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Sharing others' accidents (fires) 1

2016-11-08View Original

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“The Major Fire Incident on the Tourist Ship “Changjiang Mingzhu” I. Overview of the Incident and Its Course Around 8 p.m. on September 11, 1990, a major fire broke out on the fully constructed luxury tourist ship “Changjiang Mingzhu”, which was located outside Ship No. 9 at the Tongqianba area along the Yangtze River, in the Dongfeng Shipyard in Jiangbei District, Chongqing. All the equipment on the main deck and above was destroyed, resulting in direct economic losses of over 4.827 million yuan. At 2 p.m. on September 11, 1990, the team leader in charge of building the ship \"Changjiang Mingzhu\" held a meeting, during which the foreman of the mechanical and electrical workshop suggested that a welder was needed to work together with the fitters in the steering engine room and the boiler room in order to weld the fixing brackets for the pulleys of the tie rods and the manual safety pressure relief valves of the exhaust boilers. The welding team leader assigned welder Han to assist. At around 7 p.m. that day, Han went to the first floor and began welding the top brackets above the three boilers, following the weld points determined by the fitter Chen. When welding the first bracket, the blacksmith, Mr. Zhang, held the bracket in his hands; due to the excessive current, the deck on the second floor was burned through (with a diameter of about 0.6 cm). After adjusting the current, Han continued with the welding process. When welding the third bracket, Chen took over from Zhang. Deng, a full-time firefighter on Ship No. 9, saw a red strip about 10 centimeters long that had been heated red by welding on the second-deck deck of the Yangtze River Pearl. Not far from that red strip, there were piles of polyurethane rigid foam and wooden strips in the restaurant; he then went up to the first deck’s boiler room and informed Han and Chen. But Han and Chen continued welding; when welding the fourth bracket, excessive current caused the deck on the second floor to be burned through again. Afterwards, Han took the welder to Ship No. 9 to replace the welder’s connector. At this time, Deng told Han to be careful about fire safety, but Han ignored him. At the same time, Chen went to the second floor and saw the flammable materials, but did not pay attention to them nor remove them. About 30 minutes later, Han returned to the boiler room and continued welding with Chen. While welding the fifth bracket, they suddenly heard someone shout, \"There’s so much smoke; it’s on fire!\" Han and Chen stopped welding at that point, but the fire had already started. II. Analysis of the accident cause: According to the assessment by the Fire Brigade of the Chongqing Public Security Bureau, the ignition point of the fire on the ship Changjiang Mingzhu was located beneath the rigid polyurethane foam material, on the left side at a distance of 2.6 meters from the central axis and 4.9 meters from the back wall of the restaurant on the second floor; this location corresponded to the welding site of bracket No. 5 in the boiler room. The direct cause of the fire was that while welding the fixing bracket for the manual pulley of the safety pressure relief valve on the roof of the boiler room, the heat from the welding process melted the iron plates on the roof; this led to the ignition of the polyurethane rigid foam plastic stored on the opposite side of that weld point (on the floor deck of the restaurant on the second floor), resulting in a fire. The fire spread rapidly to the floors above the third floor through the wooden ceiling panels in the restaurant on the second floor and the surrounding flammable materials, destroying all facilities above the main deck. The People’s Procuratorate of Jiangbei District, Chongqing, believes that the massive fire on the ship “Changjiang Mingzhu” was a serious man-made liability accident. Welder Han and fitter Chen bear direct responsibility. Han is a certified welder who is familiar with the operational principle outlined in the factory rules of “Six Noes for Welding and Cutting”: welding or cutting should not be carried out unless the condition on the opposite side of the welding area is clear. The site environment was not checked before starting the operation, and the procedures were not followed. During welding, firefighters explicitly informed them that the deck on the opposite side of the weld area had been heated to a red temperature and that flammable materials were piled up there, but they still did not conduct any inspections and continued to work in violation of regulations. When welding the fifth support, this ignited the polyurethane rigid foam plastic on the opposite side, resulting in this fire accident. After personally confirming the weld points, Chen should have followed the factory’s standard operating procedures: when the welder worked together with the fitter, it was the fitter’s responsibility to monitor the welding process. Yet, without checking the back side of the weld points, Chen blindly instructed the welder, Han, to proceed with welding. When firefighters arrived to stop them and informed them that there were flammable materials on the back side, and after Chen himself discovered polyurethane foam plastic and wooden strips there, he failed to inform Han about this situation nor took any measures to remove those materials – showing extreme negligence in his duties. As a full-time firefighter, Deng failed to pay sufficient attention when he detected potential fire hazards, nor did he take decisive action to stop them. It also bears significant responsibility for this fire accident. III. Handling of the persons responsible for the accident: Since Han, Chen, and Deng ignored safety protocols and carried out serious violations of regulations, resulting in a major fire accident, their actions violated Article 114 of the Criminal Law of the People’s Republic of China, constituting the crime of causing a major responsibility accident. The People’s Procuratorate of Jiangbei District filed a public prosecution against the defendant in accordance with the law. The People’s Court of Jiangbei District sentenced Deng to 3 years and 6 months in prison for the same crime ; Han was sentenced to 3 years in prison ; Chen Moumou will be dealt with separately in other cases.
Reply #22016-11-08
Another fire accident caused by open flames; could there be issues with the wheel design regarding the use of flammable materials?
Reply #32016-11-08
1 Before starting the hot work, no risk analysis was conducted in the surrounding area, and no isolation measures were taken. 2. The workers, while carrying out their tasks, take things for granted and assume that no accidents will occur, showing a lack of safety awareness. The on-site firefighters also didn’t do enough; just giving reminders is not enough – action must be taken to stop it. Anyway, a tragedy usually can’t be caused by just one reason; when looking at accident analyses, there are always many factors involved. Regarding fires, the three elements of a fire; eliminating just one of them can prevent the fire from occurring. Insufficient attention and an incorrect attitude.

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