Report on the Investigation into the “2·15” Poisoning and Asphyxiation Incident at Yunnan Jinda Phosphorus Chemical Co., Ltd. Released

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Report on the Investigation into the Poisoning and Asphyxiation Incident at Yunnan Jinda Phosphorus Chemical Co., Ltd. on February 15 Released The report on the investigation into the poisoning and asphyxiation incident that occurred at Yunnan Jinda Phosphorus Chemical Co., Ltd. on February 15, 2022: At around 16:30 on February 15, 2022, an incident of poisoning and asphyxiation took place at Yunnan Jinda Phosphorus Chemical Co., Ltd., resulting in the death of 2 workers. In accordance with relevant laws and regulations such as the Work Safety Law of the People’s Republic of China and the Regulations on the Reporting, Investigation, and Handling of Production Safety Accidents (Decree No. 493 of the State Council), the district people’s government established an accident investigation team headed by the District Emergency Management Bureau, with participation from departments such as the District ** Office, the discipline inspection and supervision team dispatched by the District Discipline Inspection Commission and Supervision Commission to the District ** Office, the District Public Security Bureau, and the District Federation of Trade Unions. The accident investigation team conducted a thorough and detailed investigation into the incident 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\". Through questioning the relevant personnel, conducting on-site inspections, gathering evidence, performing comprehensive analyses, and carrying out other investigations, the nature of the accident and the responsibilities involved were determined. Recommendations were made regarding actions to be taken against the responsible individuals and units, as well as measures to prevent similar accidents in the future. At present, the basic circumstances of this accident have been clarified. The investigation findings and recommendations for handling are reported as follows: I. Overview of the accident (1) Time of the accident: Around 16:30 on February 15, 2022. (II) Location of the accident: Mill No. 1 workshop at Yunnan Jinda Phosphate Chemical Co., Ltd. (III) Accident-affected unit: Yunnan Jinda Phosphorus Chemical Co., Ltd. (IV) Type of accident: Poisoning and asphyxiation. (V) Casualties: This accident resulted in 2 deaths, with the following details: 1. Li XX, male, 59 years old, of Han ethnicity, residing at XXXX, Jinning District, Kunming City, Yunnan Province; ID number: 5301221962051XXXXX. Died from gas poisoning and asphyxiation. 2. Li X, male, 53 years old, Han ethnicity, residing at XXXXX, Jinning District, Kunming City, Yunnan Province; ID number: 5301221968050XXXXX. Died from gas poisoning and asphyxiation. (VI) Direct economic loss: over XXX ten thousand yuan. II. Basic Information (I) Basic Information of the Accident-Involved Unit: Yunnan Jinda Phosphorus Chemical Co., Ltd. (hereinafter referred to as Jinda Company) has a unified social credit code of 91530122678743XXXX. It was established on September 27, 2008, with its validity period extending until September 26, 2048. The registered capital of the company is 20 million yuan. On December 24, 2021, Jinda Company went through the change registration procedures at the Market Regulation Bureau of Jinning District, Kunming. The company is a limited liability company (invested in or controlled by natural persons); its legal representative is Xie XX (male, Han ethnicity, 49 years old, holding a safety management qualification certificate). His address is XXXXXXX, Jinning District, Kunming, and his ID number is 5301221973021XXXXX ； Registered address of Jinda Company: XX Base, Jinning Industrial Park, Kunming City, Yunnan Province ； The business scope is divided into licensed projects and general projects. Permitted projects: Fertilizer production ； General items: Fertilizer sales ； Manufacture of non-metallic mineral products; sale of non-metallic minerals and products ； Fertilizer sales ； Import and export of goods ； Sale of metal products. On December 17, 2018, Jinda Company obtained the \"National Industrial Product Production License\" issued by the Yunnan Provincial Quality and Technical Supervision Bureau. The license number is: (Dian) XK13-002-00033. The product in question is phosphate fertilizer (calcium magnesium phosphate), and the validity period of this license extends until April 20, 2024. Upon investigation, Jinda Company currently has 87 employees, and it has established various management systems including safety education and training, safety warning signs, power distribution rooms, a safety production responsibility system, safety inspections and hazard mitigation, as well as emergency response procedures for accidents. At the same time, establish safety operation procedures for motor vehicle drivers, on-site equipment maintenance personnel, electricians, and production staff at their posts. Jinda Company signed the 2022 Safety Production Responsibility Letter, established records for daily safety management, conveyed safety management requirements at various levels through meetings, carried out safety training and education as well as inspections and rectifications of potential hazards on site, and kept records of regular equipment inspection and maintenance. Daily safety management is carried out by the legal representative Xie XX, workshop director Li XX (who also serves as a safety officer and holds a safety management certification), deputy workshop director Wang XX, and deputy workshop director Geng XX. Jinda Company has a blast furnace workshop, No. 1 and No. 2 ball mill workshops, and a machinery repair team. Li XX is in charge of the blast furnace workshop and the two ball mill workshops, while Geng XX is responsible for the blast furnace workshop. Wang XX is in charge of the inspection and maintenance of production equipment, as well as managing the machine repair team. The maintenance team consists of 4 people: Li XX, Li X, Yang XX, and Wang X. There is no team leader; Li XX and Li X form one group, while Yang XX and Wang X form another group. The two teams in the mechanics workshop conduct a shift handover at 8 o’clock every day. After the blast furnace at Jinda Company was brought online, the production line operated 24 hours a day, with all staff working in shifts. One manager is on duty each day; on the day of the incident, Geng XX was on duty. The personnel on duty in the maintenance team were Li XX and Li X, while those on duty in the blast furnace team included Li XX (team leader), Pu XX, Zhu XX, Lei XX, Yang XX, Xiao XX, Fei XX, Han XX, Xiao XX, Xiao XX, and Lu XX – a total of 11 people. Ball milling workshops No. 1 and No. 2 were shut down on the day of the incident, with no staff on duty. (II) Regarding the enterprise’s production process, poisoning accidents occur at the head platform of the conveyor at the discharge outlet of the ball mill and at the bin platform of the packaging machine. The process flow is: raw materials → processing → packaging machine → finished products. Both the dryer and the ball mill are equipped with independent dust removal systems. The dryer was used in series with a ball mill and a bucket elevator (powder lifting conveyor); at that time, the dryer, ball mill, bucket elevator (powder lifting conveyor), and dust removal system in that workshop were all shut down. (III) Investigation into the flow direction of the gas in the accident revealed that the blast furnace was operating normally at that time, while the dryer, ball mill, and bucket elevator (powder lifting machine), as well as the dust removal system, were shut down. The dryer, ball mill, and bucket elevator (powder lifting machine) were connected in series; the dryer used gas as an auxiliary fuel. Vertical water seals and flap valves were installed on the gas delivery pipelines to prevent leaks, and these valves were in the open position. The gas generated by the blast furnace flowed through the open water seal valves and flap valves and entered equipment such as the dryer and ball mill, before leaking out into the working area via the outlet of the ball mill bucket elevator (powder lifting machine) and the discharge pipe (packaging platform). (IV) Status of the water seal valve of the gas isolation device: To meet the requirements of the Spring Festival holiday in 2022, Jinda Company decided to suspend all production after January 28th, with the blast furnaces being shut down (without any insulation). Until January 28, all production equipment at Jinda Company was operating normally. While the blast furnace was in use, Workshop No. 1 for ball milling utilized the gas produced by the blast furnace to dry the drying cylinders there; at that time, the gas flap valve and water seal valve located in front of the drying furnace in Workshop No. 1 were in the open position (with no water inside the water seal valve). After the blast furnace was shut down on January 28, the source of gas generation ceased, but Jinda Company failed to close the water seal valve (it was not filled with water). (5) Safety supervision situation: The people’s government of Erjie Town, Jinning District conducted 6 on-site inspections of Jinda Company over the past three years, including 2 inspections in 2019, 3 in 2020, and 1 in 2021. Meanwhile, on July 9, 2021, a qualified intermediary agency was hired to conduct a safety inspection of Jinda Company. Checked once on January 18, 2022. The Jinning Industrial Park Management Committee conducted a total of 11 inspections of Jinda Company over the past three years: 4 in 2019, 5 in 2020, and 2 in 2021. No supervision and inspection activities were carried out on Jinda Company in 2022. The Emergency Management Bureau of Jinning District conducted 5 inspections and supervision visits to Jinda Company over the past three years: 2 in 2019, 1 in 2020, and 2 in 2021. At the same time, hire an intermediary agency to conduct on-site hazard inspections once. In 2022, Jinda Company was included in the district-level law enforcement inspection plan, as well as on the list of experts tasked with reviewing pharmaceutical and chemical enterprises by the municipal authorities. Jinda Company failed to comply with the management requirements regarding the submission of reports for resuming work in 2022. III. Accident Occurrence and Rescue Situation (1) Course of the accident On February 7, 2022, the management team of Jinda Company and the maintenance crew returned from their Spring Festival holidays. A meeting was held with the management to plan for a gradual resumption of full operations once the blast furnace started operating on February 15; Wang XX was assigned to complete the maintenance work on the blast furnace before it was ignited. On February 7, Li XX and Li X carried out maintenance work, while on February 8, Yang XX and Wang X did the maintenance. To complete the blast furnace maintenance work as quickly as possible, Wang XX arranged for 4 members of the mechanical repair team to work non-stop without breaks from February 9th to 13th, with everyone involved in the maintenance tasks. During that time, Li X reported to Wang XX that during the pre-New Year inspection it was found that the bearings of the conveyor belt in Ball Mill Workshop No. 1 (the powder lifting conveyor) needed to be replaced. Wang XX arranged to prioritize repairs to the blast furnace and handle the issue later when there was time. After the blast furnace maintenance was completed, Wang XX arranged for shift work to resume on February 14, starting with Team 1 led by Yang XX and Wang X. At around 2 a.m. on February 15, the blast furnace was ignited, and at 8 a.m., Li XX and Li X took over their shifts as usual. At around 8:30, Li XX went to the blast furnace site to learn from the technical personnel of the external service provider how to adjust the desulfurization and purification system. At around 9 o’clock, Wang XX saw Li XX welding the guardrail of the blast furnace hopper vehicle, while Li X was welding the fan casing in Mill No. 1. Seeing that the mechanics were all working, Wang XX returned to the blast furnace to assist in the debugging of the desulfurization and purification system, and repaired the air compressor of that system. After lunch, Li XX and Wang XX went to the blast furnace site to learn how to adjust the desulfurization and purification system. At around 16:15, Wang XX saw Li X pushing a cart loaded with tools towards the tool room on his way back to the office. At 17:20, Geng XX noticed that the mechanic had not gone to the cafeteria for meals, so he got in touch with Wang XX who had returned home. They went to the security office to confirm that the mechanic had not left, and then began looking for him. At 17:30, two unconscious machine repair workers were found at the bucket elevator (powder lifting elevator) in Ball Mill Workshop No. 1. (II) Accident rescue and reporting: After the accident occurred, Geng XX immediately reported it to Li XX and Xie XX. Jinda Company immediately organized rescue efforts and secured the scene, while also reporting the incident to the Jinning District Emergency Management Bureau and the Jinning Branch of the Kunming Public Security Bureau. Geng XX organized security guard Yang XX, Li XX, the foreman of the blast furnace team, production worker Pu XX, and canteen worker Su XX to carry out the rescue efforts. Xie XX, Li XX, and Wang XX rushed to the accident scene simultaneously to handle the situation. After receiving the report, the 120 ambulance arrived at the scene; following emergency treatment by medical staff, it was confirmed that Li XX and Li X no longer had any signs of life. The public security authorities have taken control of the accident scene, conducted an on-site investigation, and collected blood samples from the deceased. Tests confirmed that the two victims died as a result of gas poisoning and suffocation. IV. Accident scene and handling measures (1) Scene description The accident occurred at the bucket elevator (powder-lifting elevator) in Mill No. 1 of Jinda Company. The blast furnace is connected via pipes to the drying furnace in Mill No. 1; gas isolation between them is achieved through water-seal valves and flap valves. Upon inspection, it was found that there was no water inside the water-seal valve, indicating that it was in an open state. The investigation team determined that this water seal valve does not meet the requirements specified in Article 7.2.3 of the \"Safety Regulations for Gas in Industrial Enterprises\" (GB 6222-2005). The drying furnace is connected to the washing tower; meanwhile, the drying drum, conveyor, and pulse bag dust collector in Mill No. 1 are linked to the washing tower as well. The location where the incident occurred is in series connection with the blast furnace. The absence of water in the water seal valve failed to effectively block the gas generated by the blast furnace; as a result, the blast furnace gas leaked out, causing the two maintenance workers on duty to be poisoned and suffocate to death. (II) Handling of the accident: Upon receiving the report of the accident, the District Emergency Management Bureau immediately informed the District Party Committee and the district authorities. The leaders of the District Party Committee and the district authorities attached great importance to this matter. Comrade Li XX, a member of the District Party Committee and the executive deputy district head, led departments such as the District Emergency Management Bureau, the District Public Security Bureau, the District Federation of Trade Unions, and the People’s Government of Erjie Town to the scene as soon as possible to handle the situation. Requirements were put forward for dealing with the accident: first, the enterprise was required to cease production immediately, and efforts were to be made to comfort the families of the victims ； Second, it is required that the Industrial Park Management Committee and the people’s government of Erjie Town **provide guidance to enterprises so that they can carry out proper compensation measures and manage public opinion effectively ； Third, an accident investigation team was established, led by the District Emergency Management Bureau and comprising members from units such as the District ** Office, the discipline inspection and supervision group dispatched by the District Commission for Discipline Inspection and Supervision to the District ** Office, the District Public Security Bureau, and the District Federation of Trade Unions. After the family members of the 2 deceased arrived at the scene, the people’s government of Erjie Town actively assisted the company in comforting the families and handling the compensation matters. On February 16, JinDa Company held discussions with the families of the 2 deceased and reached a compensation agreement, paying XXX ten thousand yuan to the family of Li XX and XXX ten thousand yuan to the family of Li X, thus properly resolving the aftermath of the accident. V. Causes of the accident
(1) Direct cause
The direct cause of this accident was that the gas generated by the blast furnace at Jinda Company leaked from the dryer area due to the failure of the isolation device and the non-operation of the dryer. This led to poisoning and asphyxiation among personnel. (II) Indirect causes
1. The gas cutoff device used by Jinda Company does not meet the requirements of the “Safety Regulations for Industrial Enterprises Regarding Gas”. 2. Jinda Company failed to conscientiously supervise and manage the operation of the gas shutoff device; the water seal device did not contain the required amount of water at the appropriate level. 3. When working in areas where gas might leak or escape, the employees of Jinda Company were not equipped with or did not use gas detection alarms. 4. Jinda Company has not established safety operating procedures for gas facilities and equipment. 5. Jinda Company did not take specific preventive and control measures to supervise and manage hazardous substances. 6. When JinDa Company carried out its regular production activities, it failed to analyze the potential safety risks associated with resuming work, and its supervision and management were inadequate. 7. Jinda Company’s management failed to conduct thorough inspections and rectifications of potential accident hazards; there were no targeted control measures in place to address the safety risks that could arise from the non-operation of the drying equipment. 8. Jinda Company’s employees lack the necessary skills for risk prevention and emergency response, and safety production training is not targeted enough. VI. Nature of the accident: The “2·15” poisoning and asphyxiation incident at Yunnan Jinda Phosphorus Chemical Co., Ltd. was a routine work safety liability accident. VII. Determination of accident responsibilities and recommendations for handling (1) Persons exempt from liability (2 in total): Li XX and Li X are both equipment maintenance workers in Jinda Company’s mechanical repair team. They failed to properly identify the safety risks present in their working environment, nor did they take any effective preventive measures to avoid accidents; they carried out hazardous operations related to the accident without checking whether the gas isolation water seal valves were closed. Given that they all died in the accident, it is recommended to exempt them from legal liability. (II) Recommendations regarding the handling of those responsible for the accident (5 persons in total): 1. Release XX, the legal representative of Jinda Company, who failed to conduct proper inspections for safety hazards and did not supervise and check the company’s work related to safe production adequately ； Safety management is inadequate, and there are gaps in safety oversight ； Failing to ensure that employees properly implement the safety production management systems and operating procedures. As the person in charge of the accident, it is recommended that the District Emergency Management Bureau initiate an official investigation in accordance with relevant laws and regulations on work safety. As the legal representative of Jinda Company, XX is also responsible for the deaths of two workers during their work due to inadequate safety management. In accordance with the provisions of the \"Interpretations of the Supreme People’s Court and the Supreme People’s Procuratorate on Several Issues Concerning the Application of Law in Handling Criminal Cases Involving Threats to Production Safety,\" he is suspected of having committed a crime. It is recommended that the public security authorities pursue their criminal liability in accordance with the law. 2. Li XX, the workshop supervisor and safety officer at Jinda Company, failed to conduct proper inspections for potential safety hazards; there were gaps in safety management. He also failed to ensure that workers complied with relevant safety procedures and regulations, and did not organize the development of operating procedures for maintenance during the blast furnace’s operation. The district emergency management bureau should be responsible for conducting an investigation in accordance with relevant laws and regulations on work safety, given its managerial responsibilities regarding the occurrence of this accident. 3. Wang XX, the head of Jinda Company’s maintenance team, failed to ensure proper on-site safety management, did not supervise maintenance operations adequately, and failed to conduct thorough and careful inspections for potential hazards. As the person in charge of equipment inspection and maintenance, failure was made to inspect the gas isolation water seal valve, which is a critical safety component. The district emergency management bureau should be responsible for conducting an investigation in accordance with relevant laws and regulations on work safety, given its managerial responsibilities regarding the occurrence of this accident. 4. Geng XX, deputy director of the blast furnace workshop at Jinda Company, who was on duty on the day of the incident, failed to conduct a thorough safety inspection during his shift and did not properly supervise the fulfillment of his responsibilities related to workplace safety. It is recommended that Jinda Company handle the matter in accordance with its internal regulations, and submit the results of such handling to the emergency management department for record-keeping within 15 working days after the decision is made. 5. Pu XX, an engineer at Jinda Company, as a technical staff member of the company, failed to inform the company in a timely manner that the gas isolation water seal valves currently in use did not meet the requirements specified in Article 7.2.3 of the \"Safety Regulations for Gas Use in Industrial Enterprises\" (GB 6222-2005). It is recommended that Jinda Company handle the matter in accordance with its internal regulations, and submit the results of such handling to the emergency management department for record-keeping within 15 working days after the decision is made. (III) Recommendations for dealing with the units responsible for the accident (4 in total): 1. Jinda Company failed to provide adequate safety training and education; after resuming operations, it did not offer on-site safety training to the maintenance staff. The workers lacked the basic safety knowledge required for their jobs, had weak safety awareness, and poor abilities to protect themselves and others. Jinda Company failed to conduct thorough, accurate, and meticulous inspections for potential hazards on site; it did not have a sufficient understanding of the dangers posed by the gas generated during the production process in the blast furnaces, and there was inadequate control over this gas at the site. Jinda Company was inadequately prepared for safety management during the resumption of work and operations; it failed to properly manage the water seal valve, which is a crucial safety element, and thus bears responsibility for the occurrence of the accident in terms of safety management. It is recommended that the District Emergency Management Bureau initiate an investigation in accordance with relevant laws and regulations on work safety. It is also recommended that Jinda Company be ordered to suspend production and operations for rectification, and that a qualified intermediary agency be hired to conduct a comprehensive on-site inspection; it may resume production and operations only after completing the required rectification and passing the inspection. 2. The Management Committee of Jinning Industrial Park has conducted inspections and supervision of the involved enterprises on multiple occasions over the past three years; however, none of these inspections covered matters related to the management of blast furnace gas by those enterprises. Since 2022, no inspections or supervision have been carried out on the involved company, thus failing to fulfill its responsibilities regarding work safety oversight. It is recommended that the Management Committee of Jinning Industrial Park submit a thorough written apology to the people’s government of Jinning District, Kunming. 3. The people’s government of Erjie Town, Jinning District **failed to engage intermediary agencies to investigate the issue regarding the unclear readings of the water level gauges for the blast furnace gas water seal valves identified by Jinda Company; it also failed to ensure proper rectification of these hazards, and no closed-loop management system was established for such rectifications. It is recommended that the people of Erjie Town, Jinning District submit a thorough written apology to the people of Jinning District, Kunming City. 4. During routine inspections of Jinda Company by the District Emergency Management Bureau, it failed to effectively supervise and guide the company in fulfilling its responsibilities regarding work safety; it also lacked a proper assessment of the hazardous operations carried out by the company, and did not take adequate preventive measures against blast furnace gas. It is recommended that the Emergency Management Bureau of Jinning District submit a written apology to the people of Jinning District, Kunming. VIII. Accident Prevention and Rectification Measures (1) Strengthen inspections to create a coordinated oversight effort. The Jinning Industrial Park Management Committee and the people’s government of Erjie Town in Jinning District should, in accordance with the principle of being responsible for their respective areas, earnestly fulfill their duties in overseeing those areas. The District Emergency Management Bureau should take targeted preventive and response measures, increase the frequency of routine inspections and supervision as appropriate, and fulfill its responsibilities in guiding and supervising work related to work safety. At the same time, the relevant departments and personnel with regulatory responsibilities must conduct regular assessments of the enterprises registered in their respective jurisdictions to keep track of the actual number of enterprises there. Relevant departments should go directly to the enterprises to carry out thorough on-site inspections, reminding and urging them to pay equal attention to both production and safety, to adopt necessary protective measures, and to conduct regular inspections of the work sites. They should also ensure that actions are taken to address any identified hazards, thereby fulfilling their responsibilities for safety supervision in their respective areas and departments. (II) Learn from the lessons of the accident and fulfill safety production responsibilities. Jinda Company must thoroughly learn from the lessons of this accident, firmly establish a sense of the red line regarding safety production, and effectively assume its primary responsibility for ensuring safety in production. Thoroughly analyze safety risk factors, and carry out thorough inspections for potential hazards and risk identification. Conduct a comprehensive inspection of all the company’s work sites, enforce strict management at these sites, and install video surveillance in all hazardous and high-risk work areas. Special attention should be paid to installing gas isolation devices that comply with the \"Safety Regulations for Gas in Industrial Enterprises\" in those areas related to gas use. (III) Improve rules and regulations to enhance intrinsic safety: Jinda Company should, in light of this accident, refine the operating procedures for relevant positions as well as the safety management rules and regulations, and improve the practicality of these systems ； Improve the safety of mechanical equipment from an intrinsically safe perspective. Formulate operating procedures for equipment inspection and maintenance personnel during the ignition and operation of the company’s blast furnace; reasonably assign gas safety management personnel in accordance with the requirements of the “Safety Regulations for Industrial Enterprises Concerning Gas”; and implement their respective management responsibilities. Jinda Company should further strengthen its system for identifying potential hazards, refine the contents and standards of on-site inspections, and increase the intensity and frequency of specialized inspections ； It is necessary to improve work safety management systems and operating procedures for each post ； Thoroughly identify potential hazards in the production process as well as weaknesses in management practices, and eliminate these hazards promptly. (IV) Strengthen personnel training and implement on-site management: Jinda Company should enhance safety education and training for relevant workers, and keep accurate records of such training activities. Strengthen the dynamic management of workers on site to improve safety control capabilities. Strengthen the safety management of on-site workers, implement effective safety precautions, and carry out operations in strict accordance with relevant regulations. Issue and ensure that workers use personal protective equipment properly. It is necessary to increase the frequency of routine safety inspections, prevent employees from engaging in illegal behaviors, and promptly identify and address various potential accident hazards. It is necessary to strengthen safety education and training, and organize employees to study in detail the operational procedures for their positions, safety operation skills, basic knowledge of safety protection, as well as relevant laws and regulations such as the Work Safety Law of the People’s Republic of China. We strictly adhere to the safety production policy of \"safety first, prevention foremost, and comprehensive management,\" continuously strengthening employees’ safety awareness and improving their capabilities in safety prevention and emergency response, so as to ensure the safety of employees’ lives and property.