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Report on the “June 1” general asphyxiation accident at Liaoning Chongyu Chemical Products Production Co., Ltd. China Chemical Industry Safety Association Published in Beijing on August 22, 2022, at 18:27. At 14:10 on June 1, 2022, a production safety accident occurred at Liaoning Chongyu Chemical Products Production Co., Ltd. Liu XX, a worker in the dinaphthalene section of Workshop 2 at the company, and Zhang XX, the shift supervisor, successively entered the dilution kettle (R2103B) to retrieve a foam pad and rescue someone. During this process, they suffered from asphyxiation. As a result, one person died and another was injured; the direct economic loss amounted to approximately 2 million yuan. In accordance with the principles of \"not letting go until the root causes are identified\" and \"being scientific and rigorous, acting in accordance with laws and regulations, seeking truth from facts, and focusing on practical results\", the accident investigation team conducted on-site inspections, gathered evidence, performed tests and evaluations, reviewed relevant documents, and sought expert opinions. Through these efforts, it determined the causes and course of the accident as well as the direct economic losses incurred. It also identified the nature of the accident and the responsibilities involved, and put forward recommendations for dealing with the responsible individuals and units, along with measures to prevent similar accidents in the future. According to the findings of the accident investigation team, the \"6·1\" general asphyxiation accident at Liaoning Chongyu Chemical Products Production Co., Ltd. was an accident resulting from failure to fulfill production safety responsibilities. The relevant details are reported as follows: accident overview, emergency response, and direct economic losses. PART.01 (I) Accident overview, emergency response, and reporting status: At 17:00 on May 30, 2022, the dinaphthyl production section in Workshop 2 of Chongyu Chemical stopped operations due to an excessive inventory of the intermediate product XXXX in the storage area. On June 1, it was decided temporarily to repair the mechanical seal of reactor R2103B. At 7:18 on June 1, Wu Dongxing, the director of the dinaphthene production section, assigned Xu XX, Huang XX, Zhang XX, Liu XX, and Chen XX to carry out preliminary work on the dilution tank. According to the surveillance footage from the scene, Chen XX and four others added water to the dilution tank at around 7:40, while using steam for steaming and displacement. At 8:42, after the replacement was completed, Liu XX, an operator at the dinaphthene production section, entered the tank without wearing any safety gear and placed foam pads inside the tank (these pads served as a barrier for the stirrer, preventing it from hitting the enamel lining of the tank while maintenance workers were performing repairs outside the tank, which could have caused damage). At 8:50, Liu XX came out of the furnace. At 8:51, Zhang XX closed the manhole cover on the tank (to prevent debris from falling inside), while maintenance workers Qin XX, Bai X, and Cao XX began repairing the mechanical seal outside the tank. At 10:38, the maintenance workers stopped their work and went to the cafeteria for lunch. At 12:32, they returned to the site to continue with the repairs, and the work was completed at 13:55. Team leader Zhang XX instructed Liu XX to remove the foam padding from the dilution tank. During maintenance, the manhole cover on the kettle remains closed at all times. At 13:56, after arriving at the scene, Liu XX opened the manhole cover. At 14:08, after confirming by observation at the kettle mouth, Zhang XX instructed Liu XX to enter the dilution kettle (R2103B) to retrieve the foam pad that had been placed there prior to maintenance. Liu XX entered the dilution tank to work again without wearing protective equipment. Zhang XX stepped on the rope ladder outside the pot to prevent it from slipping. At 14:10, Squad Leader Zhang XX noticed that Liu XX had fallen into the kettle. Without taking any safety precautions, he also entered the kettle to rescue him. At 14:10:58, Xu XX and Huang XX, who were outside the tank, noticed that Zhang XX was also lying inside the tank. Immediately report to Section Chief Wu XX; subsequently, Workshop Director Wu XX and relevant company leaders arrived at the scene one after another to arrange for emergency rescue personnel to carry out the rescue efforts. Zhang XX and Liu XX were rescued from the furnace at 14:32 and 14:36 respectively. At the same time, vehicles were arranged to be sent to Huludao Second People’s Hospital for emergency treatment. Operator Liu XX died despite resuscitation efforts; Zhang XX was injured. After the accident, Ni XX, General Manager of Chongyu Chemical, immediately reported the details of the incident to the deputy director in charge at the Huludao Municipal Emergency Management Bureau. Subsequently, he also reported the incident to the Emergency Management Bureau of the Huludao Economic Development Zone. (II) Casualties and economic losses: Based on the \"Statistical Standards for Economic Losses from Accidents Involving Enterprise Employees\" (GB6721-1986), this accident resulted in 1 death and 1 injury, with direct economic losses amounting to approximately 2 million yuan. Cause and Nature of the Incident PART.02 (I) Immediate Cause: No effective measures such as isolation were taken for the pipelines connected to the dilution tank (R2103B); a leak occurred due to the improper sealing of the nitrogen valve, which resulted in a decrease in oxygen levels. Team leader Zhang XX arranged for Liu XX to enter the tank to retrieve foam pads without obtaining approval for work in a confined space and without conducting any gas testing or analysis inside the tank. Liu XX and Zhang XX entered the furnace one after another to carry out work and rescue people without wearing any protective equipment, resulting in 1 death and 1 injury due to oxygen deficiency and asphyxiation. (II) Indirect causes: 1. Inadequate implementation of Chongyu Chemical’s special operation management system. The company has established a management system for work in confined spaces, but it fails to enforce and implement strict controls on the management of special operations. Employees lack awareness of safety in production. Before the accident occurred, the workers in the workshop (team) failed to obtain the required permits for working in confined spaces, did not conduct gas analysis or dynamic monitoring, did not implement energy isolation, and did not receive proper safety instructions. Moreover, the workers entered the dilution tank to carry out their tasks without wearing appropriate protective equipment. 2. The safety operation procedures for positions at Chongyu Chemical are not accurately formulated. There are discrepancies between the safety operation procedures for the position where the accident occurred and the process descriptions in the design documents, as well as the pilot production plan and actual operation steps; some of the relevant information is inaccurate or inconsistent, which results in a weak guiding effect for the safe operation of personnel at that position. 3. Chongyu Chemical failed to strictly implement the safety production responsibility system. The relevant personnel in the enterprise have failed to fulfill their statutory duties regarding work safety properly; the system of responsibility for work safety among all employees is inadequate, incomplete, and not effectively implemented; safety management is insufficient, with obvious gaps and deviations. The production workshop failed to fulfill its safety responsibilities, such as conducting risk analysis, identifying potential hazards, and providing safety training; the production management department failed to prepare accurate safety operation procedures for various positions. The equipment management department had significant shortcomings in terms of equipment integrity management. The human resources department did not carry out adequate safety training for employees, while the Safety and Environmental Protection Department was severely inadequate in overseeing special operations. 4. Chongyu Chemical fails to properly identify safety risks. Although the company has established a risk management system and carried out risk identification activities such as HAZOP analysis, it failed to conduct sufficient risk identification regarding the nitrogen protection system installed in the dilution tank as part of the safety facility design, and failed to identify the risk of compressed nitrogen leakage from the dilution tank ； The relevant personnel in the workshop, section, and team where the dilution tank is located are not aware of the actual condition of the tank and its associated equipment; they are even less familiar with the potential safety risks that may arise during operations at this position. As a result, they failed to carry out proper inspections and failed to identify the safety hazard posed by the nitrogen valves not being properly closed ； Employees lack a sense of risk, turn a blind eye to the company’s management systems and operating procedures, are careless in their thinking, and exhibit a clear tendency to rely on luck. 5. Chongyu Chemical fails to provide adequate safety training and education. Companies fail to provide adequate training and education for personnel on-site; they lack training regarding systems for working in confined spaces, safety procedures for specific tasks, and dual-prevention mechanisms ； The training content has a narrow scope and lacks specificity; there is no effective mechanism for monitoring and evaluating the training outcomes, resulting in the training process becoming a mere formality. 6. Chongyu Chemical has a weak foundation in emergency management, and its emergency response measures are inadequate. Before the accident occurred, the company failed to provide appropriate personal protective equipment and emergency rescue supplies in light of the safety risks associated with each job position, such as positive-pressure long-tube respirators and safety ropes. The emergency drills conducted were not targeted enough and lacked practical value; as a result, employees had severely insufficient skills and knowledge for handling emergencies ； After the accident, the company’s rescue personnel carried out rescue efforts in a hasty manner; they failed to ensure proper ventilation and gas replacement promptly, nor did they isolate the energy sources in an emergency situation, thus missing the critical window for rescue ； Rescuer Zhang Jianrong failed to wear personal protective equipment properly, which led to an further increase in the losses caused by the accident and heightened the risk of secondary accidents. 7. The Emergency Management Bureau of Huludao Economic Development Zone does not conduct thorough safety inspections of enterprises in the relevant industry sector. No thorough and detailed inspection or verification was carried out regarding the training and education practices at Chongyu Chemical; the company was not urged to strictly implement the \"Safety Management System for Work in Confined Spaces\" and the \"Safety Management System for Blind Flange Installation and Removal\", as well as the operational procedures specific to each position. The law enforcement inspections were not thorough enough. Determination of accident liability and handling recommendations PART.03 Recommendations to exempt certain individuals from liability; recommendations to hold others criminally liable; recommendations for administrative penalties against the companies and individuals involved in the accident; recommendations for internal disciplinary action against relevant personnel within the company; recommendations regarding actions to be taken against those involved by the Party Working Committee of Huludao Economic Development Zone; recommendations for actions to be taken by industry regulatory bodies