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Accident Involving Injuries to Workers While Dismantling a Condensate Oil Pump in a Petrochemical Company’s Catalytic Unit | Case Study, Original, October 20, 2016, “Team Safety”. Incident Overview: On July 27, 1998, Team 6 of machinists in a petrochemical company’s maintenance workshop was assigned a repair task. On the afternoon of July 31, Wang XX from Team 6, along with Dai XX and Li XX, went to the air-cooled pump room to remove the bolts on the cover of the condensate oil pump. After removing the bolts, Dai XX headed toward the east window, while Li XX went to the south window; thereafter, Wang XX, Ji XX, and 2 crane operators removed the pump body once the bolts had been taken off. At around 16:05, when the pump body was pulled out of the pump casing, a large amount of condensed oil (mainly liquid hydrocarbons and gasoline) sprayed out from the casing, pushing the pump body weighing about 71 kg sideways to a distance of 1.4 meters from the casing, and knocking down the 4 workers working on either side of the pump. In an instant, the pump room was covered in white mist; Dai XX and Li XX, who were standing by the window, rushed out of the pump room by touching the door. After running out on behalf of ××, he informed Ye ××, the fitter who was outside the pump room, and Ye ×× rushed to the I-catalysis operation room in Refining Unit 1 to give an alarm. Upon hearing the news, Zhang XX, the new shift leader of Catalyst Team 2, rushed to the site of the accident. He found that there was a large amount of liquefied gas leaking in the air-cooling pump room. After returning to the control room to get an air respirator and putting it on, he entered the air-cooling pump room and discovered that the third pump starting from the south side was leaking gas; he then closed the inlet valve of the pump by hand. Zhang XX, together with Wang XX, the safety officer from Refining Department 1 who arrived later, and relevant leaders, actively organized the rescue efforts. The first 4 people affected died from poisoning and asphyxiation despite attempts to save them, resulting in direct economic losses of 390,400 yuan. Analysis of the accident cause: (1) The maintenance personnel failed to isolate the maintenance equipment from the production plant system, did not implement any safety measures, and proceeded with the maintenance work without conducting any inspections at the site, which led to the accident. (2) Before the maintenance work, without the approval of the management of Refining Department 1 to cut off the power supply to the pump, without isolating the equipment system, without draining the condensed oil from the pipelines, and without an on-site inspection by safety personnel, the safety officer in Refining Department 1 fraudulently issued a \"Safe Construction (Dismantling) Permit\" on his own, which was the main cause of the accident. (3) The pump room is cramped with poor ventilation ； A forklift is blocking the entrance to the pump room, preventing smooth access to it; this poses obstacles to the evacuation of workers and to rescue efforts. Lessons from the accident (1): Equipment maintenance should strictly adhere to the \"Equipment Maintenance System\". The production unit and the maintenance unit must hand over tasks to each other; maintenance can only begin once the situation is fully understood and all safety measures have been implemented. (2) When performing maintenance work in areas where hazardous substances are present and where the space is tight with poor ventilation, enhanced forced ventilation measures must be implemented. Fire and explosion hazard areas also require explosion-proof measures. The roads in the workplace must be kept clear. (3) The accident also revealed flaws in the factory’s management of \"maintenance permits,\" as well as poor safety awareness and technical skills among some workers, including managers and frontline safety officers, along with a lack of sense of responsibility. Training should be strengthened, and those who fail the training should not be allowed to work.