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The incident in which a violation of regulations caused a fire that claimed 17 lives: At 2 a.m. on July 9, 2000, the vehicle belonging to driver Zhao from a company in Gansu broke down, so driver Wang lent his own car to Zhao. After pulling the 7th load of ore, Zhao drove to the slope switch and turned off the engine to cool it down. Around 4:40, after restarting the locomotive, Zhao noticed that fire had broken out in the right rear part of the engine, so he took the fire extinguisher from the vehicle to try to put out the fire, but it was not successful. So, he and the driver, Fan, each took a fire extinguisher (one of which was empty) to try and put out the fire again, but they were still not successful. Zhao went to another work area to look for a fire extinguisher, only to find that it was empty. Zhao tried every possible way to put out the fire, but to no success; he then left in a tank truck and arrived at ground level around 7 o’clock, without reporting the situation to the relevant authorities. A total of 59 construction workers were present near the site of the fire. At 5:30, workers noticed smoke coming from the shaft; some people ignored orders and tried to escape through the sloping passage filled with smoke, resulting in 17 deaths and 2 severe injuries. The remaining 40 people evacuated to the ventilation shaft one after another and were saved. Cause analysis: Investigations revealed that oil was leaking from the truck’s fuel line connectors. Coupled with the long operating time of the engine, which resulted in high temperatures in the exhaust system, the leaking oil formed flammable gases around the engine. When the engine was started again, sparks generated by the magnetic switch contacts or the engine’s wiring ignited these flammable gases. During combustion, the pressure inside the fuel tank’s lines increased, leading to breaks and fuel leaks. When this fuel came into contact with an open flame, it produced large amounts of toxic and harmful gases. The main causes of the accident are as follows: 1. Inadequate safety management for underground transportation, and the quality of vehicle inspections and maintenance does not meet safety standards. Zhao and Wang violated the regulations by privately swapping cars. 2. Zhao failed to follow the rule of \"not turning off the engine while parked and using a fan to cool the vehicle\"; instead, he turned off the engine after parking, and restarted the vehicle before the temperature had dropped to a safe level, which led to the fire. 3. After the fire broke out, Zhao failed to report it immediately; after several unsuccessful attempts to put out the fire, he left the scene and went back down the well, without reporting to any authorities, thereby delaying the opportunity to extinguish the fire. 4. Wang, the deputy director in charge of equipment at one work area, violated regulations by not going to the site to oversee production; instead, he agreed over the phone from home to the arrangements made by the shift leader from the previous shift regarding the tasks for the current shift leader. 5. At the time of the accident, the duty officer was not on site, and there was no one to oversee the evacuation process, which led to some workers entering the disaster area blindly. 6. The mine has failed to formulate and implement disaster prevention and emergency response plans in accordance with the law; its fire prevention measures do not meet the required standards, and the safety signs installed in the tunnels are not in compliance with regulations. 7. Safety training for employees was not conducted in strict accordance with the timing and content specified by mine safety regulations; as a result, the employees’ safety awareness is low, and they lack the necessary knowledge regarding emergency response and safe evacuation. It’s most cost-effective to learn from others’ accidents as if they were one’s own*.
Almost all accidents can be attributed to poor safety awareness, inadequate safety measures, and weak rescue capabilities...
When analyzing the causes of an accident, there are several fixed categories: Direct causes include 1) certain violations of operating procedures; indirect causes include 1) poor company management, inadequate training, and a lack of or malfunctioning emergency rescue facilities