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In-depth Analysis of the Incident | The Jingjiang 4.22 Fire Revealed Four Asymmetries

2016-11-10View Original

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At 9:40 on April 22, 2016, a fire broke out at a hazardous chemicals storage facility in Jingjiang, Taizhou, Jiangsu. The fire lasted for 16 hours, and the flames were extinguished around 2 a.m. on the 23rd. Frighteningly, if the fire gets out of control, it could trigger a chain reaction of explosions in other hazardous chemical storage tanks in the warehouse area, resulting in a disaster of unimaginable proportions. The lessons from this accident are deeply thought-provoking; they should be carefully analyzed to draw broader conclusions and prevent such incidents from occurring in the future. Please take a look at Yang Henglong from the **Office of Taizhou City’s analysis of the \"four asymmetries\" revealed by this accident. 【Summary of the accident】 In order to carry out rescue efforts, nearly 200 fire trucks from several surrounding provinces (cities), along with over 1,400 firefighters and police officers, were deployed. People living within a 5-kilometer radius were evacuated, and ships within 5 kilometers upstream and downstream of the dock were removed from the area. Navigation was prohibited in the Fujiangsha Waterway on the north side of the site. One firefighter lost his life, resulting in significant economic losses and serious social consequences. 【Cause of the accident】 Preliminary investigations indicate that the direct cause of the fire at Jiangsu Deqiao Warehouse on April 22 was the serious violation of safety regulations regarding hot work by the company in question. When contractors were carrying out pipe welding work in the exchange pump room, they failed to remove flammable materials from the trenches in that area, nor did they conduct any tests for combustible gases. The welding flames ignited the oil present in those trenches, causing the fire to spread rapidly. This led to the collapse of the upper pipeline corridor of the exchange pump room. Oil from Tank No. 2401, located on the south side of the pump room, as well as from Tank No. 2402, which contained a small amount of residual gasoline, leaked out through the damaged pipes, further exacerbating the fire. (——**The State Administration of Work Safety, the Ministry of Transport, and the Railway Bureau held a meeting to discuss the causes and lessons learned from the “4.22” fire accident in Jingjiang, Jiangsu**) 【Problems identified】 This accident revealed serious issues such as the failure of the company involved to fulfill its responsibilities regarding safe production, inadequate control of major hazard sources, poor management of special operations and contractors, as well as improper emergency response: First, the oil storage tanks did not have emergency shut-off systems in place, and the devices for detecting and alerting to leaks of flammable and toxic gases were disabled in violation of regulations; moreover, no timely action was taken after alarms were triggered. Secondly, there is a lack of management regarding hot work; hot work was carried out without first clearing the large amounts of flammable liquids present in the site’s trenches, without conducting any analysis for combustible gases, and without assigning someone to supervise the work. Third, the accident-prone enterprises assign inspection, maintenance, and repair work to units that do not meet safety production standards; they fail to provide unified coordination and management for these contractors, and safety training is merely a formality. Fourth, the initial emergency response was inadequate; after a fire broke out at the scene, the source of the materials could not be cut off in a timely manner, which led to the expansion of the accident. At present, the relevant departments in Jiangsu Province have, in accordance with the law, suspended the accident-stricken enterprise’s license to handle hazardous chemicals and ordered it to suspend operations for rectification. (—Report from the State Council’s Work Safety Committee) The fire exposed numerous safety weaknesses — Reflections prompted by the \"four asymmetries\". I. Looking at the issue of responsibility implementation through the asymmetry from \"minor triggers\" to \"catastrophic outcomes\": The progression from a \"small spark\" to a \"major accident\" seems similar to the \"butterfly effect\" – small incidents can grow into major events when amplified on a systemic scale. Among these, the absence of safety responsibilities is the core issue. The vast majority of work safety accidents are liability accidents; in the \"4.22\" fire accident, the enterprise’s management and safety officers clearly failed to fulfill their responsibilities, while the welders failed to offer help in a time of crisis and fled the scene. The primary and most important factor in determining safe production is the word “responsibility”. But safety in production hinges on responsibility, and it is also difficult precisely because of that responsibility. The responsibilities related to safe production have their particularities: firstly, the demands are stringent, which can lead to fear and aversion towards carrying out these tasks. The responsibility for safe production is \"as heavy as Mount Tai\" – it entails strict obligations and high risks. Accountability for negligence ranges from disciplinary actions under Party discipline and administrative regulations to criminal liability in severe cases. Furthermore, no matter how far back the events date—even if those responsible have been reassigned or retired for many years—they still cannot escape responsibility. Under pressure, some cadres and employees are afraid of taking responsibility and choose to avoid action; they are reluctant to take initiative or do anything, which delays matters and turns small issues into big problems. They panic when faced with challenges and become fearful in times of crisis. Especially after major accidents occur and those responsible are held accountable, a mood of negativity and weariness sets in. Secondly, there are multiple levels of responsibility, which can lead to a reduction in the transmission of pressure. Safety production responsibilities extend to all levels and aspects, but their intensity diminishes as they are passed down. It is often the frontline workers who lack both a sense of responsibility and the necessary skills that end up bearing direct responsibility; thus, there is a problem of insufficient implementation of these safety responsibilities at the \"last mile.\" Many accidents caused by minor mistakes occur among this group, and this issue requires serious attention. Again, there are many layers of responsibility, which can lead to a domino effect. From Party and government organizations at all levels, to relevant functional departments, to various enterprises, all are responsible entities. Leaders at all levels, from the central government to local authorities, as well as departmental officials and employees in enterprises, are all accountable. Tasks ranging from administrative approval to quality inspection and oversight throughout the entire process all fall under the scope of responsibilities; safety obligations exist at every moment and in every situation. Therefore, the responsibility chain for safe production is long, involves many links, and comes with numerous tasks; any negligence or mistake at any single node or by any individual can trigger a chain reaction that results in failure overall and the loss of all previous efforts. This helps to better understand the concept that \"safe production involves fragile items,\" highlighting the degree of uncontrollability. In short, it is quite complex and not an easy task to truly assign safety production responsibilities to specific individuals and ensure they are fulfilled throughout all aspects. First, it is necessary to strengthen the leadership responsibilities of Party and government organizations at all levels as well as the regulatory responsibilities of various departments; leaders at all levels must take responsibility earnestly, organize effectively, and ensure proper supervision. Secondly, it is necessary to strengthen the primary responsibilities of enterprises, as well as the role of their top executives as the \"primary persons responsible\". In particular, enterprises must ensure adequate investment in safety measures, proper employee training, effective basic management systems, and robust emergency response capabilities. This will help to overcome the \"last mile\" of challenges related to safety responsibilities, eliminate obstacles and blind spots, and strengthen the foundational aspects of safety management. Thirdly, it is essential to place great emphasis on strengthening technological support, and to vigorously develop \"Internet + safety supervision\" and \"smart safety supervision.\" By making extensive use of automated, intelligent, and information-based technologies, it is possible to improve the systems, methods, and tools used for supervision. Technology can be utilized to address shortcomings and enhance efficiency, thereby effectively solving issues such as insufficient accountability, inadequate supervision efforts, and limited methods and tools. Secondly, from the perspective of the asymmetry between \"welders\" and \"hazardous chemicals\" in relation to the patterns of safety accidents, it is understood that there were two main parties involved at the scene of the \"4.22\" fire accident: one was the party responsible for storing hazardous chemicals. The knowledge information held by this technical system relates to the types of hazardous chemicals, their production, storage and transportation, as well as safety measures and emergency response procedures. The leaders and employees of this operation unit must have a thorough understanding of the relevant knowledge and information; there must be no such thing as being ignorant regarding hazardous materials. Another entity is the welding operation entity. The knowledge information possessed by this technical system relates to welding. The technical relevance between these two entities is extremely low, and the probability of them carrying out joint operations is very small. Accidents often occur during their joint operations in the same space. Welders generally are unaware of the extent of the danger posed by small sparks in high-risk, sensitive areas, while workers handling hazardous chemicals usually don’t realize that sparks can fly during welding and are difficult to control. The probability of failure in a joint operation where one side knows its own strengths but not those of the enemy is quite high. Accidents resulting from such structural contradictions due to differences in knowledge, information, and types of technical work are numerous. In the series of oil and gas explosions that occurred at Huangtian Port in Qingdao, workers used impact drills to drill through concrete floors, and the sparks generated ignited the flammable gases in the underground pipelines, resulting in a major liability accident. On May 9, the same tragedy occurred again: an oil chemical transport ship in a dockyard in Nanjing exploded and caught fire, resulting in 2 deaths. The cause was that although the ship had been unloaded at another location, residual oil and gas remained on board; when the crew attempted to repair a gauge by welding, the ignition of those residual gases led to an explosion. It can be seen that employees from different technical systems, due to asymmetrical knowledge and information, are unable to communicate effectively, which makes it difficult to properly prevent and control the causes of accidents. This requires us to consider not only intrinsic safety but also extrinsic safety. These are two equally important aspects of safe production. Regarding intrinsic safety, people have a relatively good understanding and preparation for it, but as for non-intrinsic safety, especially accidents caused by asymmetries in knowledge and information, our level of awareness and preventive measures seem to be insufficient. Such accidents are unexpected and occur frequently; they are widespread and repetitive in nature. They require serious attention. By analyzing cases both positive and negative, it is necessary to conduct thorough studies and summaries in order to identify patterns, develop preventive procedures, enhance proactivity and foresight in work, and prevent such accidents from happening again. Examining safety investment issues from the asymmetry of \"limited investment\" to \"huge losses\": At the onset of the fire in the \"4.22\" accident, the company’s safety officers quickly grabbed two small fire extinguishers to try to put out the fire, but this was utterly insufficient against such a fierce blaze, highlighting the inadequate level of investment in fire protection by the company. The fire trucks from Jingjiang and Taizhou, which arrived later, either had outdated equipment or insufficient foam. It was not until high-performance fire trucks from surrounding cities such as Suzhou and Wuxi, as well as from Shanghai and Zhejiang, arrived that a safe route to close the oil transfer valves was created. Due to a shortage of relevant fire-fighting equipment in Taizhou City, it was necessary to mobilize resources on a larger scale, thus missing valuable rescue opportunities. The continuously burning fire in turn led to greater risks, more panic, and worse consequences. Looking solely at the economic losses: in addition to the direct losses of hundreds of millions of yuan for the enterprises involved in fire accidents, the costs associated with rescue efforts exceed 30 million yuan. Moreover, the subsequent cleanup of the accident site and the relocation of stored goods require significant investment in terms of human resources and financial resources, so the scale of these losses is evident. This requires us to handle the issue of investment in safety properly. First of all, investment in work safety must be increased and upgraded. Especially for large-scale, high-risk industry enterprises, it is necessary to equip them with facilities corresponding to their rescue capabilities. In safety economics, the cost-benefit ratio of preventive safety measures is much higher than that of corrective actions taken after accidents; the ratio of their effectiveness is 5:1. “The concepts and practices of \"production first, safety second\" and \"emphasizing production over safety\" must be completely corrected. Following the fire, Jingjiang City, where the incident occurred, issued a directive requiring chemical manufacturing enterprises in its jurisdiction to have fire trucks and personnel of appropriate capacity, as a measure to address the shortcomings after the disaster. Secondly, it is necessary to coordinate the allocation of resources for safety investments. Departments such as those responsible for safety supervision need to conduct comprehensive, systematic, and multi-faceted analyses of enterprises’ investments in safety, the level of such investment, and its rationality, in order to better guide these investments. While ensuring proper guidance and supervision regarding corporate investment, it is necessary to consider carefully which rescue facilities should be funded by enterprises and which should be funded by **. Resource allocation needs to be optimized to improve efficiency, and investments must not be made blindly or in a disorganized manner. Fourth, looking at the issue of project attraction from the perspective of the asymmetry between \"minimal financial contribution\" and \"huge resource consumption\": The Jiangsu Deqiao warehousing area has 12 tanks for storing fuel, diesel, and gasoline, as well as 30 tanks for storing chemical substances. The total length of the docks is 460 meters, and the area allocated for storage facilities associated with these docks covers more than 470 mu. This project occupies a significant amount of valuable Yangtze River shoreline resources and also covers a considerable area. However, over the more than 6 years since the project was established, its total contribution to the local finances has been only a little over 13 million yuan. It is undeniable that the establishment of this project has had certain positive effects on the local economic and social development. However, there is a clear imbalance between the project’s “minimal financial contribution” and its “huge consumption of resources”. Firstly, such a minor contribution makes it difficult to reflect the value of the vast amount of land and environmental resources it consumes ; Once again, such high-risk projects exert enormous real and potential pressures on local areas in terms of production safety, environmental ecology, social stability, etc., with minimal contributions ; Finally, throughout the entire accident rescue process, the financial and material resources invested by all parties, as well as the immense pressure and responsibilities involved, were beyond bearing. What we need to reflect deeply on is: first, why do projects of such a large scale and high risk contribute so little in terms of tax revenue? Going forward, when attracting projects and exercising source control, is it the quantity and scale that matter, or should quality and effectiveness be given priority? That is, should short-term political achievements and the long-term comprehensive economic and social costs be taken into account together? Second, while considering corporate development and profitability, should more emphasis be placed on issues such as corporate safety, environmental protection, and other negative external effects, as well as on spillover costs and the assumption of social responsibilities? Third, while considering the option of bringing in new enterprises, it is also necessary to think about the issue of eliminating those that are a burden on safety and environmental protection, consume large amounts of resources, and contribute little in terms of taxes. Those enterprises that need to be shut down or restructured, have their licenses revoked, or be eliminated by the market must be dealt with decisively through appropriate measures, so as to ensure safe, green, and scientific development.

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