Xinjiang Uygur Autonomous Region, released the "4.15" General Asphyxiation Accident Investigation Report of a Manufacturing Co., Ltd. in Jimsar County.
After investigation, it was found that the "4.15" general asphyxiation accident of a manufacturing company in Jimsar County was caused by the fact that the workers did not keep a safe distance from the reclaiming equipment, and the workers in the same shift violated the operating rules to open the 10 # feeding port. Causing one operator to be injured by accident: Yu, an employee of a rental station, violated the Shelter Safety Operation Procedures of a manufacturing company." The direct cause of the accident was that he did not keep a safe distance from the reclaiming equipment during the reclaiming operation and was buried by clinker and suffocated to death, and that Zhang Mou-3, an employee of a rental station, violated the Safety Operating Rules for the Storage Shed of a Manufacturing Co., Ltd., did not ensure the safety of the personnel in the storage shed, and directly opened the 10 # discharge port. The full
report reads as follows:
accident investigation team found out the course, causes, casualties and direct economic losses of the accident through on-site investigation, investigation and evidence collection, and comprehensive analysis, and identified the nature and responsibility of the accident. Suggestions on the treatment of relevant responsible persons and responsible units are put forward, and suggestions on accident prevention measures are put forward in view of the causes of the accident and the outstanding problems exposed.
I. Basic information
of the accident (I) Overview
of the unit where the accident occurred and the relevant responsible unit 1. Unified social credit code: 9165 * * * * * * * * * * * 67, legal representative: Zhang Moumou 1, registration status: operating (opening) enterprise. Date of establishment: February 12, 2009; registered capital: RMB three hundred and fifty million yuan; enterprise type: limited liability company; business term: long-term; domicile: No.6, a park, Jimsar County, Changji Prefecture, Xinjiang; business scope: production and sales of cement; sales of mineral powder and cement clinker; provision of labor services. On May 17, 2022, a manufacturing company appointed Zhang Moumou 1 as the principal person in charge of the company.
2. Unified social credit code: 9165 * * * * * * * * * * * 9u, organization form: individual business, type: individual business, registration date: June 26, 2015, operator: Zhang Moumou 2, business place: a logistics park in Jimsar County, Changji Prefecture, Xinjiang. Scope of business: Permitted items: Road transport of goods (excluding dangerous goods). (Projects that must be approved according to law can only be carried out after being approved by relevant departments, and the specific business projects shall be subject to the approval documents or licenses of relevant departments). General items: machinery and equipment leasing: labor services (excluding labor dispatch); hardware products wholesale; labor protection supplies sales; transport equipment leasing services; earthwork construction; sales of non-metallic minerals and products; sales of cement products; non-metallic waste and debris processing; solid waste management. (Except for projects that must be approved according to law, business activities shall be carried out independently according to law with business license)
(2) Contract signing situation
a manufacturing limited company (Party a) and a leasing station (Party B) signed the Labor Outsourcing Contract on March 15, 2025. The content of labor service agreed in the contract is to provide limestone, raw coal, gypsum crushing and transportation assistance, and the Safety Production Management Agreement was signed on March 25, 2025.
2. The course of the accident and the emergency rescue situation
(1) The basic situation of
the accident site The accident site is located at the 10 # feeding port of the clinker storage shed in the southwest corner of a manufacturing company. The feeding port is wide at the top and narrow at the bottom in a funnel shape, embedded in the underground of the clinker storage shed. The upper opening of the hopper is 0.5m higher than ground, 4m long and 3.6m wide. The lower opening is 2m long and 0.6m wide. The hopper is 2m deep. A steel bar fence is set above the discharge opening to prevent large materials from falling. The conveyor belt is set in the underground corridor, under the hopper, about 0 from the ground. Before the accident, there was clinker above the 10 # discharge opening, about 6m high.
Figure 1 Schematic diagram
of the accident scene 
21:40, Zhang Mou-3 met Yu Mou-3 at the gate of the clinker shed. They entered the clinker shed together and removed a steel wire rope at the 10 # feeding port. Then, Zhang Mou-3 went to the clinker corridor to check the feeding situation. Yu Mou-3 stood at the gate of the clinker shed. At about
21:50, Zhang Mou-3 arrived at the clinker gallery. Because the 8 # feeding port was blocked, he closed the 8 # feeding port and opened the 9 # feeding port. About 10 minutes later, the 9 # feeding port was blocked. Zhang Mou-3 closed the 9 # feeding port and opened the 10 # feeding port. After about 10 minutes of observation, the feeding was normal. Then he walked out of the gallery and went to the power room.
At 22:45, Zhang Mou-mou 4 (an employee of a rental station) called Yu Mou-mou but failed to get through. At 22:50, Zhang Mou-mou 4 called Zhang Mou-mou 3 to inquire about Yu Mou-mou's whereabouts. Zhang Mou-mou 3 replied. At 21:40, he separated from Yu Mou-mou at the gate of the clinker shed and never saw him again. Then Zhang Mou-mou 2 and Zhang Mou-mou 4 began to look for Yu Mou-mou in the clinker shed, corridor, gypsum shed, limestone shed, 8 # warehouse roof and the river opposite the color board house, and called Yu Mou-mou many times, but they were not connected, nor did they find Yu Mou-mou. From
23:16 to 01:34 on 15 April, Li Mou-mou (Vice Minister of Production and Operation Department of a Manufacturing Limited Company), Wang Mou-mou 1 (Minister of Operation Management Department of a Manufacturing Limited Company), Wang Mou-mou 2 (Production Dispatch of a Manufacturing Limited Company), Chai Mou (Minister of Security of a Manufacturing Limited Company), Liu Mou (Minister of Production and Operation Management Department of a Manufacturing Limited Company) have successively received reports from on-site employees and contractors. And carry out the search. At about
2 o'clock, Chai, Li, Zhang 3 and Zhang 5 entered the clinker corridor again to look for Yu. At about 2:20, four people saw reflective clothes at the grate of 10 # feeding mouth, and there was blood under the belt. Then Fu (the security officer of the security department of a manufacturing company) reported Yu's loss of contact to the county emergency management Bureau by telephone. Chai called 110, 120 and 119 respectively to report and carry out rescue work.
(3) Emergency disposal and assessment
of the accident 1.
At 2:44, Fu reported the loss of Yu to the county emergency management Bureau by telephone. Chai Mou dialed 110, 120 and 119 respectively at
3:05, 3:06 and 3:15, and organized on-site rescue.
30, 110, 120 and 119 received alarms and arrived at the scene of the accident one after another, and quickly launched rescue operations. Subsequently, relevant units such as the County Emergency Management Bureau, the Beiting Industrial Park Management Committee and the Commerce and Industry Bureau also rushed to the scene. The deputy county head, the deputy county head and the director of the county public security Bureau arrived at the scene to carry out rescue command work, and orderly deployed various rescue tasks. On-site commanders arrange excavators and forklifts to carry out rescue according to the needs of rescue operations. At the same time, employees of enterprises are organized to set up warning lines, fill sandbags, build formwork and scaffolding to prevent secondary accidents.
3.
On April 16, a rental station signed a compensation agreement with the family members of the deceased (Yumou). After consultation, the two sides determined that the total amount of compensation for the family members of the deceased was 1.4 million yuan, and the compensation was paid to the family members of the deceased in accordance with relevant laws, regulations and procedures. The deceased was properly buried on April 17.
4. After the accident, the county Party committee and the county people's government attached great importance to it, and the relevant functional departments responded quickly, timely and effectively to the rescue, handled the scene properly, and no secondary derivative accidents occurred in the rescue process.
3. Casualties and direct economic losses
caused by the accident Yu Moumou, male, Han nationality, 35 years old, ID card No.: 6523 * * * * * * * * * 2039, domicile: Qitai County, Xinjiang, affiliated unit: a rental station. The accident investigation team verified the direct economic loss of 1.43 million yuan according to the provisions of the Statistical Standard for Economic Losses of Casualty Accidents of Enterprise Employees (gb6721-1986).
4. Analysis of
the causes of the accident (1) The direct cause of
the accident was that Yu Mou-mou, an employee of a rental station, violated the "Safety Operating Rules for Stacking Shed" of a manufacturing company, failed to keep a safe distance from the reclaiming equipment during the reclaiming operation, and died of suffocation under the pressure of clinker. Moreover, Zhang Mou-mou 3, an employee of a rental station, violated the Safety Operation Rules of a Manufacturing Co., Ltd., failed to ensure the safety of the personnel in the shed, and directly opened the 10 # feeding port, which was the direct cause of the accident.
(2) Indirect causes
1.2.
(3) Investigation of
other possible factors The public security department of Jimsar County, through on-site investigation, investigation and inquiry, autopsy and other work, ruled out intentional criminal suspicion.
(4)
After investigation, it was found that the "4.15" general asphyxiation accident of a manufacturing company in Jimsar County was caused by the fact that the workers did not keep a safe distance from the reclaiming equipment, and that the workers in the same shift opened the 10 # feeding port in violation of the operating rules. As a result, a worker was buried by clinker and suffocated to death in a general production safety liability accident.
5. Main problems
of relevant departments (1) As an industry supervision department, the county emergency management Bureau is responsible for the supervision and management of a manufacturing limited company. In 2025, it carried out three inspections on a manufacturing limited company, found four hidden dangers and put forward two suggestions, all of which have been reviewed and the enterprise has completed the rectification. The training of the principal responsible persons and safety management personnel in the rule of law and the training of guardians of special operations in the industry and trade industry have been carried out for enterprises, but there are some problems in the supervision of production safety that are not detailed and incomplete, and the problems that enterprises have not brought contractors into the unified coordination and management have not been found in time.
(2) As a territorial management unit, the Management Committee of Beiting Industrial Park is responsible for the territorial management of a manufacturing company, and the daily management of safety production is not in place, and there is no feedback on the inspection records in the safety production inspection of a manufacturing company in 2025.
(III) As the industry management department, the County Bureau of Commerce and Industrial Informatization is responsible for the safety production management of a manufacturing company, and takes safety production as an important part of the industry management. However, in 2025, only one on-site discussion was held on a manufacturing company to guide and urge a manufacturing company to strengthen safety management.
6. Suggestions
on the handling of the responsible persons and units (1) The responsible persons (one person in total)
are exempted or not investigated for their death in the accident. Yu Mou-mou, male, the masses, employees of a rental station, has a weak sense of safety. In violation of the "Safety Operating Rules for Stacking Shed" of a manufacturing company, he did not keep a safe distance from the reclaiming equipment during the reclaiming operation, and was buried by clinker and suffocated to death. He is directly responsible for the accident, and in view of his death in the accident, it is recommended that he be exempted from accountability.
(2) It is suggested that the personnel transferred to the judicial organs (one person in total)
Zhang Mou-mou 3, male, the masses, the employees of a rental station, have weak safety awareness, violate the rules of operation, fail to implement the "Safety Operating Rules for Stacking Shed" of a manufacturing company, fail to confirm that there are no personnel and obstacles around the equipment before starting the belt at the discharge port, and fail to implement the "Safety Operating Rules for Stacking Shed" of a manufacturing company. Directly open the 10 # discharge port, resulting in an accident. He was directly responsible for the accident and was suspected of the crime of major liability accident, and suggested that he be transferred to the judicial organ for investigation of criminal responsibility according to law.
(3) Suggestions on administrative penalties for those responsible for the accident (3 persons in total)
1. Being responsible for the occurrence of the accident violates the provisions of Article 21, Items 2 and 5, of the Safety Production Law of the People's Republic of China. It is suggested that the Emergency Management Bureau of Jimsar County should impose administrative penalties in accordance with Article 95 of the Safety Production Law of the People's Republic of China.
2. His actions violated the provisions of Article 25, Items 5 and 6 of the Safety Production Law of the People's Republic of China and were responsible for the accident. It is suggested that the Emergency Management Bureau of Jimsar County impose administrative penalties in accordance with the provisions of Article 96 of the Safety Production Law of the People's Republic of China.
3. His actions violated the provisions of Article 25, Items 5 and 6 of the Safety Production Law of the People's Republic of China and were responsible for the accident. It is suggested that the Emergency Management Bureau of Jimsar County impose administrative penalties in accordance with the provisions of Article 96 of the Safety Production Law of the People's Republic of China.
(4) Suggestions
on administrative penalties for units responsible for accidents 1. Their actions violate the provisions of Article 35, Article 44, paragraph 1, of the Safety Production Law of the People's Republic of China. It is suggested that the Emergency Management Bureau of Jimsar County should impose administrative penalties in accordance with the provisions of Article 114, paragraph 1, paragraph 1, of the Safety Production Law of the People's Republic of China.
2. His actions violated the provisions of Articles 4 and 28 of the Safety Production Law of the People's Republic of China. It is suggested that the Emergency Management Bureau of Jimsar County should impose administrative penalties in accordance with the provisions of Article 114, paragraph 1, paragraph 1, of the Safety Production Law of the People's Republic of China.
(5) Suggestions
on the handling of relevant public officials 1.2.3
.
(6) Other suggestions (3 persons in total)
1. Inadequate performance of post duties. The management of the subordinate operation management department is not strict, and the operation management department is not urged to strengthen the management of the contractor, resulting in the contractor's safety management omissions, and the operator's illegal operation behavior is not found and corrected in time. It is suggested that the enterprise should carry out internal treatment in accordance with the company's management regulations and report the results to the county emergency management Bureau.
2. The performance of post duties is not in place, the management of the contractor is not strengthened, the safety management of the contractor's operation process is not inspected in time, and the operator's illegal operation behavior is not found in time. It is suggested that the enterprise should carry out internal treatment in accordance with the company's management regulations and report the results to the county emergency management Bureau.
3. The performance of post duties is not in place, and the contractor's operators'illegal operation behavior is not found in time. It is suggested that the enterprise should carry out internal treatment in accordance with the company's management regulations and report the results to the county emergency management Bureau.
7. Accident rectification and preventive measures
(1) a manufacturing limited company
first brings the contractor into unified coordination and management, strictly examines the contractor's qualifications and safety production conditions, and urges the contractor to establish and improve the safety production management system and operation rules. Strengthen the safety education and technical disclosure to the operators of the contractor, and supervise and urge the strict implementation of the post safety operation rules. The second is to conduct comprehensive risk identification and analysis on the production and operation sites of the whole plant, strictly implement the control measures according to the identification and analysis results, and set up obvious safety warning signs in the places with greater risk factors. The three is to ensure the necessary capital investment for safe production and ensure that the problem rectification is in place. Fourthly, we should organize and carry out a large-scale investigation of potential safety risks in all aspects of the cement production line, systematically sort out key positions, key parts and special links, strengthen routine and special safety inspections, eliminate potential safety hazards, and strictly implement rectification measures. Fifth, organize and carry out special rectification activities of "anti-three violations", strengthen the inspection and management of the operation site, and timely detect and correct the occurrence of various violations committed by employees. Sixthly, we should establish and improve the incentive mechanism for internal reporting of potential accidents in production and business units, fully mobilize the enthusiasm of both the responsible persons and employees of production and business units, and deepen the investigation and management of potential accidents.
(2) a rental station
should further implement the responsibility of the main body of production safety and improve the level of production safety management. The first is to establish and improve safety production rules and regulations and ensure their effective implementation. The second is to strengthen the education and training of safety production for employees, ensure that employees are familiar with safety operation rules, safety protection measures and risk factors, and constantly improve on-site safety awareness. Thirdly, we should implement the dual prevention mechanism of safety risk classification control and hidden danger investigation and management, and eliminate the hidden dangers of production safety accidents in time. Fourth, organize and carry out special rectification activities of "anti-three violations", strengthen the inspection and management of the operation site, and timely detect and correct the occurrence of various violations committed by employees.
(3) In view of the problems exposed in the accident, the county emergency management Bureau of the relevant departments
responsible for the supervision and management of production safety shall conscientiously carry out special safety inspections, highlight key points, strengthen the safety inspectio ns of similar enterprises, promptly investigate and eliminate all kinds of potential safety hazards, and strictly implement the rectification of hidden dangers; Take this accident as a warning case to hold an accident warning education conference; urge enterprises to strengthen risk identification and control, strengthen the management of contractors and safety production education and training, and consolidate the main responsibility of enterprises for safety production. The Management Committee
of Beiting Industrial Park should strengthen the allocation of safety professionals, enhance the ability to detect hidden dangers, and regularly inspect the enterprises in the park. Strictly urge the enterprises in the park to implement the main responsibility, constantly strengthen education and training, improve the safety awareness and operational skills of employees, and prevent and reduce the occurrence of production safety accidents.
The County Bureau of Commerce and Industrial Informatization should implement the requirements of "three management and three necessities", regard safety production as an important part of industry management, strengthen safety production from the aspects of industry planning, industrial policies, regulations and standards, and administrative licensing, and guide and urge industrial enterprises to strengthen safety management.
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