal pipe line had
collapes on to the walking pathway in the printing factory. .
This part of pipe line had ejected from 15’feet height
deatached from compressed air line connected to the air
commpressure no 19 and air recever no.4. Fortunetly nobody
injurd from the incident due to nobody stayed in the area
during the incident.
Page 1 of 3
08. Injury/ Ill-health/Property damage/Lost time
No injury, ill-health, property damage cause by the incident
09. Further information
Following unsafe acts and conditions recovered from the investigation which were led to this dangerous occurrence
1. This compressed air line fabricated in 2016 by Dulaj Engineering (Sub-contract Company) and following
installation lapses found.
 Pipe line threaded connection was not inserted up to the expectable extent. Only five or fore thread
inserted.
 Both end of pipe and pipe accessory such as elbow and joining sockets came with original thread cut by
pipe manufacture and have to cut same type or standard thread on the pipe when connecting different
length. In this fabrication some thread cut by E&M workshop and original thread was not match with the
locally fabricated thread. Evidence for above finding can be illustrated from below picture. Thread pitch
filled with glue and no sign of outer sleeve thread Crest inserting in to the pipe thread Root.
Page 2 of 3
2. According to the information get from boiler section, relevant pipe line failed from first testing due to air
leaking from most of the threaded joints. Then contactor had corrected the failure and handover project to the
boiler section. As per the available facts nobody monitored or supervise the corrective method during the
period or after the correction. As a correction method contractor has applied glue all over the connecting
joint instead of dismantle and reassembling the system with acceptable correction.
3. Also found no system install for the controlling pneumatic hammering effect or pneumatic stress to the
compress airline. Kind of stress/hammering arrester system should be install to the compressed air line
specially protecting the threaded joints.
4. Informed to subcontract company to give explanation about construction work but has not been received any
positive feedback from them so far.
10. Root Couse
Lack of procedure, policy and standard for supervising, evaluating the subcontract job standard.
11. Corrective/Preventive action(s)
Corrective action –
 Dismantle the pipe system and all threaded joint converted in to welding joints.
 Take all the previous job details of the contractor from the accounts Dept to find other fabrication and
major repairs done by respective subcontract company.
12. Further controls / Recommendations Responsible Target Date Completed on

person
1. Create company standards for material selection, job Senior Manager
method and testing procedure for the subcontracted E&M
projects.
2. implement effective subcontract job evaluation system Senior Manager
before commissioning the project E&M
3. Implementing system for improve subcontract job Senior Manager
supervision. E&M
4. Implement policy for certification system on high risk Senior Manager
projects such as boiler, lifts/hoist, compressed air and E&M
building structures by third party certification body
(charted engineer or certification institution).
13. Copies
I Mr. Wen Qiyong IV Mr. Prabath Ramanayake
II Mr. Meng Ji Jie V H&S committee
III Mr. Roy Balasuriya
Page 3 of 3

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OCEANLANKA OL/H&S/7/DOC/001/0120

H&S INCIDANT AND ACCIDENT INVESTIGETION REPORT

Report Number NM12

03. Person involved & incident location

05. Date of the Incident/Accident 24 04 2019 06. Time 03 45 pm

07. Details of Unacceptable Risk, Incident or Accident

No injury, ill-health, property damage cause by the incident

09. Further information

10. Root Couse

11. Corrective/Preventive action(s)

12. Further controls / Recommendations Responsible Target Date Completed on

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