Report on the Handling of the Major Accident “2•25” at Datang Changshan Thermal Power Plant

II. Causes of the accident (1) Direct cause: During the maintenance of Coal Mill C of Boiler No. 1 at Changshan Plant, Li Jun, a thermal control maintenance worker, engaged in seriously violating operations. Without the necessary conditions for equipment commissioning, and without checking the device identifiers, Li Jun arbitrarily activated the air supply solenoid valve for the pneumatic sliding door at the inlet of Coal Mill C, as well as the manual air supply valve equipped with a warning sign stating “Do not operate – personnel are present.” This caused the previously closed pneumatic sliding door at the inlet of Coal Mill C to open, allowing hot air at a temperature of 309°C and a pressure of 6 kPa to flow into the hot primary air duct of Coal Mill C, thereby leading to the accident.

(II) Indirect causes
1. Li Deyu, team leader of the coal pulverization team in the Boiler Workshop under the Maintenance Department, violated the provisions of Article 4.4.13 of the “Safety Work Regulations for the Electric Power Industry” (GB26164.1-2010). Without retrieving the maintenance work permit, with workers still present at the work site, and before the project was fully completed, he arranged for Liu Jun to contact operators from the Power Generation Management Department to conduct commissioning on the pneumatic control damper for the primary hot air at the inlet of Coal Mill C； This constitutes a violation of Article 4.2.6 of the “Safety Work Regulations for the Electric Power Industry” (GB26164.1-2010). The person in charge of maintenance work for Coal Mill C was reassigned to work in the coal feeder operation team, and team members were arbitrarily changed; this represents serious violations of safety regulations in command practices. 2. Du Bao, shift supervisor of the centralized control operation unit under the Power Generation Management Department, failed to organize relevant personnel from the operation, thermal control, and maintenance “three parties” to carry out the equipment commissioning work in accordance with the regulations on equipment trial operation. 3. Zhang Daming, a maintenance worker from the coal grinding team in the boiler workshop, asked Li Jun on site to adjust the pneumatic control valve for the hot primary air inlet of Mill C, which constitutes serious violation of operating procedures. 4. Yang Baoming, the chief maintenance worker of the furnace control shift in the Thermal Control Workshop, after receiving a call from Li Jun seeking advice, violated Article 4.1.6 of Changshan Plant’s ‘Thermal Control Workshop Shift Duty Management Regulations’, which states that in case of any issues at the work site during shift hours, the team must handle them together and no one should work alone. Instead, he allowed Li Jun to go to the work site by himself without reporting to the shift leader.

III. Identified Problems (1) Insufficient identification of hazardous factors associated with maintenance operations at the Changshan plant, as well as inadequate safety protection measures. Maintenance management is chaotic; the maintenance personnel are not familiar with the conditions on site. The company failed to adequately identify the risk factors associated with this maintenance work, and did not take the necessary measures in accordance with regulatory requirements to effectively isolate the air supply to the pneumatic slide valves at the inlet of C coal mill, nor did it cut off the power supply to the solenoid valves that control those valves. (II) The relevant departments at Changshan Plant failed to conduct supervision and inspection of the maintenance site in accordance with the provisions of Article 4.5.1 of the “Safety Work Regulations for the Electric Power Industry” (GB26164.1-2010). The Power Generation Management Department and the Equipment Management Department are the departments ultimately responsible for ensuring the proper implementation of work orders; they fail to provide adequate supervision and enforcement during equipment maintenance and calibration ； During the equipment commissioning process, the Maintenance Department failed to carry out its duties as required ； The Safety Inspection Department fails to provide adequate supervision over the entire process at the work site ； The Equipment Management Department and the Maintenance Department fail to fulfill their duties of supervision and inspection at the maintenance work sites. (III) The work on identifying and addressing potential hazards at the Changshan factory is not thorough enough, and the safety systems are inadequate. The relevant departments and personnel failed to conduct a thorough analysis of the work order; they did not identify any existing problems, nor did they include measures to effectively isolate the air supply to the pneumatic sliding door at the inlet of coal mill C, as well as to cut off the power supply to the solenoid valves controlling that air supply, as part of the safety measures specified in the work order. (IV) Changshan Factory fails to provide adequate safety skills training for its employees, and fails to enforce proper supervision and inspection of such training. The requirements stipulated in Article 3.3.2 of the \"Safety Regulations for the Electric Power Industry\" (GB26164.1-2010) were not followed regarding the provision of thorough safety training for employees; in particular, when staff changed positions, adequate training on the skills required for those new roles was not provided in a timely manner. As a result, the operators were unaware of the relevant working environment as well as the equipment and facilities, and they did not possess the necessary operational skills. The Human Resources Department failed to fulfill its responsibilities in supervising and inspecting safety training, and failed to identify the existing problems in a timely manner. (5) Jilin Company lacks a sense of crisis and urgency regarding the long-standing safety issues at Changshan Plant, and the measures taken to address these problems are insufficient in terms of scope and intensity. On October 9, 2014, an explosion occurred in the rear flue of Boiler No. 1 at Changshan Plant. Jilin Company replaced its deputy plant manager for production and chief engineer. Subsequently, no effective measures were taken for governance and rectification to reduce safety production risks, resulting in another accident.

IV. Responsibility analysis and actions against relevant responsible parties: According to the findings of the accident investigation team from the Songyuan City People’s Government, the death accident that occurred on February 25 at Changshan Factory was determined to be a serious production safety liability accident, with Changshan Factory being the entity responsible for this incident. (1) Recommendations regarding the units responsible for the accident: 1. Changshan Factory failed to comply with operating procedures during maintenance work, provided inadequate training for staff assigned to different positions, failed to fulfill its responsibilities regarding safe production, its supervisory management failed to exercise proper oversight, departmental responsibilities were not clearly defined, and supervision of the work site was insufficient; as a result, it bears primary managerial responsibility for the occurrence of the accident. In addition to the local authorities imposing a fine of 550,000 yuan on it, the group company ordered Jilin Company to impose economic penalties on Changshan Factory in accordance with relevant regulations. 2. Jilin Company failed to take effective measures to address the long-standing issues at the Changshan plant, such as the failure to implement relevant systems and responsibilities, inadequate identification, assessment, and control of safety production risks, insufficient training, chaotic management of safety production operations at the site, and frequent occurrences of illegal operations. As a result, these problems failed to be rectified, thereby increasing the risks associated with safety production; this led to another accident following the explosion in the boiler’s rear flue on October 9th. Jilin Company failed to adequately fulfill its duties regarding work safety supervision and management; it bears managerial responsibility for the occurrence of the accident. The group company imposed economic penalties on Jilin Company in accordance with relevant regulations.

(II) Measures to be taken against the relevant responsible persons: Based on the responsibilities assumed by the relevant responsible persons at Jilin Company and Changshan Plant in this accident, and in accordance with the **Interim Provisions on Violations of Laws and Disciplinary Rules in the Field of Work Safety issued by the State Administration for Work Safety, the Decision of the Songyuan Work Safety Supervision Bureau regarding the handling of the units and individuals involved in the serious work safety accident at Datang Changshan Thermal Power Plant on February 25th (Song An Jian Guan [2016] No. 31), the Incentive and Punishment Regulations for Work Safety within China Datang Group Corporation, and the Interim Provisions on the Principle of \"Shared Responsibilities by Party and Government, and Dual Responsibilities for Each Position\" in terms of work safety, the following measures are taken against the relevant responsible persons at Jilin Company and Changshan Plant: 1. Decisions taken by the group company regarding the relevant personnel: (1) Guo Shuoping, the general manager of Jilin Company, as the primary person responsible for work safety, failed to fulfill his leadership duties in this regard. After the flue explosion that occurred at Changshan Plant on October 9, 2014, he failed to ensure that proper work safety measures were implemented there; he is therefore held accountable for the occurrence of this accident. A formal warning was issued to the fruit tree farm, along with a financial penalty of 10,000 yuan. (2) Wang Liyan, the Party group secretary of Jilin Company, as the main person in charge of the Party group, failed to promptly address the major safety issues in the companies under its jurisdiction, and bears leadership responsibility for the occurrence of the accident. Wang Liyan is given an administrative warning and a financial penalty of 10,000 yuan. (3) Chen Yanping, the deputy general manager of Jilin Company and the person in charge of work safety, failed to ensure thorough implementation of the requirements set by the group company. After the flue explosion that occurred at Changshan Plant on October 9, 2014, he did not take effective measures to address the issue and reduce its safety risks, which led to another accident; he is therefore held accountable for this incident as a leader. Chen Yanping was given an administrative reprimand and fined 20,000 yuan. 2. Jilin Company’s decision regarding the relevant personnel: (1) She Tienan, the manager of Changshan Plant, as the person primarily responsible for safety production at that plant, failed to ensure proper management of safety measures. Issues such as inadequate implementation of plant regulations, lack of clear responsibility systems, insufficient training, and chaotic conditions related to safety production persisted for a long time, and he bears primary leadership responsibility for the occurrence of the accident. She Tienan is dismissed from his position, and a financial penalty equivalent to 40% of his previous year’s annual income is imposed on him. (2) Zhang Yuanda, Secretary of the Party Committee of Changshan Plant, as the main person in charge of the Party Committee there, failed to effectively implement safety production policies and guidelines, did not adequately address the major safety issues within the enterprise, and failed to carry out proper education among employees regarding safety production; he bears primary leadership responsibility for the occurrence of these accidents. Zhang Yuanda was dismissed from his position and fined 40,000 yuan. (3) Li Yesheng, the deputy director of Changshan Plant, as the main person responsible for work safety, failed to ensure proper identification, assessment, control, and management of work safety risks at Changshan Plant. He also failed to adequately implement the group company’s work order system and requirements related to operations in confined spaces, as well as to manage work safety effectively at the maintenance sites. The process of conducting inspections, making adjustments, and implementing improvements progressed slowly, and he bears primary leadership responsibility for the occurrence of the accident. Li Yesheng was dismissed from his position and fined 40,000 yuan. (4) Bai Weidong, the chief engineer of Changshan Plant, failed to exercise proper oversight as the person responsible for approving the maintenance plan; he neglected to manage the safety training for employees who were reassigned to other positions, and also failed to ensure proper safety management at the maintenance site (during the time when deputy plant manager Li Yesheng was on business trip). He bears primary leadership responsibility for the occurrence of this accident. Bai Weidong was given a demotion and fined 30,000 yuan. (5) Chen Yaoru, the director of the Safety Production Department at Jilin Company, as the main leader of the safety production department, failed to take effective measures to address the numerous safety issues existing at Changshan Plant; she also failed to carry out adequate supervision and inspection of safety production there, and is therefore accountable for the occurrence of the accident. Chen Yaoru is given a demotion and fined 30,000 yuan. (6) Song Libin, assistant director of the Safety Production Department at Jilin Company, as a supervising leader of the safety production management department, failed to effectively oversee the numerous safety issues existing at Changshan Plant, and is therefore responsible for his inadequate supervision that contributed to the occurrence of the accident. Song Libin is given a warning penalty and a financial fine of 10,000 yuan. 3. Changshan Plant’s decision regarding the personnel involved: (1) Li Jun, a maintenance worker from the Furnace Control Team in the Thermal Control Workshop of the Maintenance Department, seriously violated operating procedures, exceeded the scope of his duties, and breached work protocols, which directly led to the accident. The judicial authorities shall pursue Li Jun’s criminal liability in accordance with the law and terminate his employment contract. (2) Li Deyu, the team leader of the coal grinding team in the boiler workshop of the Maintenance Department, violated the \"Electrical Safety Work Regulations\" by giving illegal instructions and carrying out illegal operations; he bears leadership responsibility for the occurrence of the accident and should be referred to the judicial authorities so that his criminal liability can be pursued in accordance with the law. Given that Li Deyu died in the accident, he is exempt from any liability. (3) Du Bao, the head of the centralized control operation unit in the Power Generation Management Department, violated the \"Electrical Safety Work Procedures\" by ordering thermal control personnel to go to the maintenance site for adjustments verbally, without first retrieving the maintenance work order; he bears primary leadership responsibility for the occurrence of the accident. Du Bao was given a one-year probationary suspension along with a financial penalty of 40,000 yuan. (4) Liu Jun, a technician in the coal grinding team of the boiler workshop in the Maintenance Department, violated the \"Electrical Safety Work Procedures\" by giving oral instructions over the phone to arrange debugging tasks without first confirming whether the site where the maintenance work was being carried out met the conditions for trial operation; he is therefore responsible for the occurrence of the accident. Liu Jun was given a one-year probationary suspension and fined 40,000 yuan. (5) Zhang Daming from the coal grinding team in the boiler workshop of the Maintenance Department violated the \"Electrical Safety Work Procedures\" by blindly cooperating with the commissioning process; he proceeded to carry out operations together with thermal control technician Li Jun without first confirming whether the personnel from all three parties were present, and is therefore responsible for the occurrence of the accident. Zhang Daming was given a one-year probationary period as a disciplinary measure, along with a financial penalty of 40,000 yuan. (6) Liu Lichun, the director of the Thermal Control Workshop in the Maintenance Department, as the primary person responsible for safety production in the workshop, failed to provide timely workshop-level skill training to those whose roles had been adjusted. As a result, these individuals were not familiar with the operations required for their new positions and started working without the necessary skills, for which she bears primary leadership responsibility for the accident. Liu Lichun was dismissed from her position and fined 40,000 yuan. (7) Liu Liming, the director of the boiler workshop in the Maintenance Department, as the primary person responsible for safety in that workshop, failed to properly implement the group company’s work order system and requirements regarding work in confined spaces. He also failed to carry out adequate supervision and inspection at the work site, and thus bears primary leadership responsibility for the occurrence of the accident. Liu Liming is to be dismissed from his position and fined 40,000 yuan. (8) Hu Xiaohui, Secretary and Deputy Director of the Equipment Management Department Party Branch, is responsible for the daily management of equipment maintenance. He failed to properly oversee the formulation, review, and implementation of the maintenance plans and work orders, and bears direct leadership responsibility for the occurrence of this accident. Hu Xiaohui was dismissed from his position and subjected to a financial penalty of 40,000 yuan. (9) Lu Kaijun, the deputy chief engineer in charge of maintenance and head of the Equipment Management Department, is the primary person responsible for safety production within this department. He failed to carry out effective inspections and rectifications of potential equipment hazards, and did not manage work orders properly; he bears primary leadership responsibility for the occurrence of the accident. Lv Kaijun is given a demotion and fined 30,000 yuan. (10) Liu Yingwei, the director of the Power Generation Management Department, is fully responsible for the work of this department. He failed to provide proper management of the maintenance construction sites, and did not exercise adequate supervision over the department’s responsibilities and work procedures; he is therefore held accountable for the occurrence of the accident. Liu Yingwei is given a serious reprimand and fined 20,000 yuan. (11) Liu Jinsong, the person in charge of training at the Human Resources Department, failed to provide adequate skill training for those whose positions were changed, and bears managerial responsibility for the occurrence of the accident. Liu Jinsong is given a severe reprimand and fined 20,000 yuan. (12) Zhang Jiaqi, the director of the Safety Inspection Department, failed to provide adequate supervision regarding issues such as the long-standing failure to implement rules and regulations, the lack of proper accountability systems, chaotic management at safety-related work sites, and frequent instances of illegal operations at the Changshan Plant; he is therefore responsible for the safety supervision failures that led to the accident. Zhang Jiaqi was given a severe reprimand and fined 20,000 yuan. (13) Ji Dianfa, Secretary of the General Branch of the Power Generation Management Department, failed to properly address the prominent issues related to safety production within his department, failed to carry out adequate education among the department’s employees regarding safety production, and is therefore held accountable for the occurrence of the accidents. Ji Dianfa was given a reprimand and a financial penalty of 20,000 yuan. (14) Zhang Baoyuan, the director of the Human Resources Department, is responsible for the management failures related to the inadequate skill training provided to those whose positions were changed, and is thus accountable for the occurrence of the accident. Zhang Baoyuan was given a reprimand and fined 20,000 yuan. (15) Zhao Hui, deputy director of the Thermal Control Workshop in the Maintenance Department, failed to provide adequate safety training for employees and to ensure proper on-site safety management, and is therefore responsible for the occurrence of the accident due to his role in on-site management. Zhao Hui was given a reprimand and fined 20,000 yuan. (16) Li Chun, Deputy Director of the Safety Inspection Department, is responsible for overseeing the safety of power generation operations; he failed to properly supervise the implementation of work orders by the operators, and thus bears responsibility for the safety issues that occurred. Li Chun was given a warning and fined 10,000 yuan. (17) Deputy Chief Engineer Liu Bin is responsible for the technical management of the plant’s operations, and bears technical leadership responsibility for the occurrence of the accident. Liu Bin is given a warning penalty and a financial fine of 10,000 yuan. (18) Zhou Dianquan, the director of the Maintenance Department, is the primary person responsible for safety production in this department. He failed to exercise proper oversight over safety production activities, did not effectively control safety risks, and failed to manage operations at the maintenance sites properly; as a result, he bears leadership responsibility for the occurrence of the accident. Zhou Dianquan was given a warning penalty and fined 10,000 yuan. (19) Chen Lifeng, Secretary of the General Branch of the Maintenance Department, failed to properly address the prominent issues related to safety production within his department, as well as to carry out adequate education on safety production among the department’s employees; he is therefore held accountable for the occurrence of these accidents. Chen Lifeng is given a warning penalty and a financial fine of 10,000 yuan. (20) Yue Chuang, the deputy director of the Power Generation Management Department, who is in charge of centralized control operation management, failed to properly supervise and manage the implementation of relevant procedures by the staff working in centralized control, and thus bears leadership responsibility for the occurrence of the accident. Yue Chuang is given a warning penalty along with a financial fine of 10,000 yuan. (21) Shift supervisor Teng Zhihe was fully responsible for ensuring safe production during his shift; he failed to properly supervise on-site maintenance work and the compliance of operators with relevant procedures, and thus bears managerial responsibility for the accident. Teng Zhihe was given a warning and fined 10,000 yuan. (22) Yang Baoming, the person in charge of on-site duty in the furnace control shift of the thermal control workshop and the chief maintenance worker, gave illegal instructions; after receiving a call from Li Jun seeking guidance, he failed to report to the shift supervisor and allowed Li Jun to go to the site alone, thus bearing responsibility for the on-site management of the accident. Yang Baoming is given a warning and fined 10,000 yuan.

V. Preventive Measures: All subsidiary companies and affiliated enterprises should earnestly learn from the lessons of the \"2·25\" accident, firmly establish the concept of safe development, and put in place a sound safety production responsibility system that emphasizes shared responsibilities by the Party and government, dual responsibilities for each position, and accountability for failures to fulfill duties. Measures must be taken for each of the issues identified by the accident, such as the failure to implement relevant rules and regulations, the lack of clear responsibility systems, inadequate identification, assessment, and control of safety risks, insufficient training, chaotic management at work sites involving safe production, and frequent occurrences of illegal operations. These measures are aimed at improving the mechanisms for managing safety risks, strengthening safety management in production and maintenance activities, and effectively reducing safety risks. (1) Improve safety technical measures. It is necessary to conduct a thorough analysis of the problems that arise during the implementation of enterprise security technical measures, and to draw lessons from this incident by taking management actions such as locking and labeling control cabinets, as well as installing cameras above them at the work sites ； Electric doors, pneumatic doors, and sliding doors should be equipped with locking devices and mechanical interlocks, and the power supply for pneumatics as well as the control power supply should be effectively isolated. (II) Strengthen the management of the implementation of the two types of tickets. Strictly enforce the responsibilities of the \"three types of personnel\" related to work orders, implement strict checks at each level, rigorously follow the procedures for securing work orders and testing equipment, carefully identify hazards in the workplace, and ensure that safety measures specified in work orders are properly implemented. The Power Generation Management Department and the Maintenance Supervision Department must ensure that work orders are executed correctly. The safety supervision department shall conduct inspections and supervision on the implementation of work orders. (III) Strictly implement post responsibilities. All production managers must be aware of the relevant on-site operations on a daily basis, keep track of the risks associated with those operations, and conduct inspections and supervision of the production site in accordance with the established standards for being present at work. Those who fail to carry out supervision and inspection properly or do not fulfill their duties diligently will be dealt with strictly. Enterprise leaders must supervise the implementation of responsibilities across various departments to strengthen the enforcement of safety production obligations. (IV) Strengthen safety risk management and control. It is necessary to deepen the implementation of the \"Three Emphases and One Implementation\" approach; by taking into account one’s job role and responsibilities, identify and analyze the hazardous factors in the work environment, devise risk control measures, ensure that these measures are put into practice on site, and regularly summarize and analyze any issues that arise during the implementation of this approach. It is necessary to conduct strict reviews of the \"three measures and two plans\" for work in confined spaces, strengthen on-site supervision during such operations, ensure that the responsibilities of on-site supervisors are properly fulfilled, and clarify the conditions for switching between dynamic and static states, the work procedures, as well as the frequency of testing for harmful gases, in order to minimize operational risks. (5) Carry out the identification and rectification of potential hazards. It is necessary to act in accordance with **laws, regulations, standards, and various institutional requirements of the group company. By thoroughly reviewing daily tasks (typical operations) as a starting point, potential hazards should be identified comprehensively. Emphasis must be placed on ensuring timely action and establishing long-term mechanisms for addressing these hazards; responsibilities must be defined, supervision at different levels implemented, and issues addressed immediately to eliminate persistent problems and prevent their recurrence. (VI) Strengthen safety education and training. It is necessary to strengthen safety production education and training for all employees, establish a system for pre-job training and assessment for personnel performing special tasks, those working in critical positions, and those who are changing or being reassigned to new roles, and enforce this system strictly. It is necessary to strengthen daily safety production education, raise the safety awareness of all employees, and improve their ability to identify risks and handle emergencies. (7) Vigorously pursue efforts to combat the three violations. It is necessary to reinforce the concept among personnel at all levels that \"violating regulations equals accidents,\" raise their awareness, ensure strict compliance with regulations, prevent unauthorized commands, correct violations on site, and enforce strict labor discipline. In particular, efforts to combat violations must be intensified; a comprehensive analysis of such violations should be conducted on a monthly basis, and training programs should be organized for those who violate the rules. Through activities such as anti-violation campaigns, analysis of simulated violation accidents, safety awareness education, and specialized studies of accident cases, efforts to combat violations are ingrained in people’s minds and hearts, ensuring the achievement of the principle of \"no harm to four parties\". (8) Strengthen the construction of grassroots teams. Strengthen the work related to the \"three basics,\" focusing on training team leaders, organizing competition activities among teams, and improving their management skills. In strict accordance with the standards for the standardized construction of safe production at the team level, inspections and evaluations of team development are conducted on a monthly basis to improve the standardization level of team operations.

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