The broken camera system that led to an incident in which three Tata Steel crane operators had to make a daring escape from a fire caused by spilt molten steel could have been fixed in two hours using readily available parts.
Tata was fined £200,000 and ordered to pay costs of £11,190 after it pleaded guilty to breaching of Section 2(1) of the Health and Safety at Work Act over the incident at its Port Talbort works.
Trainee crane operator Kevin Watts and two colleagues had to escape the fire, which started when a ladle of the liquid metal slipped from crane hooks, by climbing along the crane’s boom after flames leapt up to the cab.
The men were working on a continuous casting process, said Joanne Carter, the HSE inspector who investigated the incident. They were using a 500 tonne overhead crane, which was about 18 metres in the air, to transfer ladles of molten steel into casters.
The ladles were about 4.9 metres in diameter, 5.6 metres deep, and weighed 470 tonnes when full. The molten steel inside was 1600 degrees.
“The ladles were connected to the crane by two hooks. The crane operator could see one hook from the cab, but not the other, so Tata had installed a camera system to allow them to see it,” said Carter.
“The camera had pan, tilt and zoom functions, but these were not working. For several weeks at least, the camera couldn’t focus on the hook.”
Operators had devised their own methods for working out whether the second hook was attached, such as feeling for a “double bump” when the hook connected, but there was no formal procedure for working safely when the camera was out of order.
“There was a training document, but it was ambiguous and the majority of operators — including Watts and the two experienced workers with him — had not seen it,” said Carter.
On the day of the incident, Watts radioed the plant control room to confirm that the crane’s hooks were properly attached to the ladle.
The control room replied that one of the hooks was not fully attached. Watts stopped the crane and put it into reverse, but the ladle came loose, spilling its load to the floor. Moments later, the metal ignited.
“Had there been any water on the floor, there would have been an explosion,” said Carter. “As it was, the whole cab was engulfed in flames and the men thought the floor was about to collapse. The lighting in the area cut out, and they had to escape along the crane’s boom, which was four to five feet wide, in the dark, with nothing to stop them falling 60 feet,” said Carter.
The camera fault had been recorded on near miss forms and in the operators’ “pre-flight checks”, so managers should have been aware of the problem, she said.
After the incident, a closed-circuit television engineer fixed the camera within a week. He told Carter the work took only two hours and all the parts he needed were readily available.
Tata has since installed a new camera system at a cost of £128,000, improved the lighting in the area and made the escape routes clear. It has provided fire extinguishers, fire blankets and safety glasses in the crane cab. It has also introduced a system of using spotters to check that crane hooks are properly attached when camera systems break down.
“Tata is very good at responding to incidents,” said Carter. “But when you have got such high consequences, controls need to be watertight.”
