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【Accident Reports – Reposted】Reports on the “3/23” and “4/25” accidents

2016-10-19View Original

Thread Content

According to a report on the website of the **State Administration for Work Safety, on October 19, the office meeting of the Director of the State Council’s Work Safety Committee reviewed and approved the investigation reports submitted by the work safety committees of Shanxi Province and Shaanxi Province regarding the serious accident that occurred at Tongsheng Anping Coal Industry Co., Ltd., part of the Datong Coal Mine Group in Shanxi Province, on March 23, as a result of a large-scale collapse of the roof which led to a gas explosion; as well as the serious water disaster that occurred at Zhaojin Mining Co., Ltd. in Yaozhou District, Tongchuan City, Shaanxi Province, on April 25. Proposals for handling were put forward regarding 65 responsible persons involved in the two accidents.   At 22:07 on March 23, 2016, a major accident occurred at Tongsheng Anping Coal Industry Co., Ltd., which is part of the Datong Coal Mine Group in Shanxi Province, due to a large-scale collapse of the roof that triggered a gas explosion. The accident resulted in 20 deaths and 1 injury, with direct economic losses amounting to 28.0437 million yuan.   Upon investigation, it was determined that this was an accident resulting from negligence. The direct cause of the accident was the illegal implementation of roof pre-splitting blasting at the 8117 working face of Anping Coal Mining (the 70m extended section), which led to a large-scale collapse of the roof in the goaf of that working face. As a result, toxic and harmful gases such as methane escaped from the goaf in an instant, generating shock waves that caused casualties and damage to equipment ; The gas in that goaf, which was within the explosive concentration range, flowed back into the air intake shaft of the conveyor belt at the working face; the shock wave caused the 10kV high-voltage cable to be damaged by external forces, resulting in electric sparks that ignited the gas and led to an expansion of the accident.   Key lessons from the accident: First, the on-site safety management at Anping Coal Industry was chaotic. In violation of the Provisions on Coal Mine Safety, roof pre-splitting blasting was carried out in the coal mining face; the \"three inspections per blast\" and \"three-person interlock system for blasting\" were not followed, and the workers were not moved to a safe distance away ; Security inspectors and coal mine safety inspectors left their posts ahead of time in violation of regulations, while blasting workers worked without the necessary licenses ; Second is severe overcapacity in production. The approved production capacity of this mine is 900,000 tons per year, but the higher-level company, Tongsheng Company, assigned a production plan that exceeded this capacity. In 2015, Anping Coal Industry was given a production target of 3.9379 million tons; the actual output for that year was 3.685 million tons, representing an overproduction rate of 309% ; In January 2016, the target was 450,000 tons, of which 361,000 tons were produced that month. No production plan was set for February due to the Spring Festival holidays. The target for March was 380,000 tons, and by the time the accident occurred, 297,000 tons had been produced. Third, the regulations for inspection and approval of resuming production after holidays were not strictly implemented. During the Spring Festival holiday in 2016, Anping Coal Mine was closed for over 10 days. According to the regulations set forth in documents from Shanxi Province, it was the responsibility of Tongmei Group to organize the inspections necessary to resume operations and give approval for that purpose. However, Tongseng Company violated these regulations by conducting its own inspections and granting approval for Anping Coal Mine to resume production. Fourth, Tongmei Group failed to draw proper lessons from the serious \"4·19\" accident that occurred at the Jiangjiawan Coal Mine in 2014; its responsibilities for overseeing the safety of its subsidiary Tongsheng Company and the mines integrated under it remain unclear, and oversight is still inadequate. It also failed to pay adequate attention to the daily safety management at Anping Coal Industry.   The \"Accident Investigation Report\" put forward handling recommendations for the 34 individuals responsible for the accident. Among them, 20 people, including the chairman and general manager of Tongmei Group, were subjected to party and administrative disciplinary actions, while Anping Coal Industry was fined 11 million yuan. 14 people, including the head of the First Inspection Department of the Safety Supervision Bureau of Tongmei Group, have been subject to actions by judicial authorities.   At 8:05 on April 25, 2016, a severe water disaster occurred at Zhaojin Mining Co., Ltd. in Yaozhou District, Tongchuan City, Shaanxi Province, resulting in 11 deaths and direct economic losses of 18.3817 million yuan.   Upon investigation, it was determined that this was an accident resulting from human negligence. The direct cause of the accident was that, as a result of mining activities, the voids and water accumulation between the overlying rock strata at the ZF202 working face of Zhaojin Mining Company increased, thereby forming sedimentary fluids ; After signs of water inrush appeared at the working face, continuing to carry out operations recklessly led to the collapse of the coal seam roof, allowing sedimentary fluids to flow in and causing the accident.   Main lessons from the accident: First, there was a lack of emphasis on flood prevention and control efforts. Zhaojin Mining Company failed to learn properly from the three instances of water inrush in the mines between July 2013 and August 2015; it did not investigate the hydrogeological conditions, failed to develop a reliable water control plan, and also did not adopt effective technical measures for water control. Secondly, the design of the water exploration boreholes is unreasonable: there are not enough such boreholes, their vertical depth is insufficient, and it is not possible to reach the overlying sandstone aquifer ; Water exploration and drainage measures are merely formalities; no dedicated team for these tasks has been established, and there is no oversight over the drilling operations related to water exploration and drainage. Thirdly, there was a poor awareness of flood prevention; starting from April 20, after signs of water inrush appeared at the working area, operations were not halted immediately nor were effective measures taken, and work continued despite the risks. Fourth, the Tongchuan City Coal Industry Bureau failed to provide adequate guidance to the Yaozhou District Coal Bureau in fulfilling its duties ; Yaozhou District **failed to detect the problems existing in the work carried out by the Yaozhou District Coal Bureau in overseeing coal mine safety production, and did not exercise strict oversight during the acceptance process for the resumption of operations at Jin Mining Company.   The \"Accident Investigation Report\" put forward handling recommendations for the 31 individuals responsible for the accident. Among them, 18 people, including the director of the Coal Industry Bureau in Tongchuan City and the head of ** District in Yaozhou District, were subjected to party discipline and administrative discipline sanctions; 8 people were given administrative penalties, and Jin Mining Company was fined 1.5 million yuan. Five people, including the chairman, general manager, and mine manager of Zhaojin Mining Company, were handed over to the judicial authorities for legal action.   The Safety Committee Office requires that all coal mining enterprises thoroughly learn from the lessons of these two major accidents, strictly abide by laws and regulations such as the Coal Mine Safety Regulations, effectively strengthen proactive measures to address major hazards such as gas and water-related disasters, strictly prohibit setting production targets that exceed capacity, resolutely eliminate overproduction, enforce strict standards for the resumption of work and production, and effectively prevent and curb serious and major accidents.
Reply #22016-10-19
As for accident analysis, the cause of an accident is basically just some human error or mistake. But at the core of it, why does such behavior occur? It is because companies fail to provide adequate training and fail to carry out proper supervision on a daily basis, which leads to employees becoming careless.

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