October 18, 2023
The first phase of Focheng Commercial Capital in Maitreya City, Honghe Prefecture, Yunnan Province
There was a large elevator fall accident
Four people were killed and 16 injured
The direct economic loss was 7,842,590 yuan
May 16th
The website of the Yunnan Provincial Market Supervision Bureau was released
Investigation Report on the Fall Accident of the "10.18" Large Elevator in Mile City, Honghe Prefecture, Yunnan Province
The accident investigation team investigated and determined that the accident was a large special equipment liability accident caused by the failure of the elevator maintenance unit to carry out substantive maintenance in accordance with the regulations, the failure to implement the main responsibility of the user unit, and the failure of the inspection agency to conduct inspection in accordance with the regulations.
The situation of the unit involved in the accident
Maitreya Jisheng Commercial Management Co., Ltd. is the user of the accident elevator;
Shanghai Edunburgh Elevator Installation Engineering Co., Ltd. is the maintenance unit of the accident elevator;
Zhejiang Intercity Special Equipment Testing Co., Ltd. is the inspection agency for the last regular inspection of the accident elevator.
The direct cause of the accident
In the process of driving down from the upper end of the elevator in the accident, the rolling bearing of the counterweight anti-rope pulley fails due to fatigue spalling, and the phenomenon of jamming or clamping occurs, and the counterweight anti-rope pulley transmits the torque to its shaft, so that there is a bolt shear fracture on each side of the baffle plate on both sides of the shaft, resulting in the failure of the axial positioning of the baffle plate; 6 suspension wire ropes are detached from the counterweight counter-rope wheel shaft end (car side) and the counterweight upper beam and separated from the counterweight, the counterweight falls into the pit, and the car loses the counterweight traction and falls into the pit.
In the process of accelerating the fall in the form of free fall near the height of about 10m from the height of the car from the sill on the first floor, the downward mechanical action of the speed limiter fails, and the safety gear fails to be pulled, resulting in the safety gear not moving, and the car fails to stop when the car falls, and the car falls into the pit.
Indirect causes of the accident
1. The accident elevator maintenance unit did not carry out substantive maintenance of the accident elevator in strict accordance with the requirements of the safety technical specifications. The management system of the accident elevator maintenance unit is not perfect, and the quality management of the accident elevator maintenance is missing; The safety education and skill training of elevator maintenance management personnel and maintenance personnel are not in place. The maintenance personnel deceived and did not go to the scene to carry out the work during the annual maintenance of the accident elevator, and did not find the hidden danger of the accident of fatigue and wear of the heavy reverse rope wheel bearing; When the accident elevator is maintained semi-monthly, quarterly, semi-annually and annually, the speed limiter is not lubricated and cleaned, resulting in obvious rust and a large amount of dust in the speed limiter, and the hidden dangers of the accident such as the deformation of the downward pawl spring of the speed limiter and the trigger device of the upward overspeed protection device are not installed, and the accident hidden danger can not be eliminated in time, resulting in the accident.
2. The accident elevator user safety main responsibility is missing, the safety management system is not perfect, the elevator safety responsibility system is not perfect, the elevator safety management personnel lack the necessary safety education and skills training, do not perform the duty of supervision and confirmation of the maintenance process and results, let the maintenance personnel cheat, carry out regular self-inspection is not in place, resulting in the accident hidden dangers are not found and eliminated in time.
3. The elevator inspection agency did not carry out regular inspection of the accident elevator in strict accordance with the relevant safety technical specifications and its quality management system document requirements. The elevator inspection agency of the Yunnan project department elevator inspection quality control is not in place, the inspectors in the implementation of the accident elevator regular inspection, the elevator maintenance and use units to implement the relevant responsibilities, independent determination of equipment safety and other work quality judgment is untrue, some of the inspection items have not carried out substantive inspection, there are "use data", "speed limiter", "car upward overspeed protection device test" inspection project conclusions are untrue, the inspection report issued is seriously untrue, failed to find and eliminate the hidden dangers of the accident.
The main problems existing in the relevant units
(1) Shanghai Edunburgh Elevator Installation Engineering Co., Ltd
Shanghai Edunburgh Elevator Installation Engineering Co., Ltd. is the maintenance unit of the accident elevator, the main problems:
1. Lack of management of maintenance personnel. When the maintenance personnel carried out the annual maintenance of the accident elevator, they did not go to the scene to carry out the work, and only filled in the fabricated maintenance situation in the maintenance record book, and did not find the hidden danger of the accident of fatigue wear and tear of the heavy reverse rope wheel bearing; In the semi-monthly, quarterly, semi-annual and annual maintenance work of the accident elevator, the speed limiter was not lubricated and cleaned, resulting in obvious rust and a large amount of dust in the speed limiter, and no accident hazards such as the deformation of the downward pawl tension spring of the speed limiter and the failure to install the trigger device of the upward overspeed protection device were not found.
2. Safety education and skill training are not in place, the quality and safety awareness of maintenance personnel is indifferent, and the maintenance work is fraudulent. After the accident elevator speed limiter is checked, the maintenance personnel do not install and reset the trigger device of the dismantled upward speed protection device; In the case of no substantive maintenance of the accident elevator, the maintenance personnel shall fill in the fabricated maintenance situation in the elevator maintenance record book, and sign the names of the personnel of the unit and the user unit; When the accident elevator was self-checked, the data such as the meshing depth of the elevator door lock, the gap between the door cutter and the sill, and the gap between the door wheel and the sill were not measured, but the fabricated data was filled. Since 2023, only one online (offline) safety education and training has been organized, and the online training time for maintenance personnel is relatively short, and some maintenance personnel have even participated in the training for less than 1 minute.
3. The company's quality system is not sound. There is no management system for the review of maintenance departments, maintenance teams, maintenance team leaders, maintenance personnel, and maintenance records, and there is a lack of effective supervision and management mechanisms for maintenance departments, maintenance team leaders, and maintenance personnel. The Quality Assurance Manual and related job responsibilities cite invalid regulations and safety technical specifications.
4. The implementation of the system is not strict. Failure to control the on-site operation process in accordance with the provisions of the company's "Quality Assurance Manual". The maintenance team leader did not strictly perform his job responsibilities and did not participate in the accident elevator maintenance work in accordance with the company's regulations.
5. The quality supervision of elevator maintenance is not in place. Knowing that there are problems in the elevator maintenance work of the accident, they will not correct it and let it go. From June 11, 2020 to the day of the accident, no supervision and assessment of the maintenance quality of the accident elevator was organized. Failure to follow up and supervise the rectification of the problem that the elevator maintenance quality evaluation of the accident was "poor".
(2) Maitreya Jisheng Commercial Management Co., Ltd
Maitreya Jisheng Commercial Management Co., Ltd. is the user of the accident elevator, the main problems:
1. Lack of responsibility for security. Failure to effectively supervise and confirm the maintenance process and results of Shanghai Edunburgh Elevator Installation Engineering Co., Ltd., and failure to stop the fraudulent behavior of maintenance personnel. Failure to prepare elevator self-inspection and elevator regular inspection plans, and the implementation of elevator self-inspection, regular inspection and follow-up rectification is not in place. The staff signed and confirmed the maintenance records fabricated by the staff and the safety department fabricated the elevator inspection work records.
2. The management system is not perfect, and the elevator safety responsibility system is not perfect. There is no work system and mechanism such as daily control, weekly inspection, and monthly scheduling, and the elevator daily inspection system does not stipulate specific inspection items and contents. The list of safety responsibilities of all types of personnel at all levels is not clarified, and the responsibilities of the personnel of the security department are not clear; Failure to formulate a safety production responsibility system for each team (post), employee, and merchant. The elevator safety director and elevator safety officer were not equipped and the job responsibilities were clarified, and the elevator safety responsibility was not implemented one by one.
3. Elevator safety management personnel lack the necessary safety education and skills training. The training of elevator safety management personnel was not carried out, and the oral explanation of the person in charge of the safety department was used to replace the elevator safety education and training.
(3) Zhejiang Intercity Special Equipment Testing Co., Ltd
Zhejiang Intercity Special Equipment Testing Co., Ltd. is a regular inspection agency for accident elevators, the main problems:
1. The quality control of inspection and testing work is not in place. In the process of regular inspection of the elevator used by Maitreya Jisheng Commercial Management Co., Ltd., the inspectors completed the elevator inspection work separately by one person and one group, and the inspectors only carried out the regular inspection work on May 19, 2023, and deliberately filled in the inspection time as May 18 and May 19. Failure to conduct on-site assessment of the quality of elevator inspection work of Yunnan Project Department in accordance with the provisions of the company's "Inspection and Testing Work Quality Control Procedures".
2. The quality management system documents have not been effectively implemented, and the conclusion of the accident elevator inspection report is seriously untrue. In the regular inspection report of the accident elevator, the inspection item "8.2 car upward overspeed protection device test" has the problem that the trigger device of the upward overspeed protection device is not installed, but the conclusion of the inspection item is judged to be "qualified", and the conclusion of the inspection item "1.4 use data" and "2.9 speed limiter" is untrue.
Identification of responsibilities and handling suggestions
According to the investigation report, according to the "Special Equipment Safety Law of the People's Republic of China" and other relevant laws and regulations, combined with the accident investigation, it is recommended to deal with the relevant personnel and units responsible for the accident as follows:
(1) Responsible personnel recommended to be transferred to the judicial organs for handling
1. Zhao Yongqing, Maintenance Manager of the Maintenance Department of the Third Center of Marketing Engineering of Shanghai Edunburgh Elevator Installation Engineering Co., Ltd. If a crime is suspected, it is recommended that it be transferred to the judicial organs for handling in accordance with law.
2. Wang Qianjun, captain of the 23rd maintenance team of Shanghai Edunburgh Elevator Installation Engineering Co., Ltd., holds the "Special Equipment Safety Management and Operator Certificate". It is recommended that their professional qualifications be revoked in accordance with law; If a crime is suspected, it is recommended that it be transferred to the judicial organs for handling in accordance with law.
3. Cheng Biao, an employee of Shanghai Edunburgh Elevator Guizhou Co., Ltd., was assigned to work in Shanghai Edunburgh Elevator Installation Engineering Co., Ltd., and holds the "Special Equipment Safety Management and Operator Certificate". It is recommended that their professional qualifications be revoked in accordance with law; If a crime is suspected, it is recommended that it be transferred to the judicial organs for handling in accordance with law.
4. Zhang Yanmei, the legal representative and general manager of Maitreya Jisheng Commercial Management Co., Ltd., is the first person responsible for the safety production of the enterprise. If a crime is suspected, it is recommended that it be transferred to the judicial organs for handling in accordance with law.
5. Hu Yaoqing, Manager of the Safety Department of Maitreya Jisheng Commercial Management Co., Ltd., Head of Safety Production of the Safety Department. If a crime is suspected, it is recommended that it be transferred to the judicial organs for handling in accordance with law.
6. Xiao Xuan, director of the safety department of Maitreya Jisheng Commercial Management Co., Ltd., holds the "Special Equipment Safety Management and Operator Certificate". It is recommended that their professional qualifications be revoked in accordance with law; If a crime is suspected, it is recommended that it be transferred to the judicial organs for handling in accordance with law.
7. Cheng Yaoxing, head of Yunnan Project Department of Zhejiang Intercity Special Equipment Testing Co., Ltd., elevator inspector, holds the "Special Equipment Inspection and Testing Personnel Certificate". It is recommended that their professional qualifications be revoked in accordance with law; If a crime is suspected, it is recommended that it be transferred to the judicial organs for handling in accordance with law.
8. Song Hongli, elevator inspector of Zhejiang Intercity Special Equipment Testing Co., Ltd., holds the "Special Equipment Inspection and Testing Personnel Certificate". It is recommended that their professional qualifications be revoked in accordance with law; If a crime is suspected, it is recommended that it be transferred to the judicial organs for handling in accordance with law.
(2) Determination of responsibility of relevant personnel and recommendations for handling.
1. Li Sui, the legal representative of Shanghai Edunburgh Elevator Installation Engineering Co., Ltd. It is recommended that the Honghe Prefecture Administration for Market Regulation impose administrative penalties on him in accordance with the law.
2. Ye Xiaobo, General Manager of Shanghai Edunburgh Elevator Installation Engineering Co., Ltd. It is recommended that the Honghe Prefecture Administration for Market Regulation impose administrative penalties on him in accordance with the law.
3. Mao Wenjie, director of the third marketing engineering center of Shanghai Edunburgh Elevator Installation Engineering Co., Ltd., and concurrently the director of the maintenance department of the third marketing engineering center, is the person responsible for the on-site construction quality control of the company's special equipment production quality control system. It is recommended that Shanghai Edunburgh Elevator Installation Engineering Co., Ltd. deal with it according to the regulations and report the treatment to the Yunnan Provincial Market Supervision and Administration Bureau.
4. Huang Zijun, Director of Engineering Technology and Quality Department of Shanghai Edunburgh Elevator Installation Engineering Co., Ltd. It is recommended that Shanghai Edunburgh Elevator Installation Engineering Co., Ltd. deal with it according to the regulations and report the treatment to the Yunnan Provincial Market Supervision and Administration Bureau.
5. Chen Zhijiao, Deputy Manager of the Security Department of Maitreya Jisheng Commercial Management Co., Ltd. It is recommended that Maitreya Jisheng Commercial Management Co., Ltd. handle it in accordance with the provisions of the company system, and report the situation to the Yunnan Provincial Market Supervision and Administration Bureau.
6. Wang Chong, staff of the security department of Maitreya Jisheng Commercial Management Co., Ltd. It is recommended that Maitreya Jisheng Commercial Management Co., Ltd. handle it in accordance with the provisions of the company system, and report the situation to the Yunnan Provincial Market Supervision and Administration Bureau.
7. Zhu Ran, a staff member of the security department of Maitreya Jisheng Business Management Co., Ltd. It is recommended that Maitreya Jisheng Commercial Management Co., Ltd. handle it in accordance with the provisions of the company system, and report the situation to the Yunnan Provincial Market Supervision and Administration Bureau.
8. Qiu Fubin, staff of the security department of Maitreya Jisheng Commercial Management Co., Ltd. It is recommended that Maitreya Jisheng Commercial Management Co., Ltd. handle it in accordance with the provisions of the company system, and report the situation to the Yunnan Provincial Market Supervision and Administration Bureau.
9. Xia Ping, general manager of Zhejiang Intercity Special Equipment Testing Co., Ltd., is fully responsible for all affairs of the company. It is recommended that the Honghe Prefecture Administration for Market Regulation impose administrative penalties on him in accordance with the law.
10. Liu Tao, the technical director of Zhejiang Intercity Special Equipment Testing Co., Ltd., the authorized signatory, is responsible for the approval and issuance of inspection and testing reports and certificates within the scope of authorization, and holds the "Special Equipment Inspection and Testing Personnel Certificate". It is recommended that the Honghe Prefecture Administration for Market Regulation revoke his qualifications and impose a fine in accordance with the law.
11. Xie Yu, Deputy Director and Head of Technical Management Department of Zhejiang Intercity Special Equipment Testing Co., Ltd. It is recommended that the Honghe Prefecture Administration for Market Regulation impose administrative penalties on him in accordance with the law.
12. Wang Jingqian, deputy director and person in charge of the quality management department of Zhejiang Intercity Special Equipment Testing Co., Ltd., elevator inspection responsible division, inspection report reviewer, holds the "Special Equipment Inspection and Testing Personnel Certificate". It is recommended that the Honghe Prefecture Administration for Market Regulation revoke his qualifications and impose a fine in accordance with the law.
(3) Determination of responsibility of relevant units and recommendations for handling
1. Shanghai Edunburgh Elevator Installation Engineering Co., Ltd. is the maintenance unit of the accident elevator, the main responsibility for the accident, according to Article 90 of the Special Equipment Safety Law of the People's Republic of China, it is recommended that the Honghe Prefecture Market Supervision and Administration Bureau shall impose administrative penalties on it in accordance with the law, and be included in the list of serious violations and dishonesty to manage and implement joint disciplinary action. In accordance with the provisions of Article 10, Paragraph 2, Article 52, Paragraph 3, Article 82 (3) of the Regulations on the Safety Supervision of Special Equipment and Article 9 of the Administrative Punishment Law of the People's Republic of China, it is recommended that the Honghe Prefecture Market Supervision and Administration Bureau revoke its elevator production qualification in accordance with the law, and request the issuing authority to cancel it. At the same time, within 3 years from the date of revocation of the license, the special equipment safety supervision and management department will not accept the company's new license application.
2. Maitreya Jisheng Commercial Management Co., Ltd. is the user of the elevator accident, the main responsibility for the accident, according to Article 90 of the Special Equipment Safety Law of the People's Republic of China, it is recommended that the Honghe Prefecture Market Supervision and Administration Bureau shall impose administrative penalties in accordance with the law, and be included in the list of serious violations and dishonesty to manage and implement joint punishment.
3. Zhejiang Intercity Special Equipment Testing Co., Ltd. is a regular inspection agency for the accident elevator, the main responsibility for the accident, according to Article 90 of the Special Equipment Safety Law of the People's Republic of China, it is recommended that the Honghe Prefecture Market Supervision and Administration Bureau shall impose administrative penalties on it in accordance with the law, and be included in the list of serious violations and dishonesty to implement joint punishment.
The investigation report pointed out that in view of the serious consequences and bad effects caused by the "10.18" large elevator falling accident in Maitreya City, Honghe Prefecture, Yunnan Province, it is recommended that the Maitreya Municipal Market Supervision and Administration Bureau make a profound inspection to the Maitreya Municipal People's Government, the Honghe Prefecture Market Supervision and Administration Bureau, the Maitreya Municipal People's Government to make a profound inspection, and the Honghe Prefecture People's Government to the Provincial People's Government. Problems and related materials discovered in the course of the investigation of the accident by public employees of local governments and relevant departments in the performance of their duties shall be transferred to the discipline inspection commissions and supervision commissions at all levels for investigation and handling in accordance with the authority of the cadres. Opinions on the disposition of party discipline and government sanctions for relevant personnel are to be submitted by discipline inspection commissions and supervision commissions at all levels.
Elevator accidents happen from time to time
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