At around 13:50 on May 15, 2022, an accident occurred at the construction site of the epoxy resin heavy corrosion protection project for the sewage tank of Zhejiang Taizhou Haishen Pharmaceutical Co., LTD., which is located at No. 12, Donghai Third Avenue, Taizhou Bay Economic and Technological Development Zone. The project was undertaken by Taizhou Haoyao Construction Co., LTD., resulting in 2 deaths and 3 injuries.
After the accident happened, the municipal Party committee and municipal government of Taizhou and Linhai attached great importance to it and immediately launched emergency plans. Lin Xianhua, Executive Vice Mayor of Taizhou, CAI Jianjun, Mayor of Linhai and Jiang Feng, executive Vice Mayor, led the relevant departments of Taizhou and Linhai respectively to rush to the scene of the accident to guide and promptly carry out emergency rescue, accident cause investigation and aftermath disposal work. On June 17, the technical expert group submitted a technical analysis report. On May 18, 2022, the Office of Taizhou Work Safety Commission put the general accident under supervision.
The accident investigation team shall carry out a comprehensive investigation of the accident in accordance with the principles of being scientific and rigorous, in accordance with the law and regulations, seeking truth from facts and paying attention to actual results. Through on-site inspection, data retrieval, investigation and evidence collection, inspection and appraisal, comprehensive analysis and expert argumentation, it shall find out the process, cause, casualties and other circumstances of the accident, and determine the nature and responsibility of the accident. To put forward suggestions on handling relevant responsible persons and responsible units and suggestions on accident prevention measures. The relevant information is reported as follows:
I. General situation of the project where the accident occurred and the basic situation of the unit
(I) Overall project overview of the accident.
The overall project name is Zhejiang Taizhou Haishen Pharmaceutical Co., LTD. Environmental protection production auxiliary room, including the auxiliary room with a building area of 580.55 square meters, the structure covering an area of 1794.4 square meters (including combination pool 1, combination pool 2, waste gas treatment equipment foundation), located in Taizhou Bay economic technology Development Zone, No.12 Donghai Third Avenue. The construction planning permit will be obtained on July 16, 2021, and the construction permit will be handled on July 30, 2021.
The accident occurred in the anti-corrosion engineering of Combination Pool 2. The pool involved belongs to the enterprise's own environmental protection facilities. The pool is 42.4m long, 18m wide and 9.2m high. Due to the requirements of environmental assessment, anti-corrosion, leak-proof and anti-seepage measures must be adopted for the sewage collection and treatment system. On January 18, 2022, the construction unit signed a contract with Taizhou Excellent Construction Co., LTD., for the epoxy resin heavy anti-corrosion engineering of the sewage tank. The project cost is about 1.36 million yuan. Later, Taizhou Excellent Construction Co., Ltd. subcontracted the anti-corrosion work to Li Liwei (no written contract). In March, after the completion of the civil engineering, Taizhou Excellent Construction Co., Ltd. carried out the epoxy resin heavy anticorrosion engineering.
The anti-corrosion project adopts epoxy glass flake paint, which is a two-component heavy anti-corrosion product with excellent weather resistance, corrosion resistance and color retention. The paint wax is tough, wear resistance, collision resistance, and can be used as a long-term anti-corrosion and anti-leakage, widely used in medicine, chemical industry, electroplating enterprises and other sites. According to the "three cloth and five oil" process construction, first epoxy resin anticorrosive primer, then a layer of glass fiber cloth, epoxy resin anticorrosive paint, repeat three times, finally epoxy resin anticorrosive top paint. Construction tools are grinding machine, Angle grinder, roller, blender, vacuum cleaner, special spray and so on.
Ii. Accident occurrence and rescue situation
(1) How the accident happened.
At around 13:00 on May 15, 2022, Li Xianghua and other 7 workers from Taizhou Excellent Construction Co., Ltd. were engaged in anti-corrosion work in the anti-corrosion project. Han Gangli used a mixer to mix epoxy resin, epoxy resin curing agent, thinner and other raw materials at the temporary epoxy resin coating mixing (workshop) in the southwest of the top of the combined pool 2, and transferred them to the pool after mixing; Li Yongxin, Han Rui, Zhang Liuyun, Li Xianghua, Li Zhongtian, Jiang Xiaojian 6 people in the combination pool 2 clear pool operation, about 13:40, because the pool operation materials are running out, Li Xianghua called Jiang Xiaojian on the top of the pool to take materials. About 13:50, Han Gangli, Jiang Xiaojian in the shed heard Zhang Liuyun climbed up the pool to shout for help, and found the pool mouth with black smoke. Then Jiang Xiaojian brought a fire extinguisher to spray down, Han Gangli called Li Liwei and at the same time to sprinkle talcum powder. After a minute or two, Li Xianghua was the second to climb up the pool. Another two or three minutes later, Li Nakata was the third to climb up the pool. After that, the factory security personnel arrived at the scene, and fire and 120 ambulance personnel also arrived successively, sending 2 people to Taizhou Hospital, 2 to Taizhou Municipal Hospital and 1 to Taizhou Central Hospital for rescue.
(2) Accident rescue situation.
After the accident, the Linhai Municipal government immediately launched an emergency response plan, and quickly organized departments of construction, emergency management, public security, fire protection and other departments as well as the Administrative Committee of Taizhou Bay Economic and Technological Development Zone to rush to the scene of the accident for rescue and disposal. At about 14:25, fire engines and ambulances arrived at the scene. Li Yongxin and Han Rui died in hospital after rescue. The skin of Li Xianghua was 92% burned, and the skin of Li Zhongtian was 87% burned. On the same day, two experts were invited from Zhejiang Second Hospital for consultation, rescue and treatment of the two patients with serious injuries. After treatment, the physical signs were stable, and the two have been transferred to Shanghai Ruijin Hospital for treatment. Zhang received treatment for minor injuries at Taizhou Municipal Hospital and was discharged on June 12, 2022.
The aftermath of the accident was completed on June 3, 2022. The aftermath has been handled smoothly and orderly. The bodies of the deceased have been cremated and their families have returned.
Iii. Site inspection and casualties
(1) Investigation at the scene of the accident.
The site of the accident is located at the clear pool below the MBR pool at the northeast corner of the combined Pool 2. Combined pool 2 is 42.4m long from east to west, 18m long from south to north, and 9.2m high; Clear pool east-west length 7.4m, north-south length 18m, depth 3.1m, southwest corner has a 3.7m*5.9m gap, the whole pool plane is L-shaped; The south-north length of the pond mouth is 1.1m, and the east-west length is 7m, showing a rectangle. The volume of the clear pool is about 329m³. Due to the small area of the pool mouth, the pool is a semi-enclosed space.
There is a temporary epoxy resin coating mixing place in the southwest of the pool top, where epoxy resin (6101), curing agent and diluent are piled on site. (After third-party testing, the diluent mainly includes dimethoxylene methane, methanol, ethylbenzene, m-xylene, p-xylene, o-xylene and other components, which are volatile and flammable. Mixing with air to achieve explosive limit) and other raw materials and mixed tools; There are 11 (9 plastic barrels, 2 metal barrels) 200L barrels at the mixing site, among which 1 barrel is curing agent (used), 2 barrels is epoxy resin (1 barrel is empty, each barrel has half a barrel of material), 8 barrels are diluent (4 barrels are empty, there is no material in the empty barrel; 1 barrel is half a barrel, 3 barrels is full); There are 53 material drums stacked in the open space to the south of the sewage tank, including 52 empty drums (27 for epoxy resin, 2 for curing agent, 23 for diluent) and 1 with materials (marked epoxy resin on the drum).
There is a ventilator and air supply pipe (about 5 meters) in the northwest corner of the pool top, and the air supply pipe is not extended to the bottom of the pool; Several gas cylinders and spray guns are also placed on the top of the pool; There is no border guard at the mouth of the clear pool.
From the outside of the pool is connected to the wire in the clear pool (the outside is made of rubber), one end is a two-foot plug, one end has 3 positions (2 feet, 1 tripper) mobile socket, the brand is not clear; The total length of the wire is 27.40m, and the length of the outer surface with melting marks near the socket is 8.8m, and the length with serious melting is 4.5m. There are two lights in the clear pool, the lights are non-explosion-proof, the outer surface of the wires of the lights is rubber material, the plugs are two-pin plugs, and the two plugs are observed. The yellow plug plug is relatively intact, and the black plug plug has a gap for electrical corrosion traces (identified by the third party as electric hot melt).
There are 4 complete buckets (3 for epoxy resin, 1 for putty) and 3 burned buckets for material. There are also two packs of cigarettes, four lighters, two mobile phones, a shovel, four scissors and so on.
There are obvious carbonization traces on the wall and mouth of the pool below 1m at the bottom of the pool.
(2) Information on the dead and injured in the accident.
Deceased: Li Moumou, male, 51 years old, Han nationality, Linquan County, Anhui Province.
Deceased: Han Mou, male, 32 years old, Han nationality, Linquan County, Anhui Province.
Injured: Li Moumou, male, 33 years old, Han nationality, Linquan County, Anhui Province.
Injured: Li Moumou, male, 36 years old, Han nationality, Linquan County, Anhui Province.
Injured: Zhang XX, male, 42 years old, Han nationality, Anhui Province, Linquan County.
Iv. Cause and nature of the accident
(1) Direct causes.
Construction personnel in the semi-closed space for anti-corrosion operations, did not take effective ventilation measures, anti-corrosion materials in the diluent continued to volatilize organic solvent vapor, in the working space at the bottom of the continuous accumulation, because of the illegal use of non-explosion-proof electrical construction site, wire movement or plug and plug lead to plug and socket contact loose resulting in electrical sparks, causing deflagging.
(2) Major problems existing in the units concerned with the accident.
1. The main responsibility of safety production of Taizhou Excellent Construction Co., LTD., the construction unit, is not fulfilled. The first is not obtained the corresponding level of qualification certificate and safety production permit, in violation of the "Regulations on Construction Project Quality Management" Article 25, paragraph 1 and "Regulations on safety Production Permit" Article 2 provisions; (2) Failure to establish the administration of production safety and staff the administration of production safety, in violation of the provision of Article 24 paragraph 1 of the Production Safety Law of the People's Republic of China (hereinafter referred to as the Production Safety Law); Third, it fails to provide education and training on production safety for employees as required, violating the provisions of Article 28, paragraph 1 of the Production Safety Law; Fourth, it failed to establish the inspection and treatment system for potential accidents and formulate safety operation rules for anti-corrosion construction, illegally used non-explosion-proof electrical equipment on the site, failed to set up safety warning signs, failed to take effective safety management measures such as ventilation, smoking prohibition, fire prevention and explosion prevention, and failed to timely discover and eliminate potential accidents, in violation of the provisions of the second paragraph of Article 41 of the Work Safety Law.
2. The construction unit, Zhejiang Taizhou Haishen Pharmaceutical Co., LTD., did not have adequate production safety management. First, in the process of procurement and construction of anticorrosive engineering, it fails to perform the duty of safety management, fails to examine the construction qualification of the contractor, and contracts the anticorrosive engineering to the unit that has not obtained the construction qualification, in violation of the provisions of Article 49 (1) of the "Safety Production Law" and Article 22 of the "Construction Law of the People's Republic of China"; Second, it does not urge the supervision unit to carry out supervision work, and unified coordination and management of the contractor's work safety, which violates the "Safety"
The second paragraph of Article 49 of the Whole Production Law; Combined pool 1 and Pool 2 unauthorized construction before obtaining the construction project planning permit and construction project construction permit, in violation of "Zhejiang Urban and Rural Planning Regulations" Article 36 (1) and "Administrative Measures for the Construction Permit of Construction projects" Article 3 provisions.
3. Supervision of Zhejiang Jianhao Engineering Management Co., LTD., the supervision unit, is not in place. Failure to supervise the anti-corrosion engineering within the scope of the contract violates the provisions of Article 14, Paragraph 2 of the Regulations of Zhejiang Province on the Supervision and Administration of Construction Projects.
4. The civil construction unit, Taizhou Gaoan Construction Co., LTD., arbitrarily organized the civil construction of composite Pool 1 and Composite Pool 2 before applying for the construction permit of the construction project, which violated the provisions of Article 3 of the Administrative Measures for Construction Permit of the Construction Project.
5. The implementation of territorial supervision responsibilities of Taizhou Bay Economic and Technological Development Zone is not enough. The Construction Planning Bureau of the Administrative Committee of Taizhou Bay Economic and Technological Development Zone has not implemented the supervision responsibility of industrial enterprise construction projects; The risk and hidden trouble check of enterprise grid personnel is not in place.
6. The regulatory responsibilities of industry regulatory departments are not fully implemented. The Eastern Affairs Center of Linhai Housing and Urban-Rural Development Bureau is not strict in the examination of construction permits, and the implementation of safety supervision responsibilities is not in place; In the process of project approval and management, the supervision responsibility of Toumengang Natural Resources Institute of Linhai Natural Resources and Planning Bureau was not fully implemented.
(3) Nature of the accident.
This is a general grade production safety liability accident.
