Investigation Report on "5 · 19" General Asphyxiation Accident of Zhangjiakou Hengtai Cement Co., Ltd.

On December 4, the People's Government of Zhangbei County, Zhangjiakou, Hebei Province, issued an investigation report on the "5.19" general asphyxiation accident of Zhangjiakou Hengtai Cement Co., Ltd. According to the

report, at about 14:40 on May 19, 2023, Zhangjiakou Hengtai Cement Co., Ltd. had an asphyxiation accident during the cleaning operation of No.3 cement silo of No.2 production line, resulting in two deaths and a direct economic loss of about 3.2 million yuan. After the

accident, Zhangbei County Party Committee and County Government attached great importance to it, and the main leaders gave instructions respectively. In accordance with the requirements of laws and regulations such as the Safety Production Law of the People's Republic of China and the Regulations on the Reporting and Investigation of Production Safety Accidents, the People's Government of Zhangbei County established the Emergency Management Bureau of Zhangbei County on May 19, 2023. The County Public Security Bureau, the Management Committee of Hebei Zhangbei Economic Development Zone, the County Bureau of Industry and Information Technology and the County Federation of Trade Unions participated in the "5.19" asphyxiation accident investigation team of Zhangjiakou Hengtai Cement Co., Ltd. (Hereinafter referred to as the accident investigation team), and hired relevant experts to conduct a comprehensive investigation of the accident in accordance with the law and regulations. The Zhangbei County Commission for Discipline Inspection and Supervision has set up an accountability group to simultaneously initiate accountability procedures for responsible units and personnel. At the same time, the Security Committee Office of Hanbin District, Ankang City, Shaanxi Province was invited to send personnel to participate in the investigation of the accident.

The accident investigation team adhered to the principles of "four not letting go" and "scientific and rigorous, in accordance with the law and regulations, seeking truth from facts and paying attention to practical results", and through on-site investigation, investigation and inquiry, access to information and expert demonstration, found out the course and cause of the accident, identified the nature and responsibility of the accident, and put forward the responsibility for the responsible personnel and units. In view of the problems exposed by the accident, suggestions for prevention and rectification are put forward.

1. Accident-related units

(1) Accident-related units

1. Zhangjiakou Hengtai Cement Co., Ltd. (Hereinafter referred to as Hengtai Cement Company), established on March 14, 2002, is a limited liability company (invested or controlled by natural persons). Unified social credit code: 91130722735641757K; legal representative: Liu Moujuan; business scope: processing and sales of cement and cement products, net fence, etc. Registered capital: RMB ten million yuan; domicile: south side of Anguli Avenue, Zhangbei Town, Zhangbei County; registration authority: Administrative Examination and Approval Bureau of Zhangbei County; business term: March 14, 2002 to March 14, 2032.

Pollutant Discharge Permit No.: 91130722735641757K001P, Industry Category: Cement Manufacturing. The issuing authority is Zhangjiakou Administrative Examination and Approval Bureau, the issuing date is July 30, 2021, and the validity period is from July 30, 2021 to July 29, 2026. Founded in 2002

, Hengtai Cement Company is a joint-stock private enterprise with an annual production capacity of 1.5 million tons and 110 employees. It has a production department, a laboratory, a financial department, a sales department and a comprehensive office. The Safety and Environmental Protection Office under the General Office is the company's safety management organization, with one safety officer. The main product is "Baqiang" brand P042.5 ordinary Portland cement.

2、 Shaanxi Ankang Dongxu Labor Service Subcontracting Co., Ltd. (Hereinafter referred to as Dongxu Labor Service Company) was established on June 1, 2016. Its legal representative is Liu Mouzhong, its unified social credit code is 91610900MA70J4D15F, and its registered capital is RMB 2 million. Domicile: Group 15, Shicun Village, Xincheng Office, Hanbin District, Ankang City, Shaanxi Province; enterprise type: limited liability company (sole proprietorship of natural person); business scope: cement packaging, loading and unloading, handling; cement warehouse cleaning and installation; scaffolding operation, carpentry operation, masonry operation, steel bar operation, welding operation; household service; Greening engineering construction, etc. Registration authority: Ankang Administration for Industry and Commerce. Business term: long-term. Institution Credit Code Certificate Code: G10610902001471003. Account opening permit, approval No.: J8010001471001, No.: 7910-01340379. The company has two main personnel, Liu Mouzhong is the executive director and general manager, the financial officer, and Liu Mouzhong is the supervisor. There are no fixed employees, and when there is business, temporary employees are employed to engage in related operations. Dongxu Labor Service Company is the outsourcing unit of the inventory clearance project of Hengtai Cement Company.

(2) Projects involved

1. Six steel cement silos and two steel homogenization silos are in use. During the storage of cement, due to the large temperature difference between the inside and outside of the warehouse and the condensation of moisture in the air in the warehouse, the cement is pre-hydrated, resulting in cement caking. After a certain period of accumulation, a certain thickness of wall-mounted cement (hardening, caking) is formed along the warehouse wall, and the actual available volume of the cement warehouse will be reduced. Therefore, when the caking reaches a certain thickness, it must be cleaned. The content of this warehouse cleaning project is the cleaning of the wall hanging cement and the block cement materials accumulated at the bottom of the three cement silos in the No.3 warehouse of No.3 production line, No.2 warehouse of No.2 production line and No.3 warehouse of No.2 production line (hereinafter referred to as No.3 warehouse of No.2 production line). 2.

On February 8, Liu Mouzhong and Hengtai Cement Company signed the Cement Warehouse Clearance Contract Agreement. Both parties: Party A is Zhangjiakou Hengtai Cement Co., Ltd., and Party B is Shaanxi Ankang Dongxu Labor Subcontracting Company. In the agreement, the two sides agreed on the project content, quality requirements, project price, construction period, safety responsibility and payment settlement method. On the same day, Party A's safety officer Xiao Moufu and Liu Mouzhong signed the Safety Agreement, in which it is clear that Party B appoints Liu Mouli as the safety officer during Party A's construction operation, who is fully responsible for the safety and fire control of the project; On February 8, Xiao Moufu made an on-site operation safety disclosure to Liu Mouli, and two people signed the Safety Disclosure Letter for Clearance of Cement Silos on Line 2 and Line 3 of Zhangjiakou Hengtai Cement Co., Ltd. On February 8, Liu Mouzhong, the person in charge of warehouse clearance, Hu Mouliang (director of packaging workshop), Xiao Moufu (safety officer) and Yang Mou (general manager of Hengtai Cement Company) of Hengtai Cement Company signed the Confirmation of Safety Responsibility for Cleaning Cement Storage to confirm the safety measures and responsibilities to be implemented by all parties in the warehouse clearance operation. 3. Due to the impact of the sales situation of Hengtai Cement Company, the cleaning work of 2 # warehouse of Line 2 and 3 # warehouse of Line 2 was temporarily delayed. After consultation between Liu Mouzhong, Wang Moubing and Liu Mouli, the clearance construction of 2 # warehouse on Line 2 and 3 # warehouse on Line 2 was contracted to Liu Mouli at a price of 32 yuan per ton. On April 8, Liu Mouzhong contacted Li Mouchun, Liu Mouli contacted Lai Mouman and Cui Moubao, and Liu Mouli led them to Hengtai Cement Company. On April 11, the clearance work of 2 # warehouse on Line 2 began, and Liu Mouli appointed a man to be responsible for the management of the construction site with a remuneration of 2 yuan per ton. On April 12, Lai Mou-man contacted his wife Feng Mouli to participate in the inventory work of Hengtai Cement Company. By April 30, the clearing work of 2 # warehouse of Line 2 was completed, and the actual clearing volume was 2000 tons. On May 7, Lai Mou-man, Cui Mou-bao, Li Mou-chun and Feng Mouli started the work of clearing the warehouse of Line 2 and 3. By the time of the accident on May 19, the lower part of the cement warehouse had not been cleaned up for more than 4 meters.

After investigation, Dongxu Labor Service Company went to Hengtai Cement Company twice for the construction of cement warehouse clearance. Hengtai Cement Company only signed the safety agreement, the safety disclosure of warehouse clearance operation and the confirmation of safety responsibility for cleaning cement storage warehouse when it first entered the factory. Before the construction operation, the safety education and training related to high-altitude operation and confined space operation were not carried out for the construction personnel. Only on April 14, Xiao Moufu went to the dormitory of the construction personnel to make a simple explanation and asked the operators to sign the training record. During the construction operation, Hengtai Cement Company did not arrange a special person to supervise the site safety. Among the four on-site workers, only Lai Mou-man holds a valid certificate of high-altitude operation, while Li Mou-chun and Cui Mou-bao's certificate of high-altitude operation has not been reexamined within the time limit. See the following table for details:

(III) The equipment involved and the site

of the accident 1. It is transported by the elevator to the bulk warehouse and bag warehouse for loading or packaging for export.

Fig. 1 Process Flow Diagram

of Cement Finished Product Warehouse Fig. 2 Structure Diagram

of 3 # Cement Silo of Line 2

Fig. 3 Geographical Location Diagram

of Enterprises Involved Fig. 4 Accident location map

< IMG SRC = "https://img7.ccement.".0181422 of 6p5ivroqel6170168.

II. Accident conditions

(I) The accident occurred

at about 12 o'clock on May 19, 2023. Cui Moubao, Lai Mouman, Li Mouchun and Feng Mouli started the 2 line 3 # warehouse clearance operation. Cui Moubao, Lai Mouman and Li Mouchun entered the warehouse to clean up the cement caking. Li Mouchun was responsible for prying the accumulated material from the warehouse wall with an electric pick. Lai Mouman and Cui Moubao smashed the large accumulated material with a pick and pushed it to the center of the cement warehouse. Three people took turns to work. Feng Mouli is responsible for putting ash outside. When it is necessary to put ash, she will contact Feng Mouli with a walkie-talkie. Feng Mouli will contact the packaging workshop personnel to confirm whether the ash can be put. The thickness of the caked material on the silo wall is about 5 meters. In order to facilitate the cleaning of the accumulated material, the accumulated material is pried into a slope from the silo wall to the inside during operation. Three people stood on the slope and cleaned up from top to bottom in a spiral. Li Mouchun used an electric pick to pry off some accumulated materials, then untied the safety rope and went to a safer place near the warehouse wall to rest. Lai Mouman and Cui Moubao tied the safety rope again. One end of the safety rope was tied to the railing near the manhole on the top of the warehouse. The safety rope hung down from the top of the warehouse along the ladder and was fixed on the ladder. The length of the safety rope from the fixed point to the working surface was more than 20 meters. Cui Moubao is tied between the fixed point of the safety rope and Lai Mouman, about 5-6 meters away from Lai Mouman, and Lai Mouman is tied at the end of the safety rope. Two people share a safety rope and stand on the slope facing the wall of the warehouse while beating the accumulated material blocks and pushing the broken accumulated material to the bottom. At 14:40, one person accidentally stepped on the false material and slipped down first, and then another person was pulled down.

(2) Li Mouchun, who was working in the same warehouse in the accident rescue situation

, saw two people fall down and hurriedly pulled the safety rope without pulling it, so he climbed from the ladder on the inner wall of the warehouse to the outside of the warehouse to find someone to help him. First, he found Feng Mouli at the outlet platform of the cement warehouse. Feng Mouli immediately went to find Hu Mouliang, the director of the packaging workshop, and reported the situation to him. At 14:42, Feng Mouli called Liu Mouli. Liu Mouli rushed to the scene immediately after receiving the report. At 15:03, she dialed 120 emergency calls. At 14:45, Hu Mouliang called manager Yang Mou. Yang Mou immediately organized maintenance workshop director Bai Mou, Xiao Moufu, Zhao Mou and other personnel to carry out rescue. First, they went up to the top of the warehouse. After they went up, they found that the dust concentration in the warehouse was very high and the visibility was low. They could not rescue from the top. They decided to cut the cone under the warehouse with a cutting torch to carry out rescue. Around 1500, maintenance workers Wang Mouxing, Jing Mouyou and Xu Moutao rushed to the scene with cutting tools. First cut a round opening with a diameter of about 300 mm, and began to discharge ash. In this process, cut a square hole of 600 × 400 mm on the opposite side (less than 180 degrees), and discharge ash at the same time. The cutting process lasted more than 10 minutes. About 5 minutes after the incision was opened, Cui Moubao was pulled out. About 20 minutes later, he saw his head lying face down, his waist tied with a safety rope, and most of his body buried in cement. So he cut a small opening about 100 mm in diameter above the gate, half a meter lower than the first two openings, and began to dig out the ash from the small opening. When the ash is loose, cut the rope and pull it out in the future. Two people were confirmed dead by 120 medical staff.

Fig. 6 φ300 Circular

Hole Fig. 7 400 × 600 Rectangular Hole

Fig. 8 φ100 Circular

Hole Fig. 9 Situation

in the East Side of the Bin Fig. 10 Safety rope

in the cabin < IMG SRC = "The deceased was buried by his family on https://img7.ccement.com/richtext/img/vek0vbq5x681701680397198.6 3.".

(4) The accident report

occurred at 14:40 on May 19, 2023. At 14:42, Feng Mouli called Hu Moumou and Liu Moumou. At 14:45, Hu Mouliang called Yang Moumou. At 15:03, Liu Mouli called the 12016

: 08, 110 received the alarm

at 16:58, Zhangbei County Public Security Bureau called the county emergency management Bureau at 17:05. Enterprise legal person Liu Moujuan reported to the county emergency management Bureau

at 18:17. After verification by the county emergency management Bureau, she reported to the emergency management Bureau of Zhangjiakou City by telephone at 18:20. The county emergency management Bureau reported the accident through the emergency command integrated business system. (5) After receiving the report, Yang Mou, the production manager

of Hengtai Cement Company, immediately rushed to the scene to direct the emergency disposal. Bai Mou, Xiao Moufu, Zhao Mou and Wang Mouxing, Jing Mouyou, Xu Moutao, the director of the maintenance workshop, responded quickly and made every effort to carry out the rescue. Dongxu Labor Service Company called the society for help. "120" and "110" quickly rushed to the scene of the accident, and the rescue organization was timely and effective, and the method was reasonable, which avoided the expansion of the accident. According to the investigation and assessment, there are still some problems in the emergency disposal of accidents. The emergency preparedness of Dongxu Labor Service Company is insufficient, and the on-site emergency response capability needs to be improved. The emergency rescue plan of Hengtai Cement Company is not perfect, the drill is insufficient, and the construction plan and emergency preparedness of the contractor are not reviewed according to the actual situation.

3. The cause and nature

of the accident (1) The direct cause

of the accident is that the operators did not have safe and reliable safety protection measures in the process of clearing the cement warehouse, violated the rules and took risks, fell into the cement in the warehouse and suffocated to death.

(2) Indirect reasons

1. No safety education and training for operators working at heights and in confined spaces.

(2) When undertaking the inventory project, the operator's high-altitude operation certificate is not provided. After investigation, the legal person of the company and Wang Moubing contracted the inventory clearance project in partnership and then subcontracted it to Liu Mouli. Only one of the three personnel working in the 3 # cement silo of Line 2 holds the high-altitude operation certificate, which meets the requirements ②; the enterprise did not perform the risk management and control responsibilities, and did not carry out the identification and control of risk factors.

(3) The operation equipment, facilities and personal protective equipment that meet the standards are not fully equipped, and the warehouse cleaning operators do not drill holes on the top of the warehouse and hang safety ropes as required; the cleaning personnel who enter the warehouse do not wear safety belts, and the operators violate the operating procedures ④. (4) There is no safety supervisor on the site, and there is no supervisor on the top of the warehouse when operating in violation of the regulations ⑤; the operator is tied to the waist with a rope instead of a safety belt in violation of the regulations, and two people share a safety rope ⑥.

2.

(2) Lack of attention to safety production, lack of full-time safety management personnel, only one safety management personnel Xiao Moufu on site, and no qualification certificate of safety management personnel; imperfect formulation of safety production responsibility system and safety management system. Failure to set up a leading group for inventory clearance in accordance with the requirements of the regulations, failure to formulate a plan for inventory clearance and on-site disposal, which were approved by the safety production department of the enterprise and the person in charge of the enterprise, and failure to exercise unified command over the inventory clearance operation.

(3) Safety production education and training is a mere formality. According to the clearance operation safety management agreement signed by both parties, the person in charge of the site and the safety management personnel shall conduct safety education and training for the outsourced operation personnel. During the investigation, it was found that the personnel who came to the site for construction twice were not the same group of personnel, and the training sign-in records were all signed by Xiao Moufu to the dormitory to find the construction personnel.

(4) The safety management of confined space is not in place, the safety precautions for confined space operation are not formulated before the implementation of confined space operation, the operators are not informed of the possible risk factors and prevention and control measures at the clearance operation site, and the safety warning education is not carried out ①; Failure to perform risk management and control duties in accordance with regulations, and inadequate identification and control of risk factors.

3.

Zhangbei County Emergency Management Bureau did not thoroughly and meticulously supervise and inspect the outsourcing project management, dangerous operation management, safety education and training, and special contingency plan of Zhangjiakou Hengtai Cement Co., Ltd. The responsibility of safety production supervision and management is not in place. Be responsible for the accident.

(3) The nature

of the accident was confirmed by investigation that the "5.19" asphyxiation accident of Zhangjiakou Hengtai Cement Co., Ltd. was a general accident of production safety responsibility.

4. Suggestions

on the handling of the persons and units responsible for the accident (1) Personnel who are recommended to be exempted from accountability (2 persons)

1. Violating the operation regulations, commanding in violation of regulations, venturing into the cement silo to clear the warehouse, and bearing direct responsibility for the accident. In view of his death in the accident, it is recommended that he be exempted from accountability.

2. Weak safety awareness, poor self-protection awareness, illegal operation, and direct responsibility for the accident. In view of his death in the accident, it is recommended that he be exempted from accountability.

(2) Personnel (2 persons)

who are recommended to be held accountable by judicial organs (1) have not worked out the responsibility system for production safety, safety management system and safety operation rules, have not worked out the operation plan, safety measures and contingency plan for inventory clearance, have not carried out safety education and training for operators in high-altitude operations and limited space operations, and have not carried out safety education and training for operators in high-altitude operations. Failure to equip all the standard operating equipment and facilities and personal protective equipment is responsible for the accident. Suspected of the crime of major liability accident, it is suggested that the case be transferred to the judicial organ for criminal responsibility.

2. No feasible safety operation plan has been formulated according to the actual situation of the site, the relevant work tickets have been examined and approved according to the regulations before the operation, the safety production management system has been formulated and implemented, the staff has not been organized to carry out special safety education and training for high-altitude operation and limited space, and the safety supervision of the operation site has not been carried out or arranged. Failure to fulfill the safety management responsibilities of the project site. He was responsible for the accident and was suspected of the crime of major liability accident. It is suggested that the case be transferred to the judicial organ for criminal responsibility.

(III) Suggested personnel for internal handling of the enterprise (1 person)

Hu Mouliang, male, packaging team leader of Zhangjiakou Hengtai Cement Co., Ltd., responsible for the management of cement silo and cement packaging. When issuing the work permit during the clearing operation of the cement silo, he failed to perform his duties properly, failed to manage the safety of the clearing operation site effectively, failed to discover, stop and correct the illegal operation of the clearing operation in time, failed to supervise the implementation of the safety management agreement of the clearing operation, and was responsible for the accident. It is suggested that Zhangjiakou Hengtai Cement Co., Ltd. should be punished according to the relevant management system of the enterprise.

(4) Suggestions on the handling of public officials (3 persons)

Zhangbei County Emergency Management Bureau (3 persons)

(5) Suggestions

on the handling of units and personnel responsible for accidents 1. Failure to implement the examination and approval system for dangerous operations, laissez-faire management of outsourced construction teams, and responsibility for accidents. It is suggested that the Emergency Management Bureau of Zhangbei County impose a fine of 650000 yuan on it in accordance with Article 114 (1) of the Safety Production Law of the People's Republic of China.

2. Failure to conscientiously perform the duties of safety production management of the principal person in charge of the production and business operation unit shall be responsible for the occurrence of the accident. It is suggested that the Emergency Management Bureau of Zhangbei County, in accordance with the provisions of Article 95 (1) of the Safety Production Law of the People's Republic of China, impose a fine of 40% of the annual income of the previous year, amounting to 24000 yuan.

3. When selecting the outsourcing construction unit, they did not carefully review the key information of the contractor's operators, did not supervise the implementation of the safety operation plan and safety measures, did not implement the responsibility of safety production education and training for confined space operations, and did not arrange special personnel to be responsible for on-site safety monitoring; As the final approver of the dangerous operation ticket, he failed to implement the examination and approval system for dangerous operations, failed to take effective measures to stop the illegal inventory operation, and was responsible for the accident. It is suggested that the Emergency Management Bureau of Zhangbei County, in accordance with the provisions of Article 95 (1) of the Safety Production Law of the People's Republic of China, impose a fine of 40% of the annual income of the previous year, amounting to 110612 yuan.

4. Safety management responsibilities are not clear, the principle is not strong, and the safety management agreement signed with Liu Mouzhong of Shaanxi Ankang Dongxu Labor Subcontracting Co., Ltd. has not fully fulfilled the responsibility of safety supervision, and is responsible for the accident. It is suggested that the Emergency Management Bureau of Zhangbei County, in accordance with Article 96 of the Safety Production Law of the People's Republic of China, impose a fine of 40% of the annual income of the previous year, amounting to 22419 yuan. It is suggested that Zhangjiakou Hengtai Cement Co., Ltd. should be dismissed according to the relevant management system of the enterprise.

5.

Accident prevention and rectification measures

(1) Effectively implement the main responsibility of enterprises for safe production. Zhangjiakou Hengtai Cement Co., Ltd. should reflect on the deficiencies in daily work, earnestly implement the main responsibility of safety production, establish and improve the safety production responsibility system, safety production management system and safety operation rules, improve the safety production management organization, and allocate sufficient safety production management personnel; It is necessary to strictly implement various risk control and hidden danger investigation and management system measures, timely identify, update and establish hazard source files, formulate a sound emergency rescue plan and organize drills; strengthen the approval and inspection of all kinds of dangerous operations, and resolutely prevent the occurrence of illegal command and operation. Strictly examine and implement the qualifications of outsourcing construction units, three systems of safety production, personnel training and construction schemes, and resolutely put an end to the lack of responsibility of the main body of safety production caused by "contracting for management".

(2) Carefully carry out safety education and training. Zhangjiakou Hengtai Cement Co., Ltd. should strengthen the education and training of safety production laws, regulations and rules through this accident case, list inventory clearance and limited space operation as the key contents of strengthening safety management, and conduct special safety training for the person in charge of the operation site, guardians, operators and emergency rescue personnel. Continuously improve the safety awareness of employees, safety production knowledge and enterprise safety management level.

(Three) earnestly implement the safety production supervision and management responsibilities of the Department. In view of the problems exposed by the accident, the county emergency management Bureau should strengthen the supervision and management of production safety within the scope of the department's responsibilities, and effectively implement the responsibility of production safety supervision.