【Ministry of Emergency Management’s Special Inspections 2022】Appendix – Pilot production accidents in recent years

This post was last edited by Desert Fish on 2022-7-20 at 11:12. At around 11:15 a.m. on October 15, 2019, an industrial safety accident occurred at No. 3, East Section of the LuChuan County Northern Industrial Park, at Guangxi Lanko New Materials Co., Ltd. According to the relevant authorities, the accident resulted in 4 deaths, 2 serious injuries, and 4 minor injuries. A working team from the Yulin Emergency Management Bureau has arrived at the scene and is handling the situation urgently. At around 8:30 a.m. on October 15, 2019, the company began trial production. The main raw materials used were phenol and formaldehyde, and phenolic resin products were produced through chemical reactions. Around 11:10 a.m., an explosion occurred in the reaction vessel, resulting in casualties and property damage. The storage capacity of raw materials and semi-finished products in the reactor is approximately 5 tons. It is understood that the explosion occurred in a reactor located in the resin synthesis workshop; this reactor is used primarily for synthesizing phenolic resin from formaldehyde and phenol. The cause of the explosion and the extent of property damage are currently under investigation.

A suspected chemical poisoning incident occurred at a chemical company in Hengshui, resulting in 3 deaths. In the early hours of November 19, 2016, Hebei Hengshui Tianrun Chemical Co., Ltd. experienced a suspected chemical poisoning incident during its trial production process. A official from the Foreign Affairs Bureau of the Publicity Department of the Hengshui Municipal Party Committee confirmed to The Paper (www.thepaper.cn) that the accident resulted in 3 deaths, and the specific cause of the accident is under further investigation. On the morning of November 19, the Management Committee of Hengshui Economic Development Zone issued a statement through its WeChat official account “Hengshui Industrial New Area”. The accident occurred at 1:30 a.m. on the 19th, when Hengshui Tianrun Chemical Technology Co., Ltd. faced a suspected chemical poisoning incident during trial production. Seven people were present at the site, and five of them were poisoned. After being taken to the hospital for treatment, three of them died despite efforts to save them by 4 a.m., while two others were out of danger

Incident details: At 8:35 a.m. on September 9, 2007, an explosion and scalding accident occurred at the lead smelting plant of Gansu Ximai New Materials Technology Co., Ltd.’s Mining and Metallurgy Branch, located in the industrial park of Guazhou County, Jiuquan City, Gansu Province, during the trial production and debugging phase of a lead smelting project. The accident resulted in 8 deaths and 10 injuries, 3 of whom were seriously injured. 　　Before the accident, the device was still in the trial production and debugging phase. In the early hours of September 9, slag was ejected from the feeding port during testing, damaging the feeding belt; manual feeding was initiated at 6:20. At 8:35, the on-site commander for debugging opened an observation hole to look inside the furnace. After that, he instructed the operator to lower the spray gun; after checking the scale on the frame holding the oxygen-enriched air spray gun, he ordered the operator to lower it again. He then observed the scale on the spray gun once more and gave the signal to lift it. Before the spray gun could move, a plume of white smoke emerged from the feed port. At that moment, more than 10 tons of slag at a temperature of 1150°C was ejected from the west side of the furnace roof, shooting straight toward the control room and destroying it along with its facilities. As a result, 6 out of the 9 people present died on the spot, while 3 others suffered serious injuries after jumping out of windows on the third floor; 2 of these individuals died despite attempts to save them. After the slag was ejected into the control room, the glass of the raw material processing building, located 47 meters away from the furnace, was shattered, injuring other people. The accident resulted in 8 deaths and 10 injuries, 3 of whom were seriously injured. 　　Cause of the accident: Direct cause: The on-site supervisors during production testing were not aware of the potential dangers posed by the \"foamy slag\" generated by the melting furnace; they gave incorrect instructions when abnormalities occurred and failed to take appropriate action to address the situation. Two slag spraying incidents had occurred prior to the accident; one of them caused the feeding belt to burn out. However, instead of taking measures such as adjusting the slag profile as required by procedures, production continued using manual feeding. Due to the prolonged abnormal hyperoxidation condition inside the furnace, the amount of iron tetraoxide in the slag reached 3.3 times the normal level, resulting in an increase in the viscosity of the slag. However, the on-site supervisor made a wrong judgment and gave illegal orders to fire twice, without cutting off the air supply or oxygen flow; as a result, the gases that entered the melt along with the smoke generated could not be discharged properly. This led to the formation of large amounts of \"foamy slag\" inside the furnace. The gases caused the melt to rise rapidly, resulting in its sudden expansion. The high-temperature melt and gas streams instantly pushed aside the furnace lid, causing it to be ejected at high speed through the cracks, which triggered the accident. 　　Key reasons: 1. The design firm lacks experience in the operational organization of oxygen-enriched top-blown melting furnaces, and has insufficient capabilities in their operation and control. The core equipment of the system (top-blown furnace and gun) was designed and manufactured by the design unit for the first time, without undergoing industrial testing. Before the accident, there were improper operations such as inaccurate control of air and oxygen levels, as well as prolonged air blowing after the material supply was stopped; moreover, no appropriate corrective actions were taken in a timely manner when problems arose. 　　2. The owner and the technical service provider carried out trial production blindly in the absence of the necessary conditions for it; without proper system testing, air flow meters and oil flow meters on site could not function properly, and parameters were controlled solely based on the opening degree of valves. 　　3. Kunming Xituo Technology Co., Ltd. designed the core equipment for systems such as melting furnaces and spray guns without possessing the necessary design qualifications. 　　4. The owner failed to exercise proper oversight when selecting the design service provider, choosing a partner without the necessary qualifications and capabilities, and did not appoint a supervision unit to effectively oversee the construction of the production workshops and the installation of equipment.

On October 21, the Emergency Management Department issued the \"Notice from the Office of the State Council Safety Committee regarding the significant explosion incident that occurred on October 15 at Guangxi Yulin Lanko New Materials Technology Co., Ltd.\" The report states that, according to preliminary investigations, as a company specializing in the manufacture of casting machinery, it illegally constructed a chemical production facility and proceeded with trial production without authorization. During this trial production, an atmospheric-pressure reactor with a capacity of 10 cubic meters in its resin production workshop – which was used to produce phenolic resin using phenol and polyformaldehyde as main raw materials – exploded suddenly. The exact cause of the accident is still under further investigation. According to the report, in particular, the \"10·15\" accident in Yulin, Guangxi, exposed the following prominent issues: First, the enterprise involved in the accident had a very weak awareness of the rule of law; it found various ways to evade supervision, started building chemical production facilities without going through the required approval and registration procedures, and began trial production without implementing proper safety measures, which led to the loss of control over risks and ultimately the accident. Secondly, there are gaps and weaknesses in local safety supervision; the enterprise involved in the accident is not located within a chemical industrial park, and according to its business registration details it does not qualify as a chemical enterprise. Yet, it actually operates chemical processing facilities and uses hazardous chemicals in violation of regulations. The local authorities fail to conduct a comprehensive and thorough assessment of the safety risks associated with hazardous chemicals, and the responsibilities for oversight are not clearly defined, which results in their failure to detect the enterprise’s attempts to evade supervision and carry out illegal construction and production activities. Third, the concept of safe local development is not firmly established or properly implemented, and there is a lack of strict oversight in attracting investment. The phenolic resin production facility involved in the accident originated in Dongguan, Guangdong, but was relocated to Guangxi due to heavy environmental pressures; local authorities’ reckless acceptance of such projects has created safety hazards.

At around 16:20 on June 7, 2018, an oil-fired gas boiler of model WNS12-1.25-Y(Q) owned by Zunyi Yixin Agricultural Technology Co., Ltd. (hereinafter referred to as “Yixin Company”), located at No. 18 Mengshan Road, Loushangguan High-Tech Zone, Tongzi County, Zunyi City, Guizhou Province, exploded. This incident resulted in 3 deaths (1 person died on the spot and 2 others died despite attempts to save them), 6 people suffered minor injuries, and direct economic losses amounted to 6.664 million yuan

Basic Information on the Unit Where the Accident Occurred and the Equipment (I) Information on the unit where the accident occurred: The company at which the accident took place is Yixin Company (Unified Social Credit Code: 91520322MA6EB9C87D). It was established on September 29, 2017. The company type is a limited liability company (invested in or controlled by natural persons), and its registered address is No. 18, Mengshan Road, Loushangguan High-Tech Zone, Tongzi County, Zunyi City, Guizhou Province (registered as part of a cluster). The registered capital is 10.33 million yuan. The legal representative is Huang Hongjiang (ID number: 510281198106025755; place of residence: Tingziyuan Village Group, Jingsheng Village, Wujiàn Town, Yongchuan District, Chongqing City). The agency responsible for overseeing the company is the Agriculture and Animal Husbandry Bureau of Tongzi County. The company’s business scope includes the cultivation, processing, packaging, retail, and wholesale of edible fungi, fruits, and vegetables; its main focus is on the production of edible fungi. There are nearly a hundred employees. The company’s organizational structure includes a chairman, general manager, deputy general managers (in charge of safety), a safety and environmental protection department, as well as departments for security, the company office, administrative and human resources, finance, production, planning and supply, technology, engineering, procurement and sales, and operation and maintenance. On June 6, 2018, the company established the Yixin Company Safety Management Committee (hereinafter referred to as the Safety Committee), with Liang Tian serving as its chairman and Liu Chun as its vice chairman. An office is established under the Safety Committee, with Liu Chun serving as its director and being responsible for the daily management of work safety. The company has specified that safety management is the responsibility of the company’s Safety Committee, with Liang Tian, the chairman of the Safety Committee, serving as the person in charge of safety matters within the company. The company’s safety management system was issued on June 6, 2018; however, it is inadequate, particularly in terms of the safety management system for special equipment and the operating procedures for such equipment, which are incomplete and not effectively implemented. Li Zhengsong, the boiler operator on duty at the time of the accident, was hired by the company on June 1, 2018. He was assigned to work without having a boiler operation certificate, and no safety education or training was provided to him before he started working. In September 2017, the company was brought to Tongzi County through investment promotion efforts by the Tongzi County Party Committee and government, where it established Yixin Company as part of a project aimed at reducing poverty through industrial development; this initiative was designed to help over 1,500 people living in rural areas find employment and escape poverty. (II) Basic information on the equipment involved in the accident: The steam boiler that was involved in the accident is of the model WNS12-1.25-Y(Q); its rated evaporation capacity is 12 t/h, and its rated steam pressure is 1.25 MPa. The fuel used is natural gas. The boiler was designed and manufactured by Sichuan Leshan Xiongshi Boiler Co., Ltd. Its full name is low-nitrogen condensing horizontal fuel (gas) steam boiler. It was manufactured on December 28, 2017, with the factory serial number 17177; the product model number is ZG489.0. The design drawings for this boiler were approved by the Sichuan Special Equipment Inspection and Research Institute in September 2017, and manufacturing supervision inspections were carried out in December 2017. The installation of the boiler was carried out illegally by personnel from companies that are not boiler manufacturers, under the supervision of Liao Zhiqiang, the person in charge of the Nanchong office of Sichuan Leshan Xiongshi Boiler Co., Ltd.; no application was made for an inspection to oversee the installation process since the boiler was installed. In October 2017, Yixin Company contacted Sichuan Leshan Xiongshi Boiler Co., Ltd. with the intention of purchasing a boiler for production purposes. Liao Zhiqiang, the person in charge of Sichuan Leshan Xiongshi Boiler Co., Ltd.’s Nanchong office, went to Tongzi to hold business discussions with Huang Hongjiang, the company’s legal representative. Based on the company’s production processes, Huang Hongjiang suggested to Liao Zhiqiang that a natural gas boiler with an evaporation capacity of 12 t/h and a rated steam pressure of 1.25 MPa was needed. On October 9, 2017, the two parties signed a boiler purchase contract (the contract covered the boiler itself, burners, water pumps, water treatment systems, economizers, as well as instruments and valves). Subsequently, Sichuan Leshan Xiongshi Boiler Co., Ltd. completed the boiler design, verification of the design drawings, boiler manufacturing, and supervision of the manufacturing process in accordance with the user’s requirements. In mid-March 2018, after the boilers purchased by Yixin Company from Sichuan Leshan Xiongshi Boiler Co., Ltd. arrived at the purchasing party, Liao Zhiqiang organized relevant personnel to carry out boiler installation work on April 4, 2018, without any permits, without having the necessary qualifications for boiler installation, without notifying the relevant authorities of the installation, and without applying to local inspection agencies for inspection. On April 10, 2018, Liao Zhiqiang submitted the boiler installation notification from Sichuan Leshan Xiongshi Boiler Co., Ltd. to the Tongzi County Market Regulation Bureau in order to complete the installation notification procedures. According to the assessment conducted by the Public Security Management Team of Wutongqiao Branch of Leshan Public Security Bureau, the seal of Leshan Xiongshi Boiler Co., Ltd. appearing on the boiler installation notice held by Liao Zhiqiang was a forged one; Leshan Xiongshi Boiler Co., Ltd. had not authorized him to represent the boiler manufacturing company in installing that boiler. After completing the procedures required for boiler installation, Liao Zhiqiang failed to request an inspection by a qualified testing agency as required by regulations. The safety and quality standards for the installation did not meet the technical specifications applicable to boiler installation, and there was no control over these aspects. Without carrying out inspections of the boiler foundation, pressure tests, burner adjustments, trial operations, or overall acceptance, the boiler was allowed to be operated by the user. In particular, on June 6, upon learning that the user was operating the boiler, he failed to inform them that the steam passage had been blocked off using blind flanges at the location where the boiler’s safety valve seat met the boiler body’s flange, and he did not prevent the user from using the boiler. The boiler sold by Sichuan Leshan Xiongshi Boiler Co., Ltd. to Yixin Company met the relevant regulatory requirements in terms of boiler design evaluation, manufacturing, and manufacturing supervision. The boiler sales contract signed by Liao Zhiqiang and Yixin Company was authorized by Leshan Xiongshi Boiler Co., Ltd., but the installation of that boiler was not authorized to Liao Zhiqiang. Leshan Xiongshi Boiler Co., Ltd. holds a boiler manufacturing license, with the license number: TS2110027-2020. III. Process of the accident, emergency rescue, and aftermath handling (I) Process of the accident: On around 13:00 on the afternoon of June 7, 2018, Yixin Company, located in the Loushangguan High-Tech Zone (Chumi Town, Tongzi County), began operating its boiler for trial production; only one sterilization cabinet was used for this trial production (there are 8 sterilization cabinets in the production workshop, located about 20 meters away from the boiler room). At around 16:18, the personnel in that workshop noticed that the pressure gauge for the steam distribution cylinder indicated overpressure; the pressure value exceeded the boiler’s rated pressure of 1.25 MPa, with the gauge showing 1.5 MPa (the equipment that requires steam is a sterilization cabinet, and the normal pressure range for it is between 0.4–0.8 MPa). At that moment, the people in the workshop reported that they heard no sound of steam being released from the boiler room’s safety valve, nor any alarm sounds from the boiler control panel. Relevant personnel immediately headed towards the boiler room; on their way there, they saw the boiler operator Li Zhengsong running from outside the workshop towards the boiler room. By the time Li Zhengsong reached the boiler room, a large amount of dust had been emitted from it, and the boiler exploded instantly. This incident occurred around 16:20 on June 7, 2018. The explosion caused the boiler cylinder to be flung to the third floor of the training building at Tongzi County Vocational and Technical School, at a distance of about 301 meters, resulting in a large hole being created in the wall of the training building (about 9 meters high and 4 meters wide). The boiler cylinder, weighing around 28 tons, became embedded in the building. The accident caused damage to the boiler room, and all the equipment inside it was rendered unusable. The accident resulted in the immediate death of the boiler operator Li Zhengsong; two students from Tongzi County Vocational and Technical School were seriously injured, five students and one school security staff member suffered minor injuries. On June 8, the two patients in critical condition died despite efforts to save them at the hospital.

Causes and nature of the accident (I) Causes of the accident 1. Immediate cause of the accident: Through inspections, investigations, and inquiries, it was found that the valve seat of the boiler’s safety valve and the steam passage in the boiler drum were blocked by blind flanges. The boiler’s pressure interlock protection system was not properly calibrated, as a result of which it failed to carry out its safety functions such as releasing pressure, stopping the burner, and issuing alarms when the pressure rose too high. Additionally, the boiler operator left his post during operation; therefore, no effective measures were taken in time to stop the boiler from operating and to relieve pressure. This led to the boiler operating under excessive pressure (the pressure, as indicated by the gauge in the steam distribution chamber, was 1.5 MPa before the explosion), causing the pressure-bearing components of the boiler to crack and ultimately resulting in an explosion. This was the immediate cause of the accident. 2. Indirect causes: (1) Liao Zhiqiang, the person in charge of boiler installation, failed to comply with the relevant regulations and technical standards for boiler installation, resulting in a loss of control over the quality of the boiler installation. Liao Zhiqiang, the person in charge of boiler installation, learned that the user intended to start trial production and use the boiler. Without ensuring that the boiler had undergone foundation inspection, hydrostatic testing, burner calibration, trial operation, and overall acceptance, he failed to inform the user that the boiler could not be put into operation as it had not passed the installation inspection ； The user was not informed of situations such as the steam passage of the boiler’s safety valve being blocked by a blind flange, and the boiler’s burner and pressure interlock protection devices not having been properly tested; moreover, the user was allowed to operate the boiler during its installation phase when it was still in an unsafe state and its safety performance could not be guaranteed. (2) Boiler operator Li Zhengsong operated the boiler without a license; lacking the necessary qualifications, he was unable to address the safety hazards associated with the boiler in a timely and effective manner. (3) The primary responsibility for the safe management of special equipment in enterprises is not properly fulfilled. Yixin Company fails to fulfill its primary responsibilities for the safe management of special equipment; it has a weak safety awareness. The company’s safety production management systems and equipment operation procedures are inadequate, and they are not properly implemented. The company fails to meet the requirements related to the \"three implementations, two certifications, one inspection, and one plan\" for special equipment. Additionally, the company does not adequately implement a safety responsibility system among all its employees, nor does it provide sufficient safety training ； Personnel in charge of special equipment engage in work related to the safety management of such equipment without possessing the required qualification certificates ； The relevant safety management personnel are failing to fulfill their duties properly ； Hiring personnel without the necessary qualifications to perform stoker duties. 3. Main causes: Illegal installation of boilers and illegal use of boilers are the main causes of the accident. (1) Liao Zhiqiang, the person in charge of boiler installation, is suspected of forging official seals and using the name of Sichuan Leshan Boiler Company to carry out boiler installation activities without permission and without having the necessary qualifications for such work. His actions violate the requirements of laws and regulations such as the \"Special Equipment Safety Law of the People’s Republic of China\" and the \"Regulations on the Safety Supervision of Special Equipment\", as well as relevant safety technical standards; thus, his behavior is illegal. During the boiler installation, no application was made to a qualified inspection agency for supervision of the installation process; the quality of the installation did not meet the requirements specified in the relevant regulations and technical standards for boiler installation, and its safety performance also failed to comply with the prescribed requirements. (2) The user entity violates the requirements of laws and regulations such as the Safety Law of the People’s Republic of China on Special Equipment and the Regulations on the Supervision of Special Equipment Safety, as well as relevant safety and technical standards, by illegally using boilers that have not undergone installation and commissioning, have not passed the installation supervision inspection, or have not been registered for use. 4. Secondary reasons: Inadequate safety supervision by the relevant functional departments is a secondary reason. (1) The Chumi Branch of the Tongzi County Market Supervision Bureau failed to enforce the laws and regulations regarding special equipment properly, and did not carry out adequate daily supervision and inspections on the safety of special equipment in its jurisdiction. (2) The Market Regulation Bureau of Tongzi County failed to enforce the laws and regulations regarding special equipment, and did not provide adequate supervision over the performance of its Chumi branch in terms of routine inspections and other regulatory duties. (3) The Agriculture and Animal Husbandry Bureau of Tongzi County failed to properly implement the principle that \"those in charge of an industry must also be responsible for ensuring safety, and those in charge of specific tasks must also ensure safety,\" and failed to conduct proper inspections of Yi Xin Company’s safety practices. (4) The Construction and Development Department of the Loushan Pass High-Tech Zone in Tongzi County failed to properly implement the principle that \"those in charge of an industry must also be responsible for safety, and those in charge of specific tasks must also ensure safety,\" and did not carry out adequate inspections regarding safety in the park. (5) The Management Committee of the Loushan Pass High-Tech Zone in Tongzi County failed to properly implement the principle that \"those in charge of an industry must also be responsible for safety, and those in charge of certain tasks must also ensure safety,\" and failed to fulfill its duties regarding work safety in this high-tech zone. (6) The people’s government of Tongzi County has failed to effectively implement the principles of \"one position, two responsibilities\" and \"those in charge of an industry must also be responsible for safety, those in charge of specific tasks must also ensure safety\", and has not fulfilled its duties regarding work safety in the Loushangguan High-Tech Zone of Tongzi County. (II) Nature of the accident: Upon investigation by the task force, it was determined that the major boiler explosion at Yixin Company on June 7 was an accident resulting from negligence in the safety management of special equipment.

At around 11:40 on December 9, 2020, during the process of replacing filter elements in the lithium hexafluorophosphate production workshop of Houcheng Technology (Nantong) Co., Ltd., anhydrous hydrogen fluoride remaining inside the filter elements splashed onto the workers, resulting in hydrogen fluoride poisoning and one death. The direct cause of the accident was that when the operator, who was not wearing appropriate protective equipment, replaced the filter element, anhydrous hydrogen fluoride remaining inside the filter element leaked out and splashed onto the operator, resulting in the accident. Suggestions for handling the personnel involved in the accident: 1. Zhang Xiaoxiao, operator. Lack of safety awareness, and carrying out filter element replacement tasks in violation of safety protocols without taking appropriate protective measures – these factors are directly responsible for the occurrence of the accident. Handling recommendation: Given that he died in that accident, it is recommended to exempt him from liability. 2. Yu Liangliang, team leader. In violation of the inspection and maintenance procedures, it is assumed that Qin Jinfeng signed the maintenance work orders without authorization, failing to carry out safety handovers, confirmations, and inspections at the site where the inspection and maintenance work was to be carried out ； Failing to strictly follow the operating procedures for filter elements, and failing to ensure that workers implemented protective measures – these are the main reasons for the accident. Handling recommendation: Due to suspected criminal offenses, it is recommended that the judicial authorities pursue his criminal liability. 3. Liu Lin, Production Manager. The statutory responsibilities related to safe production were not fulfilled properly, safety inspections were inadequate, and the hazards resulting from continuous alarms for toxic gases were not addressed in a timely manner ； Lax oversight was exercised in formulating and reviewing the procedures for filter element replacement; training on these procedures was not carried out as required, and significant responsibility lies with them for the occurrence of the accident. Handling recommendation: Due to suspected criminal offenses, it is recommended that the judicial authorities pursue his criminal liability. 4. Kim Cheol-hu, Production Director. Effective safety risk identification has not been carried out ； Insufficient training and education on personnel safety ； Inadequate safety inspections and identification of potential hazards are responsible for the occurrence of accidents. Handling recommendation: Houchéng Company should terminate its labor contract in accordance with the company’s relevant management regulations. 5. Sun Fangfang, Chief Safety Officer. The statutory responsibilities regarding safe production were not fulfilled properly; the company failed to organize or participate in the formulation of safety operation procedures in accordance with legal requirements ； Insufficient training and education on personnel safety ； Inadequate safety inspections and hazard identification failed to uncover the long-standing safety risks within the company, nor did they ensure that these risks were addressed; thus, they are responsible for the occurrence of the accident. Handling recommendation: The Municipal Emergency Management Bureau shall impose an administrative penalty of a fine on them in accordance with the relevant laws and regulations on work safety. He does not meet the qualifications to serve as the safety director of a hazardous chemicals enterprise. 6. Park Chan-bok, legal representative and general manager. The statutory responsibilities regarding work safety were not properly fulfilled; the company’s work safety responsibility system was not established, and the company failed to develop work safety procedures in accordance with legal requirements ； Inadequate identification and control of safety production risks, as well as defects in production processes and equipment ； Inadequate safety inspections and the failure to address potential hazards mean that leadership is responsible for the occurrence of accidents. Handling recommendation: The Municipal Emergency Management Bureau shall impose an administrative penalty of a fine on them in accordance with the relevant laws and regulations on work safety. He is not suitable to hold the position of general manager in a hazardous chemicals company. 7. Zhang Yufeng, Assistant Mechanical Manager. The maintenance system was violated, as the long-standing practice of signing maintenance work orders on behalf of others was not stopped ； Failing to correct the unsafe methods of replacing filter elements is responsible for the occurrence of the accident. Handling recommendation: Houcheng Company shall handle it in accordance with the company’s relevant management regulations. 8. Qin Jinfeng, DCS operator. Lack of safety awareness and legal consciousness, as well as granting Liangliang permission to sign maintenance work orders in violation of regulations, render them responsible for the occurrence of the accident. Handling recommendation: Houcheng Company shall handle it in accordance with the company’s relevant management regulations. 9. Zhang Dafang, Production Assistant. The statutory responsibilities regarding safe production were not fulfilled properly, and training on the procedures for replacing filter elements was not carried out as required ； Failing to detect and eliminate potential accident hazards in a timely manner is responsible for the occurrence of the accident. Handling recommendation: Houcheng Company shall handle it in accordance with the company’s relevant management regulations.

Course of the accident and emergency response measures (I) Course of the accident: At around 7:00 on December 9, 2020, Yu Liangliang, the shift leader for the lithium hexafluorophosphate production area, held a morning meeting to assign operators Zhang Xiaoxiao and Yang Dongjian with the task of preparing for the maintenance work on filter F2736D and compressor K2791A in that facility. At around 8:00, Yu Liangliang instructed the DCS operator Qin Jinfeng to issue a maintenance order for filter F2736D, and asked Gao Chunhui to deliver the maintenance order to the maintenance department. After receiving the Maintenance Work Order, Zhang Yufeng, the assistant to the mechanical manager, signed it and then handed it over to the maintenance workers Mao Xiaojun and Sun Jie. At around 9:10, Mao Xiaojun and Sun Jie arrived at filter F2736D on the fourth floor of the lithium hexafluorophosphate workshop. Sun Jie used a walkie-talkie to contact Qin Jinfeng, asking the production department to send someone to assist with replacing the filter element of F2736D. Qin Jinfeng arranged for Zhang Xiaoxiao to assist. After Zhang Xiaoxiao went to the fourth floor, Qin Jinfeng used the walkie-talkie to inform Mao Xiaojun, Sun Jie, and Zhang Xiaoxiao that the filter was still in use and that replacement work could not be carried out at that time; he instructed them to go to compressor K2791A on the first floor to carry out their tasks there first. Therefore, Mao Xiaojun and two others went to compressor K2791A on the first floor to carry out maintenance work. At around 9:30, Qin Jinfeng noticed that the material in reactor R2736D had been completely used up, so he instructed Yang Dongjian to purge filter F2736D. At around 10:30, Qin Jinfeng used the walkie-talkie to call Zhang Xiaoxiao and ask her to go to the fourth floor to check the purging situation. At around 10:40, Zhang Xiaoxiao replied to Qin Jinfeng that the purging was almost complete, and then went back to the first floor to continue working. At around 10:54, Qin Jinfeng used the walkie-talkie to call Zhang Xiaoxiao and asked her to take Mao Xiaojun and Sun Jie to replace the filter element F2736D. After reaching the fourth floor, Mao Xiaojun and Zhang Xiaoxiao checked whether the inlet and outlet valves of the anhydrous hydrogen fluoride pipeline were closed, as well as the status of the drainage of anhydrous hydrogen fluoride (mainly to observe whether there was any acid mist from anhydrous hydrogen fluoride at the nitrogen inlet valve). After Zhang Xiaoxiao confirmed that the purging was complete, the two of them began to remove the screws from the flange on the upper end plate of the filter. During this process, Sun Jie arrived on the fourth floor around 11:15 and joined Mao Xiaojun and Zhang Xiaoxiao in removing the screws from the flange. After removing the screws, Mao Xiaojun and Sun Jie used wrenches to pry open the filter element, lifting it with their hands and placing its bottom part on the cylinder flange. Zhang Xiaoxiao held the filter element with her hands. As the three of them tried to move the filter element to the ground, its top part tilted in Zhang Xiaoxiao’s direction, causing anhydrous hydrogen fluoride to flow out from the upper opening of the filter element and spill onto her abdomen and legs. Zhang Xiaoxiao instinctively let go, and the filter element fell to the ground. Sun Jie and Mao Xiaojun also got a little splashed with anhydrous hydrogen fluoride, and the toxic gas alarm at the scene started to sound an alarm. Zhang Xiaoxiao, Mao Xiaojun, and Sun Jie immediately took off their clothes and ran to the eye wash station at the elevator entrance to rinse their eyes. Sun Jie called the DCS control room via walkie-talkie and phoned Zhang Yufeng to inform him. (II) Emergency rescue efforts: After the accident occurred, the company’s production manager Liu Lin, production assistant Zhang Dafang, assistant to the machinery manager Zhang Yufeng, the on-duty team leader Yu Liangliang, and several employees immediately rushed to the accident site to carry out rescue operations. Those present provided Zhang Xiaoxiao with basic anti-fluoride treatment. At the same time, the company arranged for a vehicle to take the injured Zhang Xiaoxiao to the affiliated hospital in Nantong for treatment; Zhang Xiaoxiao died at 18:52 that day despite efforts to save her life. III. Casualties and direct economic losses caused by the accident: The accident resulted in 1 death. According to the relevant provisions of the \"Statistical Standards for Economic Losses from Accidents Involving Enterprise Employees\" (GB6721-1986), the direct economic loss resulting from the accident was approximately 1.408 million yuan.