Aoyi News noted that on April 8, the People's Government of Bao'an District announced the "Investigation Report on the "1.15" General Fall from Height of Baoan Xin'an Hengrun Elevator Company (hereinafter referred to as the "Accident Investigation Report").
On January 15, 2024, a fall from height occurred in the elevator procurement and installation project of Bao'an District People's Hospital, Xin'an Street, Bao'an District, resulting in one death and a direct economic loss of 1.68 million yuan. After the accident, in accordance with the requirements of the Regulations on the Reporting, Investigation and Handling of Production Safety Accidents (Order No. 493 of the State Council) and the Notice of the Office of the People's Government of Bao'an District, Shenzhen on Printing and Distributing the Rules for the Investigation and Handling of Production Safety Accident Reports in Bao'an District (Shen Bao Fu Ban [2020] No. 6), the District Emergency Management Bureau took the lead, and the Bao'an Public Security Bureau, the District Housing and Construction Bureau, the Bao'an Bureau of Market Supervision and Administration, the District Federation of Trade Unions and other departments participated in the formation of an accident investigation team to carry out the investigation and handling of the accident.
The investigation team determined that the "1.15" general high-altitude fall accident of the elevator procurement and installation project of Bao'an Xin'an District People's Hospital in Bao'an was a general production safety liability accident caused by workers' illegal operations and inadequate safety management on the construction site.
Source: Official website of Bao'an District People's Government
The incident occurred at the People's Hospital of Bao'an District
Workers fell from the fourth floor to the third basement floor
☞ How the accident happened
At 7 o'clock on January 15, 2024, Xie Mouqiao (male, 43 years old, from Guangxi), workers of Liyang Hengrun Elevator Co., Ltd., and Liang Mou'an replaced the protective railing of the elevator entrance on the fourth floor of Building 2 of the elevator procurement and installation project of Bao'an District People's Hospital in Xin'an Street. After Xie Mouqiao and Liang Mouan replaced the protective railing of the hall door on the right side of the elevator entrance together, Liang Mouan tied a canvas at the protective place of the hall door of the elevator entrance on the right side, and Xie Mouqiao went to move the protective railing of the hall door involved that needed to be replaced by the middle elevator.
At about 7:40, Liang Mou'an, who was carrying out the canvas hanging operation with his back to Xie Mouqiao, suddenly heard the sound of objects impacting, turned around and found that only the protective railing of the hall door that needed to be replaced was folded and half leaned on the wall on the side of the middle elevator entrance, so he used his headlamp to check the elevator shaft and found that Xie Mouqiao had fallen from the middle elevator entrance on the north side of the fourth floor to the bottom pit of the elevator shaft on the third floor underground (about 31.3 meters in height).
☞ The situation at the scene of the accident
1. The location of the accident is located in the middle elevator entrance on the north side of the fourth floor of Building 2 of the elevator procurement and installation project site of Bao'an District People's Hospital.
2. The width of the elevator shaft involved is about 1.40 meters and the height is about 2.55 meters, the original red hall door protective railing has been removed and moved to the west window position, and the width (unfolded) of the hall door protective fence (unfolded) replaced by the workers at the time of the incident is about 1.60 meters and the height is about 2.30 meters.
3. Because the worker involved fell from the elevator entrance to the pit of the elevator on the negative third floor, the steel pipe on the north side of the pit had been bent, and there were blood stains below, and there was a headlamp, a safety helmet, and a safety shoe left at the scene, with a fall height of about 31.3 meters.
☞ Casualties and direct economic losses caused by accidents
One person died as a result of the accident. The deceased, Xie Mouqiao, male, 43 years old, from Lingui County, Guangxi. According to the "Statistical Standards for Economic Losses of Casualty Accidents of Enterprise Employees" (GB/T6721), the direct economic loss caused by the accident is about RMB 1.68 million.
● Emergency response at the accident site
After the accident, worker Liang Mouan immediately notified the team leader Huang Mouhe and rushed to the negative third floor to rescue. Wang, the project safety director of Hengrun Elevator Company, who rushed to hear the news, dialed the 120 emergency number. After the medical staff arrived at the scene, Xie Mouqiao was sent to the nearest Bao'an District People's Hospital, and Xie Mouqiao died after rescue efforts failed.
● Emergency response of the government and relevant departments
After receiving the report of the accident, the relevant personnel of the District Construction and Public Works Department, the District Housing and Construction Bureau, the Bao'an Bureau of the Market Supervision and Administration Bureau, the District Police Station and other relevant functional departments immediately rushed to the scene of the accident to verify the on-site situation, carry out emergency response, and report the accident on time. After receiving the report, the District Emergency Management Bureau immediately organized personnel to rush to the scene to investigate and deal with the accident.
● Accident emergency response assessment
Hengrun Elevator Company reached a compensation agreement with Xie Mouqiao's family. During the aftermath treatment, the family of the deceased was emotionally stable and did not cause adverse social impact.
● Accident emergency response assessment
In the emergency response to the accident, the information was reported in a timely manner, the emergency response was rapid, the response procedures were correct, and there was no dereliction of duty or dereliction of duty by relevant government departments (units) and staff.
The safety management of relevant units is announced
There are a number of problems with the project involved
Bao'an District People's Hospital elevator procurement and installation project
● On June 9, 2020, Shenzhen Bao'an District Construction and Public Works Bureau (hereinafter referred to as "District Construction and Public Works Bureau") signed the "Bao'an District People's Hospital Whole Process Consulting Service Contract" with Zhejiang Jiangnan Company. The scope of consulting services is the whole process of project management and supervision in the construction phase.
The relevant units of the project are as follows:
Elevator installation subcontractor: Liyang Hengrun Elevator Co., Ltd. (hereinafter referred to as Hengrun Elevator Company)
Elevator installation and construction unit: KONE Elevator Co., Ltd. Shenzhen Branch (hereinafter referred to as KONE Elevator Shenzhen Branch)
Supervision unit: Zhejiang Jiangnan Engineering Management Co., Ltd. (hereinafter referred to as Zhejiang Jiangnan Company)
Overview of the projects involved
The name of the project involved is the procurement and installation of elevators from Bao'an District People's Hospital, including 116 vertical elevators, 1 garbage elevator and 16 groups of escalators (32 units) in the first stage, and 3 vertical elevators and 2 groups (4 escalators) in the second stage. At the time of the incident, the elevator was a vertical elevator in the first stage, which was used as a passenger elevator.
● In September 2021, the District Construction and Public Works Department awarded the elevator procurement and installation project of Bao'an District People's Hospital to KONE Elevator Company, and signed the "Bao'an District People's Hospital Elevator Procurement and Installation Contract". KONE Elevator Co., Ltd. handed over the elevator installation work of the project to KONE Elevator Shenzhen Branch.
● In May 2023, KONE Elevator Shenzhen Branch contracted the elevator installation of the project involved to Hengrun Elevator Company, and the two parties signed the "Entrusted Installation Contract".
● In December 2023, the general contractor of the project of Bao'an District People's Hospital handed over the elevators and escalators to KONE Elevator Co., Ltd. for the elevators and escalators involved in the civil engineering machine room.
The safety management of Hengrun Elevator Company
☛ Security management status
(1) Hengrun Elevator Company has carried out safety education for workers, and provided "New Employee Training Record Form" and "New Worker Admission Level 3 Safety Education Registration Form";
(2) Hengrun Elevator Company conducts oral pre-shift safety education and training for the installation team workers every day;
(3) Hengrun Elevator Co., Ltd. has formulated the "Civilized Construction Management System", "Safety Construction Management System", "Elevator Installation and Construction Safety Inspection Regulations" and "Elevator Emergency Measures Plan".
☛ Problems with security management
(1) Although Hengrun Elevator Co., Ltd. has formulated the "Regulations on the Inspection of Safe Operation of Elevator Installation and Construction", which requires the construction personnel of elevator installation to correctly use all kinds of labor protection equipment when entering the site, the risk identification of the edge (with a height difference of about 31.3 meters) when replacing the protective railing of the hall door is not in place, and the safety protection facilities for the operation of the edge hole are not set up.
(2) Hengrun Elevator Company did not take technical and management measures to discover and eliminate the hidden dangers of production safety accidents in a timely manner when the installation workers did not take effective anti-fall safety protection measures when replacing the protective railings of the hall door.
(3) Hengrun Elevator Company did not provide safety education to workers, did not do targeted training for workers to replace the protective railings of the hall door, and did not ensure that workers were familiar with the relevant safety production rules and regulations and safety operation procedures.
Safety management of KONE Elevator Shenzhen Branch
☛ Security management status
(1) KONE Elevator Shenzhen Branch has formulated the "Safety Production Education and Training System", "Compilation of Safety Production Management System" and "Emergency Plan for Production Safety Accidents", and provided the "Project Commencement Application Form" and "Construction Organization Application Form".
(2) KONE Elevator Shenzhen Branch has formulated the "Elevator Installation and Subcontracting Professional Construction Plan", which has made a disclosure to the elevator installation workers according to the construction plan, and provided the "Elevator Installation Safety Technology Disclosure", "Elevator Installer Safety Technology Disclosure", "Installation and Commissioning Site Environmental Health and Safety Management Requirements and Disclosure".
(3) KONE Elevator Shenzhen Branch, together with Hengrun Elevator Company, conducted safety education and training for the workers, and provided the workers' third-level safety education records.
☛ Problems with security management
(1) Although KONE Elevator Shenzhen Branch has formulated the "Professional Construction Plan for Elevator Installation and Subcontracting", it has not been able to identify the risk of the edge (with a height difference of about 31.3 meters) when replacing the protective railing of the hall door, and has not set up safety protection facilities for the operation of the edge opening.
(2) KONE Elevator Shenzhen Branch did not take technical and management measures to discover and eliminate the hidden dangers of production safety accidents in a timely manner when the installation workers did not take effective high-fall safety protection measures when replacing the protective railings of the hall door.
(3) Before the incident, KONE Elevator Shenzhen Branch began to assemble the car and erect the guide rail without completing the reporting procedures of the elevator involved in the "Shenzhen Special Equipment Installation, Transformation and Overhaul Notice", and was found by the supervision unit and ordered to stop work.
Safety management of Zhejiang Jiangnan Company
On January 7 and January 9, 2024, Zhejiang Jiangnan Company began to assemble the car and vertical guide rails because the elevator had not completed the reporting procedures of the Bao'an Supervision Bureau of the Shenzhen Municipal Administration for Market Supervision (hereinafter referred to as the "Bao'an Bureau of the Municipal Supervision Bureau"), and issued the "Supervision Notice" and the "Notice of Temporary Suspension of Construction" to KONE Elevator Company respectively, requiring it to suspend the elevator installation and construction work, and only resume work after the completion of the formalities.
The cause of the accident was ascertained
It is that no effective safety protection measures have been taken to prevent falling from heights
Through the investigation of the accident scene, the questioning of personnel, the review of information and judicial appraisal, it was determined that the direct cause of the accident was: the worker Xie Mouqiao had a weak sense of safety, and when replacing the protective railing at the elevator shaft (border), he did not take effective safety protection measures to prevent falling from height, and accidentally fell from the middle elevator mouth on the north side of the fourth floor to the bottom pit of the elevator shaft on the third floor of the basement, resulting in the accident.
☞ Direct cause analysis
1. After the workers removed the original protective railing of the hall door, a critical edge (with a height difference of about 31.3 meters) hole was formed at the elevator entrance involved, and there was a risk of falling from a height during the operation.
2. When there is a risk of falling from a height during the operation, safety protection facilities shall be set up, such as safety belt tie attachment points, safety protection nets, etc.
3. Worker Xie has a weak sense of safety at the bridge, and when replacing the protective railing at the elevator shaft (near the edge), he did not take effective safety protection measures to prevent high falls, and accidentally fell from the middle elevator mouth on the north side of the fourth floor to the bottom pit of the elevator shaft on the third floor when moving the protective railing of the hall door that needs to be replaced, resulting in a high fall accident.
The appraisal opinion of the "Judicial Appraisal Opinion" issued by the Guangdong German Judicial Appraisal Institute (Guangdong German Sijian Institute [2024] Sick Jian Zi No. 8): The deceased Xie Mouqiao died of acute trauma and hemorrhagic shock caused by multiple organs and tissue contusions (especially craniocerebral and thoracic and abdominal injuries) caused by a high fall.
☞ Indirect causes
1. Hengrun Elevator Company is not in place to fulfill the main responsibility of safety production, the risk identification of the operation area of the edge hole is not in place when replacing the protective railing of the hall door, and the safety protection facilities for the operation of the edge hole are not set up; technical and management measures are not taken to timely discover and eliminate the hidden dangers of production safety accidents when workers do not take effective safety protection measures to prevent high falls; the safety production education and training of workers are not in place, and the workers are not familiar with the relevant safety production rules and regulations and safety operation procedures.
2. Jiang Mouwei, the main person in charge of the project of Hengrun Elevator Company, did not perform the safety production management responsibilities in place, and failed to eliminate the hidden dangers of production safety accidents when workers did not take effective anti-fall safety protection measures when they were working.
3. KONE Elevator Shenzhen Branch did not fulfill the main responsibility of safety production, did not identify the risk of the side hole operation area when replacing the hall door protective railing, and did not set up the safety protection facilities for the edge hole operation, and did not take technical and management measures to timely discover and eliminate the hidden dangers of production safety accidents in which the installation workers did not take effective anti-fall safety protection measures when replacing the hall door protective railing.
4. Chen Moubin, the project executive manager of KONE Elevator Shenzhen Branch, did not perform his safety production management responsibilities in place, and failed to eliminate the hidden dangers of production safety accidents that did not take effective anti-fall safety protection measures when workers were working.
☞ Opinions on the handling of relevant responsible personnel and responsible units
(1) Persons who are exempt from accountability for death in an accident
Xie Mouqiao has a weak sense of safety, did not take effective anti-fall safety protection measures when replacing the protective railing of the hall door, and accidentally fell from the middle elevator entrance on the north side of the fourth floor to the elevator shaft on the negative third floor during operation, resulting in an accident, and should be directly responsible for the accident, in view of his death, it is recommended to be exempted from responsibility.
(2) Recommendations for administrative punishments for persons responsible for the accident
1. Jiang Mouwei, the project leader of Hengrun Elevator Company, performs safety production management
The responsibilities are not in place, the safety production work of the unit is not seriously supervised and inspected, and the hidden dangers of production safety accidents that the workers do not take effective anti-fall safety protection measures when replacing the protective railings of the hall door in a timely manner. His behavior violated the provisions of Article 21 (5) of the "Work Safety Law of the People's Republic of China", and should be responsible for the management of this accident, and it is recommended that the Shenzhen Bao'an District Emergency Management Bureau deal with it in accordance with the law.
2. Chen Moubin, project executive manager of KONE Elevator Shenzhen Branch, performs safety
The production management responsibilities are not in place, the safety production work of the unit is not seriously supervised and inspected, and the hidden dangers of production safety accidents that workers do not take effective anti-fall safety protection measures when replacing the protective railings of the hall door in a timely manner. His behavior violated the provisions of Article 21 (5) of the "Work Safety Law of the People's Republic of China", and should be responsible for the management of this accident, and it is recommended that the Shenzhen Bao'an District Emergency Management Bureau deal with it in accordance with the law.
☞ Recommendations for administrative punishment of the unit responsible for the accident
Hengrun Elevator Company
▪ The main responsibility for safety production is not in place, the risk identification of the operation area of the edge hole is not in place when the protective railing of the hall door is replaced, and the safety protection facilities for the operation of the edge hole are not set up;
▪ Failure to discover and eliminate the hidden dangers of production safety accidents that workers do not take effective safety protection measures to prevent falling from heights during operation;
▪ The safety production education and training of workers is not in place, and the workers are not familiar with the relevant safety production rules and regulations and safety operation procedures, and their behavior violates the provisions of the first and second paragraphs of Article 41 and the first paragraph of Article 28 of the "Work Safety Law of the People's Republic of China".
KONE Elevator Shenzhen Branch
▪ The main responsibility for safety production is not in place, the risk identification of the operation area of the edge hole is not in place when the protective railing of the hall door is replaced, and the safety protection facilities for the operation of the edge hole are not set up;
▪ Failure to take technical and management measures to timely discover and eliminate the hidden dangers of production safety accidents in which the installation workers did not take effective anti-fall safety protection measures when replacing the protective railings of the hall door, their behavior violated the provisions of the first and second paragraphs of Article 41 of the Work Safety Law of the People's Republic of China, and should be responsible for the management of the accident, and it is recommended that the Shenzhen Baoan District Emergency Management Bureau deal with it according to law.
The subject has been placed on Amber Alert 7 times
The companies involved were required to rectify the situation
☞ Supervision and management of government safety supervision departments
(A) the district government investment in the construction of the project safety supervision and management unit for the District Construction and Public Works Department
During the implementation of the overall project of Bao'an District People's Hospital, the leaders of the District Construction and Public Works Department and the heads of the departments and offices participate in the safety inspection of the project at least once a month and supervise and inspect the implementation of safety production management.
In 2023, the District Construction and Public Works Department requested 24 times for liquidated damages for all participating units of the project, totaling about 1.4 million yuan, and from January to February 2024, it required all participating units of the project to pay liquidated damages 25 times, totaling about 530,000 yuan. At the same time, in 2023, the District Construction and Public Works Department will give KONE Elevator Co., Ltd., Zhejiang Jiangnan Engineering Management Co., Ltd. and other companies a performance evaluation that is unqualified.
(2) The safety supervision and management unit of special equipment is the Bao'an Bureau of the Municipal Supervision Bureau
In 2023, the Bao'an Bureau of the Municipal Supervision Bureau will conduct daily supervision and inspection of 1,145 special equipment users in Bao'an District in accordance with the provisions of the "Measures for the Safety Supervision and Inspection of Special Equipment", and carry out special elevator rectification such as cracking down on elevator failure to maintain in accordance with regulations, home elevators, and special remediation of miscellaneous freight elevators in catering establishments. In 2023, the Bao'an Bureau of the Municipal Supervision Bureau will file a total of 124 cases of special equipment violations, with a fine of 1.354 million yuan.
According to the "Notice of the Bao'an Supervision Bureau of the Municipal Market Supervision Bureau on Printing and Distributing the 2023 Special Equipment Routine Supervision and Inspection Plan", the Bao'an Bureau of the Municipal Supervision Bureau conducted on-site safety supervision and inspection of special equipment users of Bao'an District People's Hospital. Before the accident, KONE Elevator Shenzhen Branch notified the elevator installation and construction to the Bao'an Bureau of the Municipal Supervision Bureau on the project.
(3) The supervision and management unit of the construction engineering industry is the Bao'an District Housing and Construction Bureau (hereinafter referred to as the "District Housing and Urban-Rural Development Bureau")
The overall engineering supervision agency of Bao'an District People's Hospital is the Bao'an District Housing and Construction Affairs Center. From April 2021 to January 2024, the supervision team inspected a total of 62 projects involved, with an average of 1.94 law enforcement inspections per month, including daily inspections, staggered law enforcement, safety inspections led by leaders on holidays, special inspections, etc., and the supervision team issued a total of 149 law enforcement documents to the project, including 46 supervision and inspection opinions, 51 rectification notices, 7 suspension notices, and 7 yellow warnings. Guangdong Provincial Department of Housing and Urban-Rural Development Housing Municipal Engineering Construction Quality and Safety Violation Scoring Notice" 45 copies.
To sum up, the relevant departments have carried out the corresponding safety production supervision and management work in their respective industries.
☞ Accident rectification and preventive measures
Hengrun Elevator Company
Strengthen the safety education and training of employees, improve the awareness of safety precautions of employees, ensure that employees have the necessary knowledge of safety production, and educate and urge employees to strictly implement the safety production rules and regulations and safety operation procedures of their units.
Establish a safety risk classification control system, take corresponding control measures according to the safety risk classification, and do a good job in safety management of the construction site.
Establish and improve and implement the system for the investigation and management of hidden dangers of production safety accidents, and take effective technical and management measures to discover and eliminate hidden dangers of production safety accidents in a timely manner.
The person in charge of the project shall conscientiously perform the duties of safety management, implement the laws and regulations on safety production and the company's management system, implement the safety production education and training plan, strengthen the supervision and inspection of the safety production work of the unit, and discover and eliminate the hidden dangers of production safety accidents in a timely manner.
KONE Elevator Shenzhen Branch
Strengthen the safety education and training of employees, improve the awareness of safety precautions of employees, ensure that employees have the necessary knowledge of safety production, are familiar with relevant safety operation procedures and master the safety operation skills of their positions.
Establish a safety risk classification control system, take corresponding control measures according to the safety risk classification, and do a good job in safety management of the construction site.
Establish and improve and implement the system for the investigation and management of hidden dangers of production safety accidents, and take effective technical and management measures to discover and eliminate hidden dangers of production safety accidents in a timely manner.
In accordance with the relevant regulations, complete the notification and filing procedures for the installation, transformation and overhaul of special equipment in a timely manner, and organize the construction only after the completion of the procedures.
The person in charge of the project shall conscientiously perform the safety management duties, implement the laws and regulations on safety production and the company's management system, organize the formulation and implementation of the unit's safety production education and training plan, strengthen the supervision and inspection of the unit's safety production work, and discover and eliminate the hidden dangers of production safety accidents in a timely manner.
District Building and Public Works Department
In strict accordance with the requirements of relevant laws and regulations on safety production, implement the primary responsibility of the construction unit, urge the construction unit and the supervision unit to strictly implement the safety production responsibilities, draw inferences from one another, and urge the elevator installation unit to perform the notification and reporting procedures for the installation and transformation of special equipment and overhaul according to the regulations, learn lessons from the accident, and strictly prevent similar accidents from happening again.
Written by: Aoyi News reporter Zhou Xiaoyuan