Learn from the lesson! Report on three recent incidents of poisoning caused by hazardous chemical leaks

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At around 17:48 on August 17, 2016, in Workshop 1 for chloromethane production at Shandong Dongyue Fluorosilicon Materials Co., Ltd. in Huantai County, Zibo City, the valve body broke during a pressure-containing leak-sealing operation on the ball valve located at the top of the vapor-liquid separator, resulting in a leakage and poisoning incident that caused 1 death and 1 injury. Preliminary analysis of the cause of the accident indicates that during the process of plugging leaks under pressure, the injection and expansion of the plugging agent caused tension between the upper and lower flanges of the vapor outlet valve in the upper part of the vapor-liquid separator. Since the plugging fixture did not provide adequate protection, the valve suffered a brittle fracture, resulting in the rapid release of gases containing toxic substances such as hydrogen chloride, chloromethane, dichloromethane, and trichloromethane, which led to an poisoning incident. At around 7:50 p.m. on August 22, 2016, an explosion and poisoning accident occurred on the premises of Shandong Binhua Dongrui Chemical Co., Ltd. in Bincheng District, Binzhou City, while a tank truck was loading dichloropropane. Preliminary analysis indicates that the direct cause of the accident was that the operator failed to open the vapor discharge pipe of the tank truck; instead, he connected the tank truck’s feed pipe (for liquid phase) to the discharge system by mistake. As a result, the air inside the tank truck could not be discharged during filling, and the dichloropropane filled into the tank created pressure in its vapor space. When the quick-connect fitting was removed, the dichloropropane in the tank truck was forced out under the pressure in that vapor space. Personnel on site handled the situation without wearing protective gear, which led to poisoning; 1 person died and 3 were injured. At around 5:50 on August 26, 2016, a leakage and poisoning accident occurred in the chloroformate production facility of Shandong Tianan Chemical Co., Ltd. in Linyi County, Dezhou City, while repairs were being carried out on the discharge pipe of a reactor, resulting in 1 death. Preliminary analysis of the cause of the accident indicates that when a minor leak was detected at the discharge pipe of the lightening reactor, the operator failed to wear safety gear and improperly removed the discharge hose; residual n-propyl chloroformate splashed onto the operator’s face, resulting in the poisoning incident. These three accidents have exposed many serious problems that require our utmost attention. From the perspective of the direct causes of the accident, the enterprise involved had serious issues such as violations of **standards, regulations, and relevant operating procedures; improper operations and breaches of labor discipline; inadequate safety management in the handling, inspection, and maintenance of hazardous chemicals that are toxic, harmful, flammable, or explosive; poor emergency response to accidents; ineffective risk management; and insufficient efforts to identify and address potential hazards. To earnestly learn from the lessons of this accident, effectively strengthen the safety management of hazardous chemicals, and prevent and curb similar incidents from occurring, the following requirements are put forward: 1. Strengthen the safety management of external workers. Chemical enterprises should strengthen safety management of external workers, particularly those engaged in construction work, equipment maintenance, and transportation and loading/unloading tasks. They must thoroughly verify the professional qualifications of such workers, incorporate them into their own safety management systems, and apply uniform standards, requirements, and management practices. Identify foreign workers as a key focus for hazard inspection, in order to promptly detect and prevent any illegal working practices. It is necessary to fully implement a system for providing safety instructions to external workers, and to ensure that such workers carry out their tasks in strict accordance with **relevant operational standards, the company’s safety management systems, and procedural guidelines. It is necessary to specify in the relevant contracts and agreements the safety responsibilities of external workers and the consequences for violating these regulations, as well as to clarify the unit’s rights regarding safety management. II. Strengthen safety management in high-risk operation stages. For high-risk operations carried out in hazardous areas such as those with toxic and harmful substances, or areas prone to fire and explosion, a strict operation approval system must be implemented; the level of control over such approvals should be enhanced, risk analysis must be conducted prior to the operations, and the safety conditions at the work site must be verified. To strengthen the safety management of leak sealing operations under pressure, it is necessary to strictly follow the \"Technical Specifications for Sealing Pressured Equipment Under Pressure\" (GB/T26467-2011) as well as the relevant internal management regulations of the organization, formulate construction plans, and ensure proper on-site supervision. In non-emergency situations, before carrying out any operations, it is necessary to reduce and maintain the temperature, pressure, flow rate, etc. of the equipment and pipelines at safe levels. In cases involving toxic and flammable/explosive gas media, leak sealing operations should, in principle, be carried out after depressurization. Strengthen the safety management of the filling process for hazardous chemicals that are toxic, harmful, flammable, or explosive. When external vehicles enter the factory area for loading and unloading operations, it is necessary to verify their relevant qualifications in accordance with regulations, provide safety training, ensure that the safety conditions for such operations are met, enhance supervision, and strictly control the number of people present at the operation site. It is strictly prohibited for company staff responsible for loading/unloading and supervision to work alongside vehicle drivers and escorts, in order to ensure safety at the operation site. Strictly manage safety during maintenance operations; maintenance work must not be carried out without approval. Establish comprehensive safety procedures for the maintenance of equipment and facilities, and ensure full supervision of all aspects of work on site. III. Accelerate the development of a dual-prevention system for risk classification and control, as well as the identification and remediation of potential hazards. It is necessary to pay due attention to and strengthen the identification, assessment, and control of safety risks associated with highly hazardous substances such as liquid chlorine, liquid ammonia, and liquefied gas, as well as toxic, harmful, flammable, and explosive materials like chlorine-containing products and organic chlorine-based fine chemicals. In accordance with the requirements of the \"Notice of the General Office of the People’s Government of Shandong Province on Establishing and Improving a Dual Prevention Mechanism for Risk Control and Hazard Identification and Rectification\" (Lu Zheng Ban Fa [2016] No. 36) and the \"Regulations on Safety Management in Hazardous Chemical Enterprises in Shandong Province\", it is necessary to carry out comprehensive risk control in those work areas of the unit where toxic and harmful gases are generated or may accumulate, such as certain devices, equipment, facilities, and key locations. Corresponding preventive and control measures in terms of engineering technology, management, training, and personal protection should be formulated and implemented, with clear responsibilities for risk control assigned. It is necessary to effectively carry out the work of identifying and addressing potential hazards, implementing a closed-loop management system for this purpose, and ensuring that the responsibilities, measures, funds, time frames, and contingency plans related to rectification are all properly implemented. By establishing and improving a dual prevention mechanism, it is possible to shift focus to earlier stages, address issues at their source, and carry out scientific prevention. For enterprises that have achieved compliance with safety standards for hazardous chemicals, the \"risk management\" element must be implemented in accordance with the requirements of the two systems related to risk classification and control, as well as the identification and resolution of potential hazards. This element serves as a disqualifying factor in the evaluation process for achieving compliance; any enterprise that fails to meet the requirements of these two systems will not be approved. IV. Strengthen emergency response and scientific rescue capabilities. Chemical enterprises should develop emergency rescue plans and on-site response plans tailored to the types and characteristics of accidents that may occur within their operations; such plans must be practical and actionable. To improve the professionalism of on-site emergency response, chemical enterprises that have the necessary resources can adopt the standards of chemical defense units and fire departments to establish specialized rescue teams equipped with professional rescue equipment. It is necessary to strengthen training and drills so that every rescue worker and operator can master proficiently the procedures and methods for handling emergencies, thereby significantly enhancing the ability of these professionals to assess situations, resist external harmful factors, and organize self-rescue and mutual rescue efforts in a rapid, scientific, safe, and effective manner. In the event of someone being in danger, it is necessary to respond promptly, carry out rescue operations in a scientific manner, and handle the situation effectively. It is strictly prohibited to attempt rescue efforts without properly wearing rescue equipment and protective gear, in order to avoid causing further casualties and to ensure the safety of those involved. V. Strengthen safety supervision and law enforcement inspections. The occurrence of these three accidents once again exposes prominent issues such as the failure to fulfill enterprises’ primary responsibilities for safe production, as well as inadequate implementation of the centralized campaigns aimed at thorough inspections, rapid rectification, and strict enforcement of regulations. It is necessary to resolutely implement the series of important directives on work safety issued by ****, the Prime Minister, as well as the leaders of the provincial Party committee and provincial government. We must raise our awareness of the importance of work safety, draw lessons from accidents, apply those lessons to similar situations, and carry out comprehensive, thorough, and sustained efforts to conduct thorough inspections, prompt rectifications, and strict enforcement in the area of work safety. The goal is to achieve \"full coverage, zero tolerance, strict enforcement, and tangible results,\" leaving no gaps or blind spots. It is necessary to conduct a thorough analysis of the safety production situation regarding hazardous chemicals in the region, as well as the patterns of accidents that occur. By focusing on existing problems, it is important to increase supervision over those enterprises with weak safety management systems and numerous issues and risks. At the same time, large and medium-sized enterprises with relatively better safety management practices should be urged to maintain a high level of attention to safety production, giving it greater priority. Additional measures must be taken, and efforts must be sustained consistently to ensure that safety protocols are properly implemented and to prevent all types of safety accidents. It is necessary to thoroughly implement the Notice issued by the Provincial **Safety Committee (Lu An Fa [2016] No. 21). By leveraging the centralized campaign for comprehensive inspections, prompt rectification, and strict enforcement in the field of work safety, special efforts should be made to address issues related to hazardous chemicals. Potential safety hazards must be identified and addressed, so as to reduce safety risks associated with the production, storage, handling, transportation, and use of hazardous chemicals, and to effectively curb the trend of frequent accidents.