An Epitaph to My Valiant Colleagues Who Laid Their Lives While Struggling to Make Steel in Bhilai!

It was just a day before. And the time was already 11 PM and sleep had just begun to take away my consciousness temporarily for the rest of the night as usual. But I was compelled to get back to awareness by the cell phone ring. 

It was a colleague living a couple of blocks away on the other side. With an obvious voice of high anxiety he asked whether I saw the 'breaking news' clip that was getting flashed on the national channels at that moment.

I knew the biggest breaking news at that time was naturally the World Cup 2014  Football inauguration on the other end of the globe in Brazil. And I am no blind fan of any game or any entertainment. So that breaking news was no news for me.

'It is about your plant at Bhilai'. My colleague interrupted my thoughts. 'Something serious has just happened there. Several casualties! The news is not clear, but find out through your sources!' He told.

I got it. Something serious have happened at the steel plant at Bhilai- the plant where I had been working for most of the time right from the beginning of my career. And at the fag end of my career, I was moved out and that plant has not been in my day to day routines for the past over three years. Yet my job required me to be associated with some technical and engineering problems of that plant occasionally at least. Some engineer colleagues were required to be in touch with me mostly for official purposes.

I tried scanning the TV news channels for some more information. It was of no use as the news flash has now reduced to occasional text flash which added no further information. And most of the national TV news channels at that time of the night would simply be killing the time by various techniques only for becoming 24 x 7!

So, I thought of calling some body in Bhilai Steel Plant who could give me the first hand information. The first name that flashed on my mobile screen was of Mr B K Singh, the Dy General Manager of Water Management Department of the plant. His name appeared on my call logs as he was one among the few who talked to me in the time that immediately preceded. At that time I could have never imagined that this junior colleague of mine was no more to answer my call as he had already left to his heavenly abode in the accident that had just happened about 3-4 hours ago! 

I do not know the reason, why I did not call him. Instead I called another friend. From him I got a vague idea of what could have happened. And that information pointed out to the possibility of people whom I know for years who are working in the Water Management Department involved in the accident. My friend who talked to me had pretty no idea of what caused the accident!

The information was that already six or seven are dead and several are in the Intensive Care Unit of the large 1000 bedded hospital and research center owned and managed by the PSU steel plant. I was also shocked to hear about the possibility of Mr Singh too affected seriously. My friend also informed me of the  rumour that he was one among the dead! And the casualties are all due to gas poisoning! There was no explosion as was flashed in the national news channels!

Strange! How come the people of the water management got affected by gas poisoning? 

Integrated steel plants are huge industrial mammoths that process millions of tonnes of minerals, water and air to convert them to millions of tonnes of finished products. In that process, these plants generate job opportunities to thousands of people directly and indirectly. They are the economic prime mover engines that keep working non stop to fill the coffers of the national exchequer even while their own balance sheets are not so comfortable!

But integrated steel plants are also a kind of battlefields for the thousands of employees who work there day in and day out. They are in reality a net work of scores of factories networked locally by innumerable connection lines such as roads, railways, gas pipelines, conveyor galleries, water pipelines, compressed air lines, oxygen lines, fuel lines, power lines, etc, etc. Any short or long oversight could possibly turn out to cause a safety risk to people.

Due to their complex structure and layouts, it is very difficult for people to gain a full knowledge of all the systems. Even engineers who have worked their whole life time in the steel plant may not be conversant fully with all aspects!

Design and installation of integrated steel plants are a complex process involving several national and international agencies. Operation and maintenance management of an integrated steel plant is also not an easy task, because of this complexity. Major accidents do take place in steel plants mostly in long intervals of time and those accidents are all the out come of several factors. Cumulative human oversight being the most prominent!

I had the opportunity to be a member of some inquiry committees on major accidents in this steel plant in the past. Being worked as an in-house consulting engineer for this steel plant for several years, I have had the opportunity to understand the techno-human dynamics of integrated steel plants that affected it both positively and negatively. 

An engineer's natural curiosity gripped me and I wanted to know how these water engineers became victims of gas. More than a decade ago, I used to be a kind of technical adviser on the water management systems of this same plant. My area of work now involves engineering management of all utilities including water, gas, etc for the integrated steel plants. The curiosity was therefore purely professional coupled with the pain of knowing the sad fates of some of the known faces!

The present head of the department of water management at Bhilai is my long time friend. I called him to know more. He took up the phone. He was more worried than me as he was not in Bhilai. He had been on a long leave and was answering me from a south Indian city. He too had heard about the accident just as me and was trying to find out what actually happened. In his absence, Mr Singh was acting as the head of the department who by now was no more living to tell about what happened. To add to the confusion, I learnt that the General Manager concerned (a known colleague of mine who was to retire in this same month) and two other well known DGMs are affected and are fighting for their lives in the ICU. Perhaps one another among them was also no more including another officer of the fire department. 

Later in the night, I had pretty no sleep or had a disturbed sleep. The faces of my Bhilai colleagues who met with the accident kept flashing in my mind.

Yesterday, the news media came up with more news about this industrial tragedy in Bhilai.

The president of India condoled the loss of lives in Bhilai. A magisterial probe is already ordered as per the news reports. There are opinions from occupational health experts. Foreign media too covered the tragic incident. Media also reported Congress VP's demand for a high level probe.

I have talked to a few of my engineer colleagues who are in Bhilai. With my own understanding of the system and the other information in bits and pieces, I could make out the picture of what could have really happened to cause such a serious and painful industrial disaster. It was an unprecedented case of what is known as the 'siphon effect' causing poisonous carbon monoxide rich Blast Furnace gases from the Gas Cleaning Plants (GCP) getting drawn through the suddenly emptied water supply pipes which supply water to the GCPs for cleaning the gases from dust. The sudden emptying of the supply pipe could have happened due to a sudden rupture of the old pipes some where at the lower most positions! And the lower most position of the pipe is the pump house floor where there is possibility of people present doing some work. At least that was what I could reason out. But the difficulty is that such things are almost difficult to foresee and rectify till such accidents happen! It is impossible for any one to foretell when an old pipe would rupture! Therefore, the best practice normally done elsewhere is the replacement of such pipes and connected equipment after they exceed their useful age. Unfortunately, there are no standards in India which stipulate the useful age of pipes and equipment of Industry, beyond which it is mandatory to replace them.

All metallic structures are subject to failure after some time due to various mechanisms such as creep, corrosion, inter-crystalline changes, etc. Metal pipes and vessels may look outwardly and physically in reasonably good shape even after years of service. However, their inherent strength to withstand load and pressure might have changed much over time. Thus a new pipe and an old serviced pipe having the same physical features may not give the same performance; the latter might fail unexpectedly. However, such failures happen only once in a blue moon!

Had there been some attention to one or two simple things perhaps this accident would not have happened. It could have been avoided had the system be designed with proper water seals, air release valves, etc which could have prevented total emptying of the water from the pipeline causing a through passage for the gases. 

But all accidents cause due to cumulative errors and omissions of many individuals over a period of time. It is the short term and long term actions, attitudes and reactions of the people at all levels that are more important and responsible to effect well thought actions that keep the complex equipment and machinery work safely.

Some may think it is the integration of the equipment and machinery that cause the problems. That may be true to some extent. But integration of peoples' thoughts could always win over the complex human made systems effectively. If that does not happen for any reasons, the man made machines and equipment might inflict painful accidents like this now and then. 

B.K Singh, N.K Kataria, R K Sharma, Samuel, Sahu and Verma are no more. I feel sad for them and their bereaved families. They have lost their lives battling for the nation in a different battlefield! May their souls rest in peace! May the souls of all those who met with such fates in the past in the same field also rest in peace!

I do pray for the speedy recovery of the others who are undergoing medical treatment.

Yet, this question keep ringing in my head. Could this have been avoided?

Perhaps, yes! Only thing that was needed was an honest determination for 'safety first' that does not lose its priorities midway or every now and then!

Even when profits, money and returns are all important aspects of industrial production!

Are we failing to learn certain important lessons in technical and professional leadership?

It is time to introspect honestly!

Er Rajan C Mathew FIE
Ranchi , Sat 14th June 2014
11:30 AM IST