Reflections on the “four asymmetries” of the “4·22” fire in Jiangsu

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1.jpg The lessons learned from the \"4·22\" fire accident at Jiangsu Deqiao Warehouse are thought-provoking. In particular, it is necessary to carefully analyze the \"four asymmetries\" identified in this accident, draw conclusions from them, and take preventive measures in advance. 　　I. The issue of accountability from the perspective of the asymmetry between ‘minor triggers’ and ‘catastrophic consequences’ According to preliminary investigations, the ‘4·22’ fire accident was caused by the illegal use of open flames by the involved company; small sparks generated during welding triggered the fire, which burned for over 16 hours. Nearly 200 fire trucks from several surrounding provinces/cities, as well as more than 1,400 firefighters and police officers, were deployed. People living within a 5-kilometer radius were evacuated, and ships within 5 kilometers upstream and downstream of the dock were removed from the area. Navigation was prohibited in the Fujiangsha Waterway on the north side of the site. One firefighter lost his life in this incident, resulting in significant economic losses and serious social impacts. What’s alarming is that once the fire gets out of control, it could trigger successive explosions in other hazardous storage tanks in the warehouse area, resulting in a disaster of unimaginable proportions. From a \"small spark\" to a \"major accident,\" this seems similar to the \"butterfly effect\": small things can turn into major events when amplified by a system. Among these, the absence of safety responsibilities is the core issue. The vast majority of work safety accidents are liability accidents; in the \"4·22\" fire accident, the enterprise’s management and safety officers clearly failed to fulfill their responsibilities, while the welders failed to offer help in a time of crisis and fled the scene. The primary and most important factor in determining safe production is the word “responsibility”. However, safety in production hinges on responsibility, and it is also difficult precisely because of that responsibility. The responsibilities related to safe production have their particularities: Firstly, the accountability is strict, which can lead to fear and aversion towards carrying out such tasks. The responsibility for safe production is \"as heavy as Mount Tai\" – it carries strict obligations and high risks. Those who fail in their duties will be held accountable; in mild cases, they face disciplinary action under party or governmental rules, while in severe cases, criminal prosecution follows. Moreover, even those who have been removed from their positions or retired for many years can still not escape accountability if traced back to the root of the issue. Under pressure, some cadres and employees are afraid of taking responsibility and avoid taking action; they are reluctant to do anything, which delays matters and turns small issues into big problems. They panic when faced with challenges and become fearful in times of crisis. Especially after major accidents occur and those responsible are held accountable, a negative and demoralized atmosphere takes hold. 　　Secondly, there are multiple levels of responsibility, which can lead to a reduction in the transmission of pressure. Safety production responsibilities extend to all levels and aspects, but their intensity diminishes as they are passed down. It is often the frontline workers who lack both a sense of responsibility and the necessary skills that end up bearing direct responsibility; thus, there is a problem of insufficient implementation of these safety responsibilities at the \"last mile.\" Many accidents caused by minor errors occur among this group, and this issue requires serious attention. 　　Again, there are many layers of responsibility, which can lead to a domino effect. From Party and government organizations at all levels, to relevant functional departments, to various enterprises, all are responsible entities. Leaders at all levels, from the central government to local authorities, as well as departmental officials and employees in enterprises, are all accountable. Tasks ranging from administrative approval and quality inspection to comprehensive supervision throughout the process all fall under the scope of responsibilities; safety obligations exist at every moment and in every situation. Therefore, the responsibility chain for safe production is long, involves many stages, and comes with numerous tasks; any negligence or mistake at any node or by any individual can trigger a chain reaction in which one misstep leads to total failure and the loss of all previous efforts. This helps to better understand the concept that \"safe production involves fragile items,\" highlighting the degree of uncontrollability. In short, it is quite complex and not an easy task to truly assign safety production responsibilities to specific individuals and ensure they are fulfilled throughout all aspects. First, it is necessary to strengthen the leadership responsibilities of Party and government organizations at all levels as well as the regulatory responsibilities of various departments; leaders at all levels must take responsibility earnestly, organize effectively, and ensure proper supervision. Secondly, it is necessary to strengthen the primary responsibility of enterprises, as well as the role of their top executives as the \"primary persons responsible\". In particular, enterprises must ensure adequate investment in safety measures, proper employee training, sound basic management systems, and effective emergency response mechanisms. This will help to overcome the \"last mile\" of challenges related to safety responsibilities, eliminate obstacles and blind spots, and strengthen the foundational aspects of safety management. Thirdly, it is essential to place great emphasis on strengthening technological support, and to vigorously develop \"Internet + safety supervision\" and \"smart safety supervision.\" By making extensive use of automated, intelligent, and information-based technologies, it is possible to improve the systems, methods, and tools used for supervision. Technology can be utilized to address shortcomings and enhance efficiency, thereby effectively solving various problems such as insufficient capacity for responsibility, inadequate supervision efforts, and limited methods and tools. 　　II. The regular patterns of safety accidents from the perspective of the asymmetry between \"welders\" and \"hazardous chemicals\". Based on preliminary information, there were two main parties involved at the scene of the \"4·22\" fire accident: one was the party responsible for hazardous chemical storage. The knowledge and information held by this technical system relates to the types of hazards, their production, storage and transportation, as well as safety measures and rescue procedures. The leaders and employees of this operational entity must have a thorough understanding of the relevant knowledge and information; there must be no such thing as a \"blindness to hazards\". Another entity is the welding operation entity. The knowledge information possessed by this technical system relates to welding. The technical relevance between these two entities is extremely low, and the probability of them carrying out joint operations is very small. Accidents often occur during their joint operations in the same space. Welders generally have no idea how dangerous even small sparks can be in high-risk, sensitive areas. Hazardous material handlers usually have no awareness that sparks can fly everywhere and be difficult to control during the welding process. The probability of failure in a joint operation where only one side is aware of the plan is quite high. 　　Accidents resulting from such structural contradictions due to differences in knowledge, information, and types of technical work are numerous. In the series of oil and gas explosions that occurred at Huangtian Port in Qingdao, sparks generated by workers using impact drills to drill through concrete floors ignited the flammable gases in underground pipelines, resulting in a severe liability accident. On May 9, the same tragedy occurred again: an oil product transport ship in a dockyard in Nanjing exploded and caught fire, resulting in 2 deaths. The cause was residual oil and gas on the ship after it had unloaded its cargo elsewhere; when the crew attempted to repair equipment by welding, the presence of those residual fuels and gases led to an explosion. It can be seen that employees from different technical systems are unable to communicate effectively due to asymmetrical knowledge and information, which makes it difficult to properly prevent and control the causes of accidents. 　　This requires us to consider not only intrinsic safety, but also to place greater emphasis on non-intrinsic safety. These are two equally important issues regarding safe production. Regarding intrinsic safety, people have a relatively good understanding and preparation for it, but as for non-intrinsic safety, especially accidents caused by asymmetries in knowledge and information, our level of awareness and preventive measures seem to be insufficient. Such accidents are unexpected and occur frequently; they are widespread and repetitive in nature. They require serious attention. By analyzing cases both positive and negative, it is necessary to conduct thorough studies and summaries in order to identify patterns, develop preventive procedures, and enhance the proactivity and foresight in handling such situations, thereby preventing their recurrence. 　　III. The issue of investment in safety from the perspective of the asymmetry between \"limited investment\" and \"huge losses\" When the fire broke out in the \"4·22\" accident, the company’s safety officers quickly grabbed two small fire extinguishers to try to put out the fire, but this was utterly insufficient against such a fierce blaze, which illustrates the inadequate level of investment the company made in fire protection measures. The fire trucks from Jingjiang and Taizhou that arrived later either had outdated equipment or insufficient foam. It was not until high-performance fire trucks from surrounding cities such as Suzhou and Wuxi, as well as from Shanghai and Zhejiang, arrived that a safe route to close the oil supply valves was created. Due to the lack of appropriate firefighting equipment in Taizhou, it was necessary to mobilize resources on a larger scale, which resulted in the loss of valuable rescue opportunities. The continuously burning fire in turn triggered greater risks, more panic, and worse consequences. Looking solely at the economic losses: in addition to the direct losses of hundreds of millions of yuan for enterprises due to fire accidents, the costs associated with rescue efforts exceed 30 million yuan. Moreover, cleaning up the accident site and transferring stored goods later on require significant investment in human resources and financial resources, so the scale of these losses is evident. 　　First of all, investment in work safety must be increased and upgraded. Especially for large-scale, high-risk industry enterprises, facilities with corresponding rescue capabilities must be equipped. In safety economics, the cost-benefit ratio of preventive safety measures is much higher than that of corrective actions taken after accidents; the ratio between the two is 5:1. “The concepts and practices of \"production first, safety second\" and \"emphasizing production over safety\" must be completely corrected. Following the fire, Jingjiang City, where the incident occurred, issued a directive requiring that hazardous enterprises within its jurisdiction must be equipped with fire trucks and personnel of appropriate capacity, as a measure to prevent similar incidents in the future. 　　Secondly, it is necessary to coordinate the allocation of resources for safety investments. Departments such as those responsible for safety supervision need to conduct comprehensive, systematic, and multi-faceted research and analysis on enterprises’ investment in safety, the level of such investment, and its rationality, in order to better guide these investments. While ensuring proper guidance and supervision regarding corporate investment, it is necessary to consider carefully which rescue facilities should be funded by enterprises and which should be funded by **. Resource allocation needs to be optimized and the efficiency of resource use improved; investments must not be made blindly or in a disorganized manner. 　　IV. The issue of project attraction from the perspective of the asymmetry between \"minimal financial contribution\" and \"huge resource consumption\" The Jiangsu Deqiao warehousing area features 12 fuel tanks, diesel tanks, and gasoline tanks, as well as 30 chemical storage tanks. The total length of the wharves is 460 meters, and the area allocated for storage facilities associated with these wharves covers more than 470 mu. This project occupies a significant amount of valuable Yangtze River shoreline resources, and it also covers a considerable area. However, over the more than 6 years since the project was established, its total contribution to the local finances has been only a little over 13 million yuan. It is undeniable that the establishment of this project has had certain positive effects on the local economic and social development. However, there is a clear imbalance between the project’s “minimal financial contribution” and its “huge consumption of resources”. Firstly, such a minor contribution makes it difficult to reflect the value of the large amount of land and environmental resources it consumes. Secondly, such high-risk projects exert significant actual and potential pressures on local areas in terms of production safety, environmental ecology, and social stability, with their contributions being minimal. Lastly, throughout the accident rescue process, the financial and material resources invested, as well as the pressures and responsibilities involved, are utterly overwhelming. We need to reflect deeply on the following points: First, why do projects of such a large scale and high risk contribute so little in terms of tax revenue? When attracting projects and implementing control measures at the source, is it more important to focus on quantity and scale, or should quality and efficiency take precedence? In other words, should short-term political achievements be considered alongside the long-term comprehensive economic and social costs? Second, while taking into account corporate development and profitability, should we pay more attention to issues such as corporate safety, environmental protection, and other negative external effects, as well as the issue of spillover costs and corporate social responsibilities? Third, when considering how to attract new enterprises, should we also think about how to eliminate those that pose significant risks to safety and the environment, consume large amounts of resources, and contribute little in terms of taxes? Those enterprises should be shut down, have their licenses revoked, or be eliminated by the market forces; decisive actions must be taken to ensure safe, sustainable, and scientific development.