調(diào)查報(bào)告| 4·18 較大中毒和窒息事故
Source: Yongkang Zhongyi Manufacture & Trade Co., Ltd.Publication time：2023-10-18
Investigation report on major poisoning and suffocation accidents on April 18th
Recently, the People's Government of Qianxinan Prefecture in Guizhou Province released the "Investigation Report on the" 4.18 "Major Poisoning and Suffocation Accident of Qianxinan Pu'an Jianxin Resource Development Co., Ltd.".
At around 18:45 on April 18, 2023, a major poisoning and suffocation accident occurred at Jianxin Resource Development Co., Ltd. located in Pu'an County, Qianxinan Prefecture, Guizhou Province, resulting in 4 deaths and 4 injuries, resulting in a direct economic loss of 9.4986 million yuan.
The report points out that after investigation, it has been determined that the "4.18" major poisoning and suffocation accident of Qianxinan Pu'an Jianxin Resource Development Co., Ltd. is a major production safety responsibility accident caused by the failure to implement the main responsibility of safety production, illegal operations, and blind rescue.
Accident process
——April 18, 2023
Jianxin Company decided to take shutdown insulation maintenance measures on April 18, 2023 at around 12:00 am due to the detachment of the lower part of the alkali overflow pipe of the No. 3 alkali spray tower in the No. 4 desulfurization tank of the old tower in the desulfurization workshop about a month before the accident (the diameter of the detached alkali overflow pipe was 63cm, the length was 4.74m, and the weight was 129.39kg). The desulfurization workshop also arranged for the desulfurization workshop staff to pump water from the No. 4 desulfurization tank of the old tower for maintenance.
Section A-A of No.4 Desulfurization Tank
——Around 18:36 on April 18th
Hao Moufei, the director of the desulfurization workshop of Jianxin Company, organized workshop personnel Li, Zhang Moukun, Lu Mouhua, and Li Mouguang to carry out pre maintenance preparations for the No. 4 desulfurization tank of the old tower. At around 18:40, the fixation of the expansion staircase was completed.
Section B-B of No.4 Desulfurization Tank
——Around 18:45
Li and Lu were responsible for lighting. Hao, wearing protective clothing, went down to the bottom of the desulfurization tank and tied the pipe that had fallen off from the bottom of the alkali overflow pipe with a rope. During the tying process, Hao suddenly fainted and fell into the desulfurization tank. Zhang, Li, Li, and Lu were all shouting and unresponsive. Zhang, Li, Lu, and Lu successively went down to the desulfurization tank to lift Hao from the liquid in the desulfurization tank, Zhang Moukun, unable to withstand the stimulation of toxic gases in the pool, asked Lu Mouhua to help Hao Moufei. He then climbed up the stairs and fainted on the stairs. Both Lu Mouhua and Hao Moufei fainted in the desulfurization pool. While Lu Mouhua and Zhang Moukun went down to the desulfurization pool to rescue Hao Moufei, Li Mouguang went to the control room without wearing a mask and searched for a mask. Li was guarding above the desulfurization pool, After returning to the scene of the accident, Li Mouguang found that Li had fainted on the surface of the desulfurization tank. Later, Li Mouguang dragged Li under the fan and asked Tang Mouqin to contact the factory manager to arrange rescue in the control room. Later, he fainted in the control room.
Diagram of falling alkali liquid overflow pipe
——19:02
Tang Mouqin reported to Zhang Moucheng and Zhang Mouhua through the "Desulfurization Work Group": "A person fainted in the desulfurization tank and was sent to the desulfurization tower to rescue someone. After hearing the news, factory director Zhang Moucheng first went to the control room to inquire about the situation with Tang Mouqin. He saw Zhan Moufan running towards the desulfurization pool, and then Zhang Moucheng and Zhan Mousong rushed to see Li under the fan, so they first rescued Li. Zhang Moucheng felt unwell and did not go to rescue again. Zhan Mousong continued to rescue people in the No. 4 desulfurization tank alone. Zhang and Guo Mouhua arrived and used ropes to pull the people in the tank with Zhan Mousong. During the pulling process, Zhan Mousong fell into the tank. Zhang Mouhua felt unwell and rested on the platform for about 10 minutes before seeing Zhang, Guo, and others outside the No. 4 desulfurization tank, Arrange on-site personnel to open a hole on the wall of No. 4 desulfurization tank to rescue people. Zheng received a phone call from Zhang Mouhua stating that there was an accident in the factory. Zheng and Wang Mouzhi drove to the factory.
——Around 20:00
Zheng first went to the No. 4 desulfurization tank and entered the tank through a ladder from the platform to rescue people (at this time, the enterprise rescue personnel had already started drilling holes on the wall of the No. 4 desulfurization tank). Wang Mouzhi went to the warehouse to get a mask, and Dai Mouping entered the desulfurization tank through the hole made on the wall of the desulfurization tank. He tied Zhang Moukun with a rope and rescued Zhang Moukun from the opening.
Schematic diagram of the location relationship of casualties
——Around 21:45
The relevant rescue department rushed to the scene to continue the rescue, but Hao Moufei, Lu Mouhua, Zhan Moufan, and Zhan Mousong were rescued by the rescue department and were sent to medical treatment but died of ineffective treatment.
Direct cause of the accident
The operators did not follow the "ventilation, detection, and operation" procedure for confined space operations, and entered the confined space to work in violation of regulations. They inhaled toxic gases and became intoxicated and unconscious. After discovering that the operator was intoxicated and unconscious, the rescue personnel blindly rescued without wearing effective personal protective equipment that met the regulations, resulting in inhalation of toxic gas poisoning.
Indirect causes of accidents
1. Enterprise level (Jianxin Company)
① The safety management measures for limited space operations are not implemented.
② Lack of implementation of enterprise safety management.
③ Failure to implement safety education and training.
2. At the level of government and regulatory authorities
① The Industrial and Scientific Technology Bureau of Pu'an County did not perform its duties properly.
② The Pu'an Branch of Qianxinan Prefecture Ecological Environment Bureau did not perform its duties properly.
③ The Pu'an County Emergency Management Bureau (Pu'an County Safety Committee Office) did not perform its duties properly.
④ There is a gap between the Party Committee and the People's Government of Xingzhong Town in Pu'an County in implementing safety production work.
⑤ There is a gap in the implementation of safety production work between the Pu'an County Party Committee and the County People's Government.
⑥ There is a gap in the performance of the Ecological Environment Bureau in Qianxinan Prefecture.
Persons held criminally responsible
① Hao Moufei is the person in charge of the desulfurization workshop of Jianxin Company, responsible for the work of the desulfurization workshop. Directly responsible for the occurrence of the accident, and exempt from criminal responsibility due to his death in this accident.
② Zheng Mouyin, a member of the Communist Party of China and the largest shareholder of Jianxin Company, holds 55% of the company's shares and is the actual controller, exercising the power of the company's chairman. Directly responsible for the occurrence of the accident, in accordance with Article 96 of the Safety Production Law of the People's Republic of China, it is recommended to transfer the case to judicial authorities for criminal responsibility.
③ Zhang Mouhua, a member of the Communist Party of China and the legal representative of Jianxin Company, holds 40% of the company's shares and exercises the authority of the company's general manager. He is mainly responsible for sales, safety and environmental protection, logistics, and external communication work. Taking direct responsibility for the occurrence of accidents, in accordance with Article 94 (2) and Article 95 (2) of the Safety Production Law of the People's Republic of China, it is recommended to impose a fine of 60% of the annual income of the previous year and transfer it to judicial authorities for criminal responsibility.
④ Zhang Moucheng, a member of the Communist Party of China, is the production manager of Jianxin Company, responsible for the company's production work. Directly responsible for the occurrence of the accident, in accordance with Article 96 of the Safety Production Law of the People's Republic of China, it is recommended to transfer the case to judicial authorities for criminal responsibility.
⑤ Zhang, the masses, is the head of the safety and environmental protection department and administrative department of Jianxin Company, responsible for the company's safety and environmental protection work. Directly responsible for the occurrence of the accident, in accordance with Article 96 of the Safety Production Law of the People's Republic of China, it is recommended to transfer the case to judicial authorities for criminal responsibility.
The "Three Word Code" for Safety in Confined Space Operations
