Source: Ash Desulfurization and Denitrification Technology Alliance
After the failure of the slag scooping machine of No. 2 furnace was dealt with in a power plant, a large amount of ash suddenly collapsed to the slag scooping machine, and a large amount of hot steam, hot water and hot slag were sprayed, resulting in 9 people working on the upper platform of the slag scooping machine, of which 2 people died after rescue was ineffective. According to the "Regulations for the Investigation of Electric Power Production Accidents of a Group Company", an accident investigation team formed by a power generation company conducted an investigation into the accident, and on June 13 and June 17, it went to the group company twice to "explain clearly" and report on the relevant situation of the accident investigation. Now that the investigation of the accident has basically been completed, in order to extensively draw lessons from the accident, draw inferences from one case, and effectively put an end to the occurrence of similar accidents, the accident is hereby reported as follows:
First, the accident happened
Before the accident, Unit 2 (300MW) had a load of 250MW and a total coal volume of 116t/h. A, B leading, sending and primary fan operation, A, B, C, D coal mill operation, E grinding for each purpose, the unit operation is normal.
(1) Fault handling of slag removal machine
At 9:18 on the 12th, the No. 2 furnace slag machine tripped. After inspection, it was judged that the south side of the slag scooping machine was tightened and the chain jumped buckle and deviated from the rear guide wheel. The Gangu Project Department of an electric power maintenance company arranged 3 maintenance personnel, and the working time of the invoice processing plan was from 9:40 on the 12th to 23:40 on the 13th, and the end time of the work approved by the chief was 15:30 on the 12th. The safety measures are the shutdown and power outage of the No. 2 furnace slag fishing machine; Hydraulic shut-off door at the bottom of the furnace is closed; The hydraulic oil pump of the slag removal machine was out of operation. At 10:07, the operation permit started. At 10:15, the maintenance personnel arrived at the scene and organized the start of construction, and at 10:30, the person in charge of the work dispatched one maintenance personnel to support. At 14:20, the defect handling ended. After the on-site inspection and acceptance of the equipment department, the inspector of the equipment department asked to adjust the chain tension and the angle of the scraper of the slag machine, and the maintenance personnel immediately dealt with it. At 15:20, because the maintenance work did not end as planned, the handling work was postponed to 23:17:40 on the 12th. After the joint inspection of the person in charge of the work and the inspector, it was judged that the scraper of the underwater part of the slag fishing machine was stuck, and it was decided on the spot that the water seal of the slag fishing machine was re-inspected and treated.
At around 18 o'clock, the person in charge of the work asked the gray control operation personnel to release water into the water sealing tank of the slag fishing machine and check the stuck astringents. At 18:20, Zhang ##到达现场, the chief inspector of the boiler of the equipment department, asked the ash control operation personnel to release water into the water sealing tank of the slag fishing machine. At 18:36, Li #, deputy director of the equipment department, #给值长打电话, asked to release water into the water sealing tank of the slag removal machine and check the stuck astringency.
At 18:40, the chief reported the situation to Chief Engineer Sun ##, Deputy Chief Engineer and Director of the Power Generation Department of the Plant Department Zhou # that night, and Deputy Director of Production Li ##. After obtaining consent, the slag removal machine was ordered to release the water, and the load was reduced from 250MW to 200M at the same time. At 18:45, when the gray control operation personnel released the water, they found that the screws of the water discharge door were rusted, and the water discharge pipe was blocked by ash, and Zhang # #要求检修人员配合处理. At 19:27, the water began to be released. In order to speed up the water discharge, the maintenance personnel are asking for Zhang # #同意后打开捞渣机人孔门.
At 21 o'clock, the water in the water seal tank of the slag removal machine is exhausted. Check that the scraper is stuck at the guide wheel on the north side of the bottom of the slope, but it is difficult to deal with more slag. Zhang##联系5名消防人员配合检修人员冲洗水封槽内积渣. 10:23 Lee##电话询问值长捞渣机故障处理情况. At 22:30, the defect processing was completed, the trial transfer was normal, and the work system was terminated.
(2) System recovery
At 22:47 on the 12th, the operator restored the system and started the slag removal pump to fill the water seal of the slag machine. At the same time, the maintenance personnel use fire water to inject water into the water seal tank.
At 0:25 on the 13th, the water seal of the slag removal machine was normal, the ash control operation personnel opened the hydraulic shut-off door to release the cold ash hopper slag, and the deputy director of the power generation department Wang ## (the deceased was 42 years old) and the ash control specialist Ye ## (the injured) were present for supervision. During the slag removal process, it was found that the east door was opened and closed normally, and one of the inner doors on the west side was not fully opened##联系检修人员前来处理.
At 1:02 on the 13th, the ash of the cold ash hopper on the west side of the slag scooping machine of the No. 2 furnace was emptied, and after opening the hydraulic shut-off door on the east side, it was found that there was no bright light, which was judged to be the slag on the top of the slag scooping machine. The chief of the duty is #汇报 to Zhou#, deputy director of the power generation department Zhang ##, Sun ##, Li ##, and director of the safety supervision department Jia #. In the report, the chief stressed the urgency and danger of the situation.
(3) Decoking operations
At 1:20 on the 13th, Wang ##, Ye ##, and Zhang # #和检修人员一起来到捞渣机处. Take measures to vibrate with a sledgehammer and open and close the hydraulic shut-off door, and the ash has not yet fallen. The hydraulic shut-off door is in an open state after being opened and closed many times, leaving hidden dangers for the occurrence of accidents.
At 1:28 on the 13th, the chief and Zhang ##先后电话联系设备管理部主任禄# (the deceased, male, 42 years old) asked to go to the scene to organize the disposal of unkempt slag. After Lu # arrived at the centralized control room, he organized a meeting to study the defect treatment plan and decided to use fire water to flush the slag in the inspection hole of the 4-meter platform. The chief of the No. 2 furnace slag was invalid after beating and other methods, and prepared to use fire water to #汇报 the slag flushing plan to Li #, replied that he agreed, and asked the chief to notify Zhou # to the scene. At 2:19 on the 13th, Li # #电话询问周#处理情况, making it clear that the load can be reduced and the furnace cannot be stopped.
At 2:21 on the 13th, the fire brigade was notified by phone to go to the scene immediately, and the maintenance personnel were required to jointly assist them in coking, pulling the fire hose At 2:30 on the 13th, the fire brigade captain led 11 firefighters into the production site Lu # After explaining the matters to the firefighters and maintenance personnel, 4 firefighters used a fire gun to rotate the slag flushing at the two inspection holes of the 4-meter platform on the south side of the east side, and 3 firefighters and 3 maintenance personnel took turns to use iron pipes to coke.
At about 5 o'clock on the 13th, the ash on the north and south sides of the cold ash hopper on the east side was basically removed, and a large piece in the middle was not cleared. The maintenance personnel thought that the ash and slag in the cold ash hopper had been opened at both ends, and there was no need to coke again, so they went to the centralized control conference room to rest. Lu# Arrange for all staff to rest.
Lu#, Sun##, Zhang Qianyong, Wang##, Zhang##, Ye##到集控会议室商量下一步处理方案. Lu # contacted Chen # (injured), the manager of Huatang maintenance project, by phone and asked him to go to the centralized control room and organize manpower to cooperate with the coking work. Chen# immediately called the boiler maintenance team leader to inform Mo# #组织人力参加作业.
At 7:10, 6 people, including ##带领锅炉队检修工王## (injured), entered the scene. At 7:15, Li # #来到集控会议室 and Lu # reported on the disposal of unkempt slag. At 7:40, Li # #等9人返回现场 and continued to organize coke. Li # #看了现场情况后, then left to check the operation of the coal mill, and returned to the office building to organize the 8 o'clock production scheduling meeting. Zhou # went to check the defects of the coal mill to discharge the stone coal, Zhang # #集控室, Zhang # #身体不适也离开了现场.
(4) Accidents occur
At 8:10, Lu #, firefighter door ## (injured), Yan ## (injured) Wang ## (injured) were lined up in turn, and the slag was flushed with fire water at the first inspection hole on the southeast side. Chen#, Wang##, Mo##在东南侧第二个检查孔处用铁管焦, Mo##安排其他锅炉检修人员在锅炉房大门口等候. Sun##, Ye##, Wang##在北侧检查孔处观察. Suddenly, a large amount of ash collapsed, the water seal under the boiler cold ash hopper was destroyed, a large amount of hot steam, hot water, and hot slag were sprayed out of the last ##迅速就地卧倒成功避险, and the other 9 people were burned.
Second, the accident rescue situation
After the accident, a power plant immediately organized to send the wounded to the hospital for simple treatment, and then sent them to Tianshui City Hospital for rescue. At 13:40 on the 13th, Wang # #经抢救无效死亡.
At 21:30 on the 13th, Lu Jing died after rescue efforts failed.
At 22 o'clock on the 13th and early morning of the 14th, under the guidance of experts from the Fourth Military Medical University, Ye ## and Sun # were #实施喉部插管.
At 15 o'clock on the 14th, Ye ##, Sun ##, and Chen # were transferred to the Affiliated Hospital of Xi'an Fourth Military Medical University for treatment. At 19 o'clock on the 15th, Door ##, Yan #, Wang ##, and Wang # #转送第四军医大学附属医院治疗. At present, the wounded are recovering well.
3. Analysis of the cause of the accident
(1) Direct causes
1. The work ticket system is not implemented in the decoking work, and the operation is in violation of regulations; The "three stresses and one implementation" activity was not carried out before the operation, and the risk of sudden occurrence of large pieces of coke slag was not clear; Operators violated safety work regulations, did not wear anti-scald work clothes, helmets, etc., and did not implement personal safety protection measures.
2. There is no lighting at the decoking operation site (cold ash bucket 4-meter platform), and a large number of people gather in a narrow space (the trail is 1.22 meters wide, and surrounded by the descending pipe and water distribution pipe, and the passage is not smooth (the height of the staircase is 80cm, and you can only bow your waist and pass slowly), and you can't avoid it in case of danger.
3. The defect treatment time of the slag scooper is too long, resulting in a large amount of ash gathering at the cold ash hopper; In the process of decoking operation, the countermeasures, operation procedures and safety work procedures were violated, and technical measures to prevent the sudden fall of ash such as closing the hydraulic shut-off door and reducing the load of the unit were not taken.
4. When the coking is serious and there is the possibility of large coke slag falling, the furnace is not stopped for coking removal.
(2) Indirect causes
1. The safety production responsibility system is not implemented, and the safety production system is not operating normally. In the case that the defects of the slag removal machine cannot be eliminated for a long time, and the safety risk is increasing, the chief has reported to the relevant leaders by telephone many times, but it has still failed to attract great attention, failed to effectively organize, analyze and deal with it in a timely manner, and the production leaders lack a sense of responsibility and worry.
2. Production management is chaotic and supervision and management are not in place. In the process of eliminating defects, the scope of maintenance operations has been continuously expanded, and the number of personnel for slag removal machine maintenance, system recovery, and decoking has increased at will, and firefighters without special training have been arranged to participate in decoking operations. In major dangerous operations, factory leaders and safety supervision and management personnel did not go to the operation site to organize, guide and supervise, and the production organization was not effective.
3. Failure to follow rules and regulations. The operators have a poor sense of compliance with rules and disciplines, the on-site operation organization is arbitrary, and the effective systems and measures such as "safety work procedures", "two votes and three systems", "three stresses and one implementation", "key countermeasures" and "operation procedures" are in vain. Organizational and technical measures to ensure security have not been implemented.
4. The business level of equipment management personnel, operation personnel and maintenance personnel is not high and cannot meet the requirements of on-site work. The equipment management personnel have an inaccurate grasp of the analysis, judgment and treatment plan of the defects, and lack of planning and guidance for the elimination of defects; The maintenance personnel take too long to eliminate the defects of the slag machine, leaving hidden dangers for the occurrence of accidents; The operation personnel did not strictly implement the requirements of the operation procedures and key countermeasures, and did not take safety measures to prevent a large amount of coke slag from falling off in operation.
Fourth, the responsibility analysis and the handling of the relevant responsible personnel
The second meeting of the safety production committee of the group company in 201# researched and determined that the "5.13" accident was a liability accident caused by the failure to implement the safety production responsibility system of a power plant, the chaos of production management, the irresponsibility of production leaders, and the ineffective production command and illegal operation. According to the "Regulations on Rewards and Punishments for Work Safety of a Group Company" and the "Measures for the Management of the System Safety Production Responsibility System of a Group Company", in accordance with the authority of cadre management, the group company, a power generation company, and a power plant respectively imposed administrative sanctions and economic penalties on relevant leaders and responsible personnel.
(1) The group company's punishment of relevant personnel
1. Yan ##, general manager of a power generation company, is the first person responsible for the safety production of a power generation company, and lacks an effective grasp of the safety production situation; Responsible for the leadership of safety production management, the construction of the cadre team and the construction of the work style of the production system; Take leadership responsibility for the production safety accidents that have occurred in Gansu Power Generation Company since the beginning of this year. An administrative warning was given.
2. Ping #, deputy general manager of a power generation company, is directly responsible for the safety production work of a power generation company, can not accurately grasp the main problems of safety production, can not take timely and effective measures to solve the problem, and extensive safety production management is directly responsible for the accidents that have occurred in Gansu Power Generation Company since the beginning of this year. Administrative demerits are imposed.
3. The group company's rectification and supervision of the construction of the safety production system and the implementation of the responsibility system of a power generation company are not fully in place; The implementation of anti-accident measures and rules and regulations has not been grasped to the end; Failed to solve the shortcomings of the safety production of the group company's system in a timely manner, and was responsible for the supervision and management of the production safety accident of a power generation company. In accordance with the "Interim Measures for the Management of Performance Appraisal of the Headquarters of a Group Company", Gao Zhibo, director of the safety production department of the group company, was given an economic penalty.
(2) The punishment of relevant personnel by a power generation limited company
1. Qiao ##安全责任缺失, the director of a power plant, did not manage in place and was mainly responsible for the accident. It was decided to give Qiao # #撤职处分 and give him a financial penalty of 10,000 yuan. In view of the fact that the Tianshui Municipal Safety Supervision Bureau imposed an economic penalty of 20,000 yuan on individuals, the economic penalty of the provincial company will no longer be implemented.
2. Li ##安全责任缺失, Secretary of the Party Committee of a power plant, did not manage well and was mainly responsible for the accident. It was decided to give Li # #撤职处分 and give him a financial penalty of 10,000 yuan.
3. Li ##是分管安全生产的第一责任人, deputy director of production of a power plant, was not clear in his daily production work, lack of management, irresponsible work, illegal command, and serious dereliction of duty, and was directly responsible for the accident and decided to be dismissed and given an economic penalty of 10,000 yuan.
4. Sun # #负责全厂技术指施管理和现场人员的技术培训, chief engineer of a power plant, did not have adequate technical management and supervision of major maintenance operations, and was responsible for the technical management of the accident. It was decided to give an administrative demotion and an economic penalty of 10,000 yuan.
5. Huo ##, director of a power plant, Huang ##, chairman of the labor union, and Long ##对企业安全生产齐抓共管执行不力, chief accountant, bear certain leadership responsibility for the accident. It was decided to impose an economic penalty of 10,000 yuan each.
6. Zhou ##, deputy chief engineer and director of the safety production department of a power generation company, has a weak sense of crisis and responsibility for safety production, and does not have a good supervision and management of safety production in grassroots units, and is responsible for the management of this accident. A financial penalty of 10,000 yuan will be given.
(3) The punishment of relevant personnel by a power plant
1. Deputy Chief Engineer and Director of the Power Generation Department Zhou #, as the on-site leader, did not supervise and guide the major maintenance operations on the site, sat idly by and ignored the on-site violations, and was responsible for the on-site leadership of the incident. He was given a demotion and a financial penalty of 8,000 yuan.
2. Jia ##负责全厂安全监督工作, director of the safety supervision department, is mainly responsible for the lack of on-site supervision. He was dismissed from office and imposed a financial penalty of 5,000 yuan.
Zhang #, deputy director of the power generation department, #对异常事件的危险分析预控不到位, underestimated the consequences, failed to stop the on-site violations in time, and was mainly responsible for the inadequate management of operation technology, and was given an administrative demerit and an economic penalty of 5,000 yuan.
4. Zhang ##, the chief inspector of the equipment department, is not effective in the daily inspection and maintenance management of the equipment, the maintenance time of the slag fishing machine is not strict, the understanding of the dangerous work on the site is insufficient, and the preventive measures taken are not perfect, and he is mainly responsible for technical management. A penalty of 6 months on the job will be imposed.
5. Han ##, a member of the equipment department, as the person in charge of the slag removal machine equipment, does not check and maintain the slag machine equipment in place, so that small defects develop into major defects, and the maintenance time of the slag fishing machine is not strict, and the main responsibility for the equipment management is not in place. A penalty of 3 months of on-the-job waiting will be given.
6. After the night shift on duty on duty He ##, the on-site dangerous work is not strictly controlled, and the main responsibility for on-site supervision and management is not stopped. A penalty of 6 months on the job will be imposed.
7. After the night shift, the ash removal squad leader leads #, fails to stop the dangerous work on the site in time, and bears the main responsibility for on-site supervision and management. A penalty of 6 months on the job will be imposed
8. Jian ##, the shift leader of the middle shift, and Li ##, the shift leader of the night before, did not take relevant measures in accordance with the operation regulations after the failure of the slag removal machine and bore secondary responsibility for the accident. A financial penalty of 2,000 yuan was given.
9. Sun ##对异常事件危险性认识不足, deputy director of the equipment department, said that the technical precautions were not perfect, and the awareness of personal safety protection was not strong, which was secondary to the accident. In view of the injuries, responsibility for the accident is no longer pursued.
10. The power generation department's ash removal specialist Ye # #对异常事件危险点分析不到位, the technical measures are not perfect, and the awareness of personal safety protection is weak, so he is secondary to the accident. In view of the injuries, responsibility for the accident is no longer pursued.
11. Zhang ##, Kong ##, safety officer of the power generation department, Li ##, safety officer of the equipment department, Gong ##, Liang ##, and Chai ##负有对现场监不到位的次要责任 of the safety supervision department. A financial penalty of 2,500 yuan will be imposed on each other.
12. Lu #, director of the equipment department, anti-"safety regulations" stipulates that in the case of not perfecting any safety measures, illegal command, no ticket operation, no work instructions, no danger point analysis blindly start maintenance; Poor on-site supervision, failure to stop the accident in time, and serious dereliction of duty; The main responsibility for this accident is beared. In view of the death, responsibility for the accident is no longer pursued.
13. Wang ##分管除灰专业, deputy director of the power generation department, was mainly responsible for the accident because the risk analysis and pre-control of the abnormal event was not in place, the consequences were underestimated, and the on-site road chapter behavior was not stopped in time. In view of the death, responsibility for the accident is no longer pursued.
5. Preventive measures taken to learn from the lessons of the accident
(1) All branches, subsidiaries and grass-roots enterprises should seriously reflect on the lessons of the continuous personal injury accidents of Gansu Power Generation Company, further strengthen the supervision and inspection of the implementation of the "ban on production safety in central enterprises", intensify the work of fighting against "luck, paralysis and irresponsibility", and vigorously carry out anti-"three violations" activities to ensure the effective operation of the safety production management system. We should further strengthen the comprehensive management of production safety, make up for shortcomings, and ensure the stability of the situation of production safety.
(2) All branches and subsidiaries should start with strict discipline, strict management, and serious investigation, and earnestly ensure the smooth implementation of safety production decrees and prohibitions, effectively strengthen the construction of the production team's work style, cultivate the production team's "rigorous, meticulous, and solid" work style, cultivate professional and technical personnel's habit of "learning procedures, standards, and systems", strengthen production technology training, and improve the technical quality of all employees.
(3) All branches, subsidiaries and grass-roots enterprises should carry out the "four inspections and one reform" activities in depth. Carefully analyze and accurately grasp the weak links of safe production, and plug the management loopholes in a timely manner. Through the activities, we will further strengthen the safety awareness of production leaders, strengthen the supervision and inspection of responsibilities in place, and take the failure to implement the responsibility system as the biggest hidden danger, and effectively strengthen rectification. It is necessary to focus on solving the problem of the organization guarantee and technical support of the headquarters and its affiliated enterprises in combination with the actual situation of the enterprise, and effectively strengthen the construction of safety production control capacity of the subsidiary company.
(4) Implement comprehensive management of production safety, strengthen process control, and prevent the occurrence of similar accidents. Leading cadres at all levels must earnestly enhance their understanding of the extreme importance of safe production, adhere to the principle of taking safe production as the foundation and economic returns as the center, correctly handle the relationship between economic returns and safe production, straighten out their thinking, and grasp the main contradictions. The group company and all subsidiaries should further strengthen the process supervision and inspection of safety production, and implement comprehensive management of enterprises with disorderly management, many problems, and poor rectification in a timely manner, so as to put an end to the phenomenon of "after the accident".
(5) Grass-roots enterprises should strictly implement the rules and regulations and anti-accident measures, strictly enforce the principles and procedures of "five confirmations and one fulfillment" for the problems existing in safety production, and give full play to the guarantee role of the "two full" mechanism to ensure the effective operation of the safety production management system. Resolutely put an end to the arbitrariness of production technology management and on-site operations.
(6) Grass-roots enterprises should continue to carry out the activities of "equipment defect reduction" and "civilized production level", start from strengthening the analysis and management of defects, conscientiously grasp the operating conditions and technical conditions of equipment and systems, and start from improving the health level of equipment to provide guarantee for safe production.
(7) Further strengthen the training and assessment of employees' business skills. For special dangerous operations such as coking and decoking, the staff must undergo special training, master the relevant requirements of safety work procedures and key countermeasures, master the operation process, process and emergency escape methods, and correctly use safety protection equipment.
(8) Grass-roots enterprises should systematically carry out employee safety education and training to improve the safety awareness and comprehensive quality of all employees, improve the ability of employees to identify and control operational risks, strengthen the training of safety production laws and regulations and safety production rules and regulations, and improve the safety management ability and management level of personnel at all levels.
(9) The first person responsible for the safety of grass-roots enterprises should personally organize and carry out a special safety day activity, conscientiously study the accident report, analyze the violations in the process of the accident and the arbitrariness of the work organization, find out the inevitability of the accident, combine the management and work of the enterprise, the post, and check the situation, [Power Eagle] from the perspective of protecting each employee's own safety and family happiness, and effectively improve the understanding of the importance of carrying out the "three stresses and one implementation" activities, and improve the understanding of compliance with rules and disciplines. From production leaders to production front-line employees, everyone must write a piece of experience, and the safety supervision department must collect and comment on it in a unified manner.