【Accident Case Analysis】The “3·29” Poisoning and Asphyxiation Accident at Hebei Wei County Hongshun Chemical Raw Materials Co., Ltd
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I. Accident investigation and analysis(1) Summary of the accident
1. Brief description of the accident
At around 8:00 on March 29, 2013, a poisoning and asphyxiation incident occurred at Wei County Hongshun Chemical Raw Materials Co., Ltd. while workers were attempting to clear a blockage in the carbon disulfide condensation pipeline. The incident resulted in 3 deaths and 2 people sustaining minor injuries; the direct economic loss amounted to approximately 2 million yuan. 2. Cause analysis: (1) Direct cause – After discovering the blockage in the pipeline, the furnace operator, Mr. Sun, failed to report it to the factory in a timely manner. Without taking any preventive measures, he arbitrarily removed the soil seal from the access point of the toxic gas pipeline that was in use, and attempted to clear the blockage. This led to a massive leakage of hydrogen sulfide and carbon disulfide gases. Inhaling these toxic gases caused him to become unconscious and fall into the pool, which was the direct cause of the accident ； Zhu, Guo, Zhang, and Yao failed to take any protective measures and attempted rescue recklessly, resulting in them all being poisoned and losing consciousness, which led to the expansion of the accident. (2) Indirect causes ① Wei County Hongshun Chemical Raw Materials Co., Ltd. failed to complete the filing procedures and illegally carried out production. ②The employees of Wei County Hongshun Chemical Raw Materials Co., Ltd. lack safety awareness, as well as the most basic professional knowledge and self-protection skills. ③Yali Town in Wei County has failed to fulfill its responsibilities for local supervision of work safety. ④The Weixian Safety Supervision Bureau has failed to fulfill its responsibilities regarding the comprehensive supervision of safety production in hazardous chemical enterprises. (II) Basic Information
1. Information on the entities involved in the incident
Weixian Hongshun Chemical Raw Materials Co., Ltd. was registered with the Weixian Administration for Industry and Commerce on October 9, 2005. Address: 280 km along the Ning-Wei Road, Wei County (east side of the road) ； Legal representative: Ren Mou (changed to Zhang Mou in 2008) ； Registered capital: 500,000 yuan ； Company type: Limited Liability Company. On June 29, 2006, the company obtained the “Safety Production License” issued by the Hebei Provincial Work Safety Supervision and Administration Bureau. The license number is (Ji) WH Safety License No. 040159. The business scope includes the production and sale of charcoal and carbon disulfide. After its hazardous chemicals safety production license expired on June 28, 2009, the company moved to a location 280 kilometers along the Ningwei Road in Wei County (on the west side of the road) to carry out renovations there. On November 19, 2009, the company’s business scope was changed from the production and sale of charcoal and carbon disulfide to the sale of charcoal only. The company currently has 21 employees and is capable of producing 5,000 tons of carbon disulfide per year. On September 1, 2010, the Handan Work Safety Supervision Bureau, through the “Opinions on the Safety Permit for Construction Projects Involving Hazardous Chemicals” (Document No. Ji-Han Safety Supervision Hazardous Chemicals Project Review 59), approved the company’s application for a safety review regarding the establishment of its 5,000-ton/year carbon disulfide project, thereby giving consent for the company to proceed with the construction of this project ； On September 28, 2010, the Handan City Safety Supervision Bureau approved the design of the safety facilities for the company’s 5,000 tons per year carbon disulfide production project through the \"Safety Permit Opinion for Hazardous Chemicals Construction Projects\" (Ji Han An Jian Wei Hua Project Review No. 74) ； On October 29, 2010, the company organized experts to review the trial production plan in accordance with regulations, and the expert group provided comments on it. However, the company failed to submit the trial production plan for approval to the safety supervision authorities at the county and city levels as required, and the Weixian Safety Supervision Bureau also did not approve the company’s attempt to carry out trial production. (III) Timeline of the incident: Description of the date and time – On the morning of March 29th, a blockage occurred in the pipeline located between the third desulfurizer and the carbon disulfide cooler, on the northern production line. At 8:00 on March 29, the on-duty furnace operator, Sun, climbed up the wall of the cooling tank (at a height of about 1.6 meters above the ground and with a water depth of about 2 meters) to remove the soil blocking the pipe opening in order to clear the pipe. The toxic gases released from the pipe caused Sun to become poisoned and pass out, after which he fell into the cooling tank. When technicians Zhang and furnace operator Zhu noticed that Sun had fallen into the water, they called for help without taking any safety precautions before going in to rescue him. Zhu fainted due to poisoning and fell into the secondary desulfurization cooling tank located in front of the main cooling tank. Upon sensing the presence of toxic gases, Zhang ran along the edge of the cooling tank and fainted on the road to the north of the cooling tank, before eventually recovering on his own. After noticing that the three people had been poisoned, Jiang, a sulfur-addition worker, called for help. At that time, Zhang, the manager in the office, along with Guo and Yao, who were working on sorting coal, heard the call and also rushed to the scene to provide assistance. When Zhang, Guo, and Yao went to render aid, they also failed to take any safety precautions, and all of them were poisoned and fainted. Guo and Zhang fell into the small cooling tank, while Yao slipped on the sulfonation operation pathway; he managed to crawl out on his own while still unconscious, and then fainted again on the road to the north of the tank. Ren and others, who rushed to the scene to provide assistance, pulled Zhang out of the pool and immediately took both Zhang and Yao to the hospital for emergency treatment. (IV) Accident losses: The accident resulted in 3 deaths and 2 people suffering minor injuries, with direct economic losses of approximately 2 million yuan. http://www.chemicalsafety.org.cn/uploads/allimg/161024/7-161024204515255.jpg Figure 1: Site view (A) http://www.chemicalsafety.org.cn/uploads/allimg/161024/7-161024204526259.jpg Figure 2: Site view (B) http://www.chemicalsafety.org.cn/uploads/allimg/161024/7-16102420453Y61.jpg Figure 3: Site view (C) (V) Analysis of the cause of the accident 1. Analysis of the direct cause: After discovering that the pipeline was blocked, worker Sun failed to report it to the factory in a timely manner. Without taking any preventive measures, he proceeded to remove the soil seal from the outlet of the toxic gas pipeline that was in use, in order to clear the blockage. This led to a large release of hydrogen sulfide and carbon disulfide gases. As a result of inhaling these toxic gases, he became poisoned, lost consciousness, and fell into the pool – this was the direct cause of the accident ； Zhu, Guo, Zhang, and Yao failed to take any protective measures and attempted rescue recklessly, resulting in them all being poisoned and losing consciousness, which led to the expansion of the accident. 2. Analysis of indirect causes ① Wei County Hongshun Chemical Raw Materials Co., Ltd. failed to complete the filing procedures and illegally carried out production. ②The employees of Wei County Hongshun Chemical Raw Materials Co., Ltd. lack safety awareness, as well as the most basic professional knowledge and self-protection skills. ③Yali Town in Wei County has failed to fulfill its responsibilities for local supervision of work safety. ④The Weixian Safety Supervision Bureau has failed to fulfill its responsibilities regarding the comprehensive supervision of safety production in hazardous chemical enterprises. II. Upon arriving at the scene, the emergency rescue fire team rescued Guo, Sun, and Zhu from the pool. Sun, Zhu, and Guo died one after another; Zhang and Yao were hospitalized for treatment. In total, the accident resulted in 3 deaths and 2 minor injuries. III. Reflections and Recommendations
(1) All enterprises engaged in the handling of hazardous chemicals within the jurisdiction of Wei County must earnestly fulfill their primary responsibilities regarding work safety, and resolutely prevent any acts of construction without approval or production and operation without permits. (II) It is necessary to effectively strengthen safety training for employees, continuously improving their safety awareness as well as their abilities to protect themselves and carry out self-rescue. (III) The Party committees at the county and township levels in Wei County must earnestly assume their primary responsibility for overseeing enterprise safety, and continuously raise awareness of the importance and seriousness of work related to safe production. It is necessary to thoroughly learn from the lessons of this accident, draw broader conclusions from it, resolutely implement the principle of \"safety in production, prevention first, and comprehensive management,\" and earnestly focus on work related to safety in production in order to protect the lives and property of the people. (4) The entire city must continue to carry out in-depth special operations to “crack down on illegal activities and rectify violations” in the field of hazardous chemicals, and strictly punish any illegal or unlawful production activities. Regarding illegal and unlawful production activities, laws and regulations must be strictly observed: those operations that should be shut down must be resolutely closed down; those required to cease operations must do so immediately; and those deserving punishment must be penalized to the fullest extent permitted by law. It is necessary to build a coordinated effort, enforce strict monitoring, and prevent a rebound.
This equipment really looks quite rudimentary; it seems like a small workshop, with severely outdated devices. Frontline employees, technicians, and supervisors were all unprepared for emergency rescue in the event of an accident; their reckless attempts to provide aid only led to the escalation of the incident.
Indirect cause: 1. Low safety awareness among employees； It should not be liability based on causation: It is necessary to confirm whether the company has provided the relevant personnel with the necessary level-3 training ； 2. As can be seen from the pictures, the company is dirty, messy, and in poor condition, indicating serious deficiencies in its own safety management ； 3. From the employees’ blind attempts at rescue and their handling of the blockage, it is evident that the company has no emergency response plan or standards for handling abnormalities whatsoever (in fact, the employees have no grasp of any relevant handling procedures).
For hazardous tasks, individual protective measures must be implemented, and isolating gas masks must be worn
Safety training is inadequate; there’s a rush to make money, and the lives of workers are forgotten.
The first issue is that operators, and even maintenance personnel, lack a strong safety awareness. Whether they have received training from the company or not, to be competent in their work they need to be aware of the dangers associated with the equipment or tasks they handle; failing to do so is irresponsible on their part. The second issue is that the company’s training is inadequate. There are no soldiers who can’t be trained; there are only lazy generals. Corporate safety awareness is not adequately developed, emergency response training is insufficient, or some companies simply lack such things altogether. The third aspect is the implementation of the safety production responsibility system among management personnel; the lack of proper implementation at each level indirectly leads to workers carrying out operations in violation of regulations. Inadequate safety training is a major hazard. Please conduct proper training; after all, everyone values their own life.