Analysis of a personal safety accident!
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Analysis of the hydrogen sulfide poisoning incident on May 12 (all names are pseudonyms) I. Incident timeline: On May 12, 2008, in the precision desulfurization unit of a chemical manufacturing company in Hebei, the passivation process for medium-temperature iron oxide A was completed. After taking over the shift, the operators needed to remove the ceramic balls from tank A. At 8:30 a.m., they prepared the necessary tools and requested maintenance personnel to open the manhole. Team leaders Feng Hongseng and Wang Feng climbed to the top of tank A to open the manhole and facilitate natural ventilation. At around 9 o’clock, a request was made to conduct a test to measure the oxygen level in Tank A. Su Jiajia, the supervisor in charge of the testing, rushed to the site immediately. Since Tank A was quite tall, and it would be difficult for a woman to climb into it, Yu Zhanlei (real name*) went in to take samples. While sampling was in progress, Zhan Lei suddenly fainted. Squad leader Feng Hongsheng immediately called for help, ordering the people below to contact the dispatch center to call emergency services 120, and to report the situation to the workshop supervisors as soon as possible. Due to the urgent situation at the time, the personnel on Platform A immediately performed artificial respiration and chest compressions on Zhan Lei, and thanks to prompt first aid, Zhan Lei gradually regained consciousness. During this period, on-site operator An Ziliang felt unwell after performing artificial respiration on Zhan Lei and collapsed on the spot after leaving the area. Those around him immediately moved him to a well-ventilated and open area. Afterward, when the 120 emergency ambulance arrived, Yuan Zhanlei and An Ziliang were taken to 105 Hospital. II. Accident analysis: 1. Insufficient attention was paid to problem analysis in advance, and the work was not done thoroughly ； 2. On-site operators fail to provide sufficient reminders regarding the working conditions for sample collectors, and supervision is inadequate ； 3. The preparation work for removing the tank was inadequate; a blind plate should have been installed in advance ； 4. Trainees without work experience should not be sent to the tank to take samples. III. Preventive measures: 1. Enhance safety awareness and strengthen on-site safety management. 2. When taking samples for laboratory analysis, it is necessary to take precautions first ； 3. Purchase advanced electronic equipment to reduce the chances of workers being exposed to hazards ； 4. Train employees in life-saving methods as soon as possible ； 5. Strengthen employee safety training and safety education. IV. Handling suggestions: 1. Yu Zhanlei and An Ziliang, who are responsible for the accident, violated regulations during their work; each of them shall be fined 50 yuan. 2. The director of XXX failed to provide proper management; a fine of 200 yuan is imposed. The deputy director of XXX did not pay enough attention; a fine of 100 yuan will be imposed. Chief Engineer XXX failed to provide proper supervision; a fine of 100 yuan is imposed. This post was last edited by hw197358 on 2009-2-22 21:06.]
Safety work must be carried out meticulously, as the damage to people is irreparable.
It’s a great example of on-site personnel handling emergencies in a reasonable manner.
The moderator has a thorough understanding of the accident and provides a comprehensive analysis, as if they were there in person; I really admire that. Let’s keep communicating more in the future!
The original poster’s analysis is really good! There are no trivial matters in chemical production! We need to be vigilant at all times!
What a close call! Luckily, it was handled properly; otherwise, the consequences could have been disastrous.
It’s a great fortune that no one was hurt. “II. Accident Analysis III. Preventive Measures” – these two points are very thorough. But “2. The XXX director failed to provide proper management; a fine of 200 yuan is imposed.” The deputy director of XXX did not pay enough attention; a fine of 100 yuan will be imposed. Chief Engineer XXX failed to provide proper supervision; a fine of 100 yuan is imposed. ” Such punishment is far from sufficient to leave a lasting impression or serve as a lesson.
Severe punishment is not the goal, but it can indeed make an impression.
The insufficient analysis of potential risk factors in the early stage – analyzing only the oxygen content without examining hydrogen sulfide levels – was likely the main cause of the accident
I think the root cause of the accident is the employees’ poor safety awareness! It can be said that there is virtually none; a production supervisor should have extensive experience in production and work! He doesn’t even have a basic sense of safety; I think this company’s safety training is seriously inadequate!
Fortunately, no serious injuries or deaths occurred in this accident; the location of the incident was favorable, as it wasn’t inside a confined space. The analysis conducted after the accident and the preventive measures taken were adequate, and the employees at the company where the incident took place had good capabilities for emergency response (which is likely due to regular training). The penalties imposed were acceptable. What I want to say is that punishment is not the goal – the aim is to ensure that employees always remember the importance, necessity, and urgency of safety； Create an environment where everyone talks about safety and acts for safety ； Maintaining a culture where safety is always on mind and everywhere is essential, which requires safety managers to strengthen regular education on safety for employees.
1. Insufficient attention was paid to problem analysis in advance. 2. On-site operators fail to provide sufficient reminders regarding the working conditions for sample collectors, and supervision is inadequate ； 3. The preparation work for removing the tank was inadequate; this tank should be purged or a blind flange should be installed ； I have also been witness to several cases of hydrogen sulfide poisoning that resulted in deaths, and I would like to share them with you if I get the chance.
The analysis is comprehensive and the penalties are reasonable. Thank you. It will be published in the Accident Analysis section of Issue 4 of the Petroleum Safety e-journal (released on April 5th)
The analysis is thorough and comprehensive; I’ve learned from it.
Has a work plan been prepared in advance? Did the participants attend the meeting to learn? Have you gotten the permit? It seems that the person in charge on site was the team leader, and there was no safety supervisor. The main responsibility for the accident lies with the poor management by the supervisors; such a dangerous task was carried out without any supervisors or safety officers present, nor were there any safety measures such as gas masks. Our company also has methanol, from which we can learn lessons. This post was last edited by ldh525386 on 2009-2-26 14:24.]
For sampling analysis, appropriate gas protection equipment such as gas masks and long-circuit breathing masks can be used, depending on the conditions of the on-site work.
Personal opinion: 1. Inadequate preparation of the drainage channels: Before opening the manhole, it is necessary to take samples to analyze the hydrogen sulfide concentration; only after it drops to a certain level (for example, 30PPM, which does not cause poisoning in humans) can the manhole be opened for ventilation； Sufficient ventilation time must be ensured; in this case, it is only 30 minutes. Factors such as the size of the container, ventilation openings, and the contents inside need to be taken into account ； Before sampling, such containers containing toxic substances should be treated as hazardous, and protective equipment must be worn. 2. Yu Zhanlei and An Ziliang carried out operations in violation of regulations; it is not specified which rules were violated – was it that actual workers are not allowed to take samples? So, real employees can never be made permanent, and An Ziliang can’t provide on-site rescue? In my opinion, the handling of the accident was not thorough enough; the people on site were not aware of the risk of poisoning, and laboratory technicians certainly had no such awareness. An Ziliang’s attempts to provide first aid on site were due to inadequate training and the use of incorrect methods – for those suffering from hydrogen sulfide poisoning, artificial respiration should be avoided as much as possible, and chest compressions should be used instead. 3. Agree with the view from the 16th floor; the main issue is a lack of emphasis, as no hazard identification was carried out.
First, the on-site operators do not have multiple gas detection instruments. Second, there are no mandatory ventilation measures, and no work confirmation forms. Third, there was a lack of awareness regarding the use of blind flanges, and experience was insufficient; fortunately, no serious incident occurred, otherwise it would have been another liability accident. Fourth, there is no mention of on-site safety supervision; where are the safety officers?
Personal opinion: Hydrogen sulfide is a toxic gas as well as a flammable and explosive one. Inadequate preparations were made in case of leaks, the company’s management did not pay enough attention to this issue, and employees lacked sufficient safety awareness, which indicates that the company does not provide adequate training and education in terms of safety； Moreover, during this accident, the ventilation period was only 30 minutes, which from another perspective reflects the aforementioned issue ； Why were the necessary personal protective equipment not worn during sampling? Is the company not equipped with it, or are the employees not wearing it as required? During first aid, artificial respiration is performed; however, when exposed to toxic gases such as hydrogen sulfide, mouth-to-mouth respiration cannot be used – only exhalation toward the victim is possible, not inhalation. If the degree of poisoning is not severe, chest compressions can also be carried out. In this incident, the team leader was quite successful in handling it, effectively preventing the incident from escalating! Among the preventive measures, efforts should start with safety training and safety management!
The issue of personal safety protection for sampling personnel has not received adequate attention in a considerable number of enterprises; this accident is quite typical.