Recently, the Emergency Management Bureau of Xian'an District, Xianning City, Hubei Province announced the Investigation and Treatment of "August 14" General Poisoning Accident of Xianning Siyuan Water Co., Ltd.
At about 17:10 on August 14, 2022, when Xianning Siyuan Water Co., Ltd. started to use the standby water transmission pipe in Wuyi Reservoir, the raw water intake, a harmful gas poisoning accident occurred, resulting in the death of two employees Xiong Mengxiong and Peng Yifu.
According to the Regulations on Reporting, Investigation and Handling of Work Safety Accidents (Order No. 493 of the State Council), the Measures for Reporting, Investigation and Handling of Work Safety Accidents in Hubei Province (Order No. 354 of the provincial government) and other relevant laws and regulations, and with the approval of the People's Government of Xian'an District, the District Emergency Management Bureau, the District Commission for Discipline Inspection, the District Procuratorate, the District Public Security Branch The "August 14" accident joint investigation team (hereinafter referred to as the accident joint investigation team) composed of cadres of the District Human Resources and Social Security Bureau, the District Federation of Trade Unions and other departments carried out the accident investigation.
The joint accident investigation team shall follow the principles of "four no let go" and "scientific, rigorous, legal, realistic, fair, and focused actual effect ”Through multiple investigations, evidence collection and comprehensive analysis, the process, causes, on-site emergency disposal, casualties and property losses of the accident were found out, the nature of the accident was identified, accident responsibilities were divided, and treatment suggestions and accident prevention and rectification measures for relevant responsible units and responsible personnel were proposed. The relevant information is reported as follows:
1、 Basic information of the accident
（1） The accident occurred at about 17:10 on August 14, 2022.
（2） Location of the accident: Spillway area of Wuyi Reservoir, the raw water intake area of Xianning Siyuan Water Co., Ltd.
（3） Accident category: poisoning.
（4） Casualties: 2 people died.
（5） Direct economic loss of the accident: 2.8 million yuan (excluding accident fines).
2、 Basic information of accident unit and personnel
（1） Basic information of accident unit
Xianning Siyuan Water Affairs Co., Ltd. (hereinafter referred to as Siyuan Water Affairs), established in two thousand and sixteen On August 31, 2006, the registered capital was 60 million yuan, and the legal representative was Tao Ying (female, 51 years old). Business scope: production and supply of tap water; Water supply equipment sales; Water works installation and maintenance services; Water meter detection and maintenance services; Installation, operation and maintenance services of secondary water supply facilities; Water quality testing services; Technical service and consultation of water supply business.
Siyuan Water has 32 registered employees. The company's management has a chairman, general manager, executive deputy general manager, and eight other departments, including the production department, customer service department, pipe network department, quality safety department, human resources department, finance department, administration department, and procurement department. Siyuan Water is fully responsible for the daily production and operation management by the general manager Fan Huashan.
The company has two water plants, Henggou and Guanbu, with a water supply pipe network of 114.55 kilometers above DN100mm. The water supply service covers Henggouqiao Town, Guanbuqiao Town, surrounding villages and groups, and some towns and villages of Heshengqiao Town. It also serves Xianning High tech Industrial Park, Xianning Vocational Education Park and other areas. The planned daily water supply scale is 124000 m ³, and the current daily water supply capacity is 24000 m ³, with a total water supply population of more than 120000 people and a water supply area of 123 square kilometers. Water supply production facilities include Henggou Water Plant and Guanbu pump House and two water sources (Wuyi Reservoir and Guanbu Pump House), of which Wuyi Reservoir mainly purchases raw water from Wangying Reservoir and Simenlou Reservoir in the upstream, and Guanbu Pump House is sourced from the well water of Hehua Spring in Guanbuqiao Town.
（2） Siyuan Water Production Process
Siyuan Water obtained raw water from the water source The Conduit Through the elevation difference, it flows into the grid flocculation tank of Henggou Water Plant by gravity, and then adds polyaluminum chloride solution to make the raw water produce flocculent reaction, and then enters the inclined tube sedimentation tank for sedimentation. The settled water flows into the siphon filter, and then flows into the clean water tank after being filtered by the siphon filter. Chlorine dioxide is added to disinfect the filtered water before entering the clean water tank, Finally, it is pressurized by the booster pump and then enters the main urban water supply network.
（3） Basic information of Wuyi Reservoir in the water source area
Wuyi Reservoir in Henggouqiao Town is the raw water storage point of Siyuan Water. The reservoir is located in Yuanpu Village, Henggouqiao Town, Xian'an District, Xianning City, with the original design rain bearing area of 2.3km2. In 2005, it was identified as a safe drinking water reservoir in Xian'an District, and 2.78km of Wuyi drinking water trunk canal was newly built. The rain bearing area has changed. The current capacity is 1.17 million m ³, and the designed irrigation area is 2500 mu. It is a small (I) water reservoir mainly for irrigation, and also has comprehensive benefits such as flood control, water supply, aquaculture, etc. The hydroproject of the reservoir consists of the dam, spillway, water delivery pipe and other main structures. There are two water transmission pipelines from Wuyi Reservoir to Henggou Water Plant, with diameters of 100cm and 60cm respectively. The pipe with a diameter of 100cm is used as the main pipe for a long time, and the pipe with a diameter of 60cm is used as the standby water delivery pipe for emergency use in case of large water supply demand. The standby water transmission pipe is directly connected to Henggou Water Plant from Wuyi Reservoir, and switches are set at Wuyi Reservoir water intake and Henggou Water Plant respectively valve Doors.
The standby water delivery pipe is buried about 2.5m below the ground at the spillway, and there is a special maintenance well space under the ground of the spillway. The pipeline inlet valve and the maintenance flushing straight pipe are directly connected with the standby water delivery pipe and set in the maintenance pit. The underground shaft enters through a square hole with a side length of 60cm on the spillway floor (no other access channel and vent), which is about 20cm higher than the spillway floor. The upper part of the hole is square, and the access channel is round. The internal space plane of the underground shaft is a circle with a diameter of about 153cm and a depth of about 240cm. The maintenance and flushing straight pipe is directly connected with the standby water delivery pipe. The pipe orifice is facing the entrance of the underground well, with a length of 102cm and a diameter of 15cm. It is usually closed.
（4） Related personnel information
1. Zheng Yun, female, 53 years old, is the executive deputy general manager of Siyuan Water Affairs, in charge of the daily work of six departments, including the production department, customer service department, engineering department, pipe network department and quality safety department.
2. Yu Bin, male, 39 years old, is the quality and safety supervisor of Siyuan Water, responsible for managing the daily work of the quality and safety department.
3. Xiong Mengxiong, male, 50 years old, manager of Siyuan Water Pipe Network Department, responsible for managing the daily work of the pipe network department, died in the accident.
4. Peng Yifu, male, 49 years old, is the maintenance and inspection supervisor of Siyuan Water Affairs Pipe Network Department, responsible for managing the maintenance and inspection related work of the Pipe Network Department, and the accident victim.
5. Chen Zhenhua, male, 55 years old, is an engineer of Siyuan Water Supply Network, who was present at the time of the accident.
6. Fan Donglin, male, 53 years old, is a maintenance inspector of Siyuan Water Supply Pipe Network Department, who was present at the time of the accident.
7. Fan Kexiong, male, 57 years old, is a maintenance inspector of Siyuan Water Supply Pipe Network Department, who was present at the time of the accident.
8. Chen Jun, male, 42, driver of Siyuan Water, was present at the time of the accident.
9. Xiao Peng, male, 34, deputy manager of the production technology department of Siyuan Water, was present at the time of the accident.
3、 Specific process of the accident
In August 2022, due to the high temperature in consecutive days, Siyuan Water decided to start the standby water pipe for water supply (the last time the pipe was used was in 2013) in order to meet the company's water supply demand. In the afternoon of August 12, Fan Huashan organized the relevant personnel of the Pipe Network Department, the Production Department and the Quality Safety Department to hold a meeting, and decided to take the Pipe Network Department as the main part, the Production Department as the assistance, the Quality Safety Department as the supervision, and the three departments cooperate with each other to go to the water source of Wuyi Reservoir to start the operation of standby water pipes, and maintain and flush the standby water pipes that have not been used for a long time to ensure normal water supply. In the afternoon of the same day, Xiong Mengxiong applied to the Quality Safety Department for a work permit. Because Yu Bin, the head of the Quality Safety Department, was out on Friday, the work permit was finally issued by Zhengzheng Cloud.
At about 14:00 on August 14, 2022, Xiong Mengxiong led Peng Yifu, Fan Kexiong, Chen Zhenhua, Fan Donglin, Chen Jun and Xiao Peng from the production department to the Wuyi Reservoir from Henggou Water Plant, and arrived at about 15:00.
After Xiong Mengxiong and others arrived at the site, they first opened the cover of the maintenance shaft, and found that there was a lot of water in the shaft, so they used a submersible pump with a generator to drain the water in the shaft. At about 15:20, the water in the underground well was drained. Xiong Mengxiong used the air blower to force air exchange in the underground well, and then used the gas detector to detect. Upon detection, the underground well is free of toxic and harmful gas and meets the operation conditions. At about 15:40, Xiong Mengxiong commanded Fan Kexiong to fasten the safety rope and enter the underground well from the underground wellhead. He was ready to use a wrench to unscrew the sealing screw on the upper part of the maintenance flushing pipe (the upper nozzle of the maintenance flushing pipe was sealed with an iron blind plate, with a rubber sheet in the middle, and fixed with four screws). Fan Kexiong found that the screws were severely corroded and could not be opened. After discussion between Chen Zhenhua and Xiong Mengxiong, they decided to use an angle grinder to cut the rusted screws. Xiong Mengxiong arranged Xiao Peng and Fan Donglin to go to Henggou Water Plant to get the angle grinder. At about 16:20, Xiong Mengxiong arranged Fan Donglin to go down to the underground well to cut the screws. After cutting the third screw, it was found that a small amount of water and gas were ejected from the blind plate gap. At this time, Fan Donglin felt uncomfortable and his head was dizzy, so he told Xiong Mengxiong on the ground well that he was uncomfortable. Xiong Mengxiong and his colleagues immediately pulled Fan Donglin out of the underground well and arranged for everyone to have a rest under the shade of the nearby trees for about 30 minutes.
At about 17:00, seven people went to the underground wellhead after a rest, and found that there was still gas discharged from the maintenance and flushing pipe orifice in the underground well (no odor was heard). After on-site discussion, it was decided to stop the operation. Several people packed up tools and prepared to return to the company, but they did not move the space well cover of the underground well back to the original position to seal the underground well head. At about 17:10, seven people were on the way back to the engineering vehicle when carrying tools. Peng Yifu said that he had forgotten something and returned to the spillway again to look for it. (After asking Fan Kexiong in the later stage and confirming by the on-site survey, the wrench used by Fan Kexiong to screw in the underground shaft for the first time has been left on the ground in the underground shaft.) After a few minutes, Xiong Mengxiong did not see Peng Yifu returning, but went to the spillway to check the situation. About 30 seconds later, Xiong Mengxiong shouted for help to others at the underground wellhead. Fan Kexiong, Fan Donglin, Xiao Peng and others immediately ran to the wellhead after hearing the cry. They found that Xiong Mengxiong had entered the underground well and was unconscious, but one hand still held Peng Yi's arm, who had fainted in the underground well. Fan Kexiong and other three people quickly rescued Xiong Mengxiong. During the rescue, Xiao Peng fainted. When Chen Zhenhua arrived at the underground wellhead, he pulled him aside to rest. Fan Kexiong also fainted during the rescue of Xiong Mengxiong, and was moved aside by Chen Zhenhua. At this time, Fan Donglin also felt unwell, and Chen Zhenhua stopped the rescue. Xiong Mengxiong had slipped into the underground well.
Chen Zhenhua called Zhao Xuebin and Liu Hao of Henggou Pump Station to come to the rescue after he saved three people from Fan Kexiong and had a rest. At the same time, he called 119 and 120 to request rescue. After the rescue call, Chen Zhenhua called Fan Huashan, Shi Zhengyun and others. At about 17:20, Zhao Xuebin and Liu Hao arrived at the scene. Chen Zhenhua asked Zhao Xuebin to find a way to rescue Xiong Mengxiong and Peng Yifu. Zhao Xuebin saw that the two people in the underground well had no action. After several people discussed, Zhao Xuebin tied the safety rope and went down to the underground well to hold Peng Yifu, and several people outside the underground well pulled him out. At this time, Zhao Xuebin also felt unwell and did not continue to go down the well. At about 17:30, 110 and 120 rescue workers, Fan Huashan and other enterprise leaders arrived at the scene one after another, and medical staff diagnosed Peng Yifu as dead. After the fire rescue personnel rescued Xiong Mengxiong from the underground well, he was confirmed dead at the scene. 120 The rescuers sent Fan Kexiong, Fan Donglin and Xiao Peng to the hospital for treatment.
4、 Post accident disposal
After the accident, the District Committee and the District Government attached great importance to the rescue and disposal of the accident. Du Xinguo, member of the Standing Committee of the District Committee and executive deputy head of the District, was entrusted by the main leaders of the District Committee and the District Government to rush to the scene as soon as possible to command the rescue. The government of Henggouqiao Town, the District Emergency Management Bureau, the District Fire Brigade, the District Public Security Bureau and other relevant functional departments also rushed to the scene at the first time to participate in the rescue. Under the overall leadership of the District Party Committee and the District Government, the relevant functional departments and the accident unit actively cooperated. Fan Kexiong and other three injured people were treated and discharged the next day after the accident. The compensation work for the dead has been completed, without causing adverse social impact. After receiving the accident report, the Municipal Emergency Management Bureau led a team to the scene of the accident on August 15 by a member of the Party Committee in charge of industry and trade, and actively analyzed the cause of the accident. The District Emergency Management Bureau, together with the third party company hired by Siyuan Water, has carried out several rounds of discussions on the causes of the accident, prepared a technical analysis report, and provided technical support for the accident investigation.
5、 Accident cause analysis and nature determination
（1） Direct cause
1. Poisoning by harmful gas. The space structure of the maintenance shaft belongs to a limited space. Fan Donglin loosened the blind plate of the maintenance flushing pipe after cutting the screws, and harmful gas in the pipe was ejected, which caused Fan Donglin to feel unwell. Within half an hour from Fan Donglin's coming up from the underground well to Peng Yifu's going down, the harmful gas quickly filled the space of the underground well and spread slowly from the wellhead, causing Peng Yifu, Xiong Mengxiong and other people to faint from poisoning to varying degrees.
2. Venture into dangerous places. Peng Yifu, knowing that Fan Donglin felt unwell after cutting the screws and had planned to return, was not alert enough. He ventured into the underground well space alone to find tools without confirming the gas composition at that time, whether there were potential safety hazards, and insufficient self-protection, leading to poisoning and death.
3. Improper emergency rescue. According to the relevant provisions of the Interim Provisions on Safety Management and Supervision of Work in Confined Space of Industry and Trade Enterprises, when an accident occurs in confined space operations, an alarm shall be given immediately, blind rescue is prohibited, and rescuers shall strictly protect themselves. However, Xiong Mengxiong found that Peng Yifu was poisoned and fainted in the underground well. In an emergency, he rescued Peng Yifu without doing his own protection and without the rescue conditions, resulting in poisoning during the rescue process.
（2） Indirect causes
1. The effect of safety production education and training is not ideal.
In the daily safety production management, Siyuan Water has organized the staff to carry out the corresponding education and training for confined space operations according to the training plan, but the training effect is not ideal, resulting in a few staff who have participated in the training, but failed to understand the training and education knowledge in depth, and paid insufficient attention to the risk hazards and emergency response measures of confined space operations, There was a certain carelessness, and the operation was not carried out in strict accordance with the rules and regulations and operating procedures.
2. The targeted emergency rescue drill was not carried out in combination with the actual operation at the grass-roots level.
Although Siyuan Water has organized and carried out emergency rescue drills corresponding to confined space operations, it did not fully consider the complex operating environment that the company's grass-roots employees may face under special circumstances, so it carried out targeted live drills in combination with the actual situation, resulting in the lack of emergency handling experience of employees in the event of hazardous gas poisoning.
3. Insufficient safety risk analysis and identification.
The maintenance flushing pipe in the underground well space is connected with the standby water delivery pipe, and there is a vertical space of about 1.2 meters above the flushing pipe. During normal water supply, there is residual air in the space. However, the standby water pipe has not been put into use for nearly 9 years, and there is residual water in the pipe. The carbon monoxide, carbon dioxide and other harmful gases produced by fermentation after the death of microorganisms in the water pipe can not be removed in time. As time goes on, the residual harmful gas in the pipe accumulates more and more, and the pressure in the pipe increases continuously due to the influence of high temperature weather. The space structure of underground wells belongs to a complex and changeable limited space with a special environment, which is different from the traditional limited space. In addition, the water purification industry generally has more awareness and protection against chlorine poisoning, and less carbon monoxide poisoning. Under normal circumstances, the quality of raw water is good, and the probability of producing toxic and harmful gases is extremely low. Therefore, Siyuan Water follows its daily experience in arranging operations, and does not fully consider that the operating environment may be special and changeable due to the superposition of multiple factors such as long idle time of water pipes, high temperature weather and terrain conditions when using standby water pipes, so as to strengthen prevention, As a result, Xiong Mengxiong and others lacked sufficient awareness of the hazards of the confined space operation, did not conduct a comprehensive risk identification and hidden danger analysis on the confined space before the operation, did not fully consider the possible safety risks of the confined space under special complex conditions, and took effective self prevention measures.
4. Safety supervision is not in place.
The Party Committee and Government of Henggouqiao Town, as the territorial management unit of Siyuan Water Affairs, has carried out inspection on Siyuan Water Affairs within the jurisdiction, but due to the relative lack of professional knowledge of safety production, there is still a certain degree of vacancy in the supervision of enterprise safety production, and the efforts to urge enterprises to implement the main responsibility of safety production need to be further strengthened.
（3） Nature of accident
After investigation and analysis, it was found that the "8.14" poisoning accident of Xianning Siyuan Water Co., Ltd. was a general production safety liability accident.
6、 Handling suggestions of relevant responsible units and persons
（1） Relevant responsible units
1. Xianning Siyuan Water Service Co., Ltd
This accident is caused by the poisoning of carbon monoxide and other harmful gases under the special operating environment, which is relatively rare. As an accident unit, Xianning Siyuan Water Co., Ltd. paid insufficient attention to the effect of safety production education and training of employees in daily safety production management, failed to ensure that employees have necessary safety production knowledge, understand and comply with emergency response measures; And inform the employees of the dangerous factors, preventive measures and accident emergency measures in the workplace and work posts, which respectively violate the relevant provisions of the first paragraph of Article 28 and the first paragraph of Article 44 of the Production Safety Law of the People's Republic of China, and bear direct management responsibility for the occurrence of accidents, Xian'an District Emergency Management Bureau has imposed corresponding amount of administrative punishment according to the provisions of Item (1), Paragraph 1, Article 114 of the Work Safety Law of the People's Republic of China and the relevant provisions of Hubei Province's Discretionary Standards for Administrative Penalties on Work Safety.
2. Party Committee and Government of Henggouqiao Town
The Party Committee and Government of Henggouqiao Town have not made enough efforts to supervise the safety of the enterprises within their jurisdiction, and the inspection of the enterprises is not thorough enough. It is not enough to urge the enterprises to implement the main responsibility for safety production, and the responsibility for safety production is not really stressed. There are still some shortcomings in the work deployment of safety production, and they are responsible for the local management of this accident, The Office of the Safety Committee of Xian'an District has made a corresponding notification.
（2） Relevant responsible person
1. Xiong Mengxiong, the victim of the accident, as the manager of the pipe network department and the person in charge of on-site operations, was not careful about the management of on-site safety production. After Fan Donglin became ill and was ready to stop the operation, Peng Yifu was allowed to go back alone to look for tools, and blindly rescued Peng Yifu after he fainted from poisoning, leading to his own poisoning. He was directly responsible for the accident, He should have been transferred to the judicial authority for investigation and treatment on whether he was suspected of constituting a crime, but he was exempted from investigation because he died in the accident.
2. Peng Yifu, the victim of the accident, who was aware of Fan Donglin's physical discomfort caused by his operation in the underground well space when he was ready to return after completing the operation, still entered the underground well space alone and caused poisoning. He was directly responsible for the accident. He should have been transferred to the judicial authority for investigation and treatment on whether he was suspected of constituting a crime. Because he died in the accident, he was exempted from investigation.
3. Tao Ying, the chairman and legal representative of Siyuan Water, will not be held accountable in this accident because he is not working in the company and does not participate in the daily production, operation and management of the company.
4. Fan Huashan, the general manager of Siyuan Water, as the main person in charge of the company, did not manage the company's safety production in place and did not strictly implement the unit's safety production education and training plan, which led to the failure of safety production education and training to achieve the desired effect; The emergency rescue plan for production safety accidents of the unit was not formulated and implemented in combination with the actual situation, which led to Xiong Mengxiong's lack of emergency handling experience, violated the provisions of Article 21 (3) (6) of the Production Safety Law of the People's Republic of China, failed to fulfill the legal responsibilities for production safety, and took the main leadership responsibility for this accident, Xian'an District Emergency Management Bureau has imposed an administrative penalty of 40% of the annual income of the previous year in accordance with the provisions of Article 95 (1) of the Production Safety Law of the People's Republic of China.
5. Zheng Yun, the executive deputy general manager of Siyuan Water, as the deputy general manager in charge of safety production of the company, failed to notify Yu Bin to supervise and guide Xiong Mengxiong and others to work in limited space when Yu Bin, the head of the Quality Safety Department in charge, was not in the company, the safety production management of the department in charge was not in place, and the emergency rescue plan of the unit was not prepared in combination with the actual operation of the company, As a result, the company's emergency rescue drill guidance is not strong; The organization of the safety production education and training of the unit is not enough, the training content is not comprehensive, and the effect is not ideal, leading to the weak awareness of safety production and self-protection of Xiong Mengxiong and other employees, respectively violating the provisions of Article 25, paragraph 1 (1) (2) of the Production Safety Law of the People's Republic of China, and the performance of safety production management responsibilities is not in place, The Xian'an District Emergency Management Bureau has suspended the qualification of production safety management and imposed an administrative penalty of 40% of the annual income of the previous year in accordance with the relevant provisions of Article 96 of the Production Safety Law of the People's Republic of China.
6. Yu Bin, head of the Quality and Safety Department of Siyuan Water Affairs, as the safety production management personnel, failed to organize the safety production education and training of the unit in place, resulting in Xiong Mengxiong and other employees not familiar with the safety risks and emergency response measures in the workplace; The incomplete identification and assessment of hazard sources before this operation led to inadequate preventive and preparatory measures for Xiong Mengxiong and others during confined space operations, which respectively violated the provisions of Item (2) (3), Paragraph 1, Article 25 of the Production Safety Law of the People's Republic of China, failed to fulfill the responsibility of production safety management, and took important responsibility for this accident, Xian'an District Emergency Management Bureau has suspended its qualification for safe production management in accordance with the relevant provisions of Article 96 of the Production Safety Law of the People's Republic of China, and imposed an administrative penalty of 20% of the annual income of the previous year.
7. The performance of relevant leading cadres of Henggouqiao Town Government and the handling of party and government disciplines involving CPC members among the relevant responsible persons of Siyuan Water Company have been investigated and held accountable by the District Commission for Discipline Inspection.
7、 Accident lessons and rectification measures
（1） Accident lessons
The "8 · 14" general poisoning accident of Xianning Siyuan Water Service Co., Ltd. was a casualty accident caused by the relatively complex operating environment, insufficient identification of risks and hidden dangers under special circumstances, and the unsatisfactory effect of safety production education and training and emergency rescue drills. Work in confined space is the focus of safety production supervision, and also a topic that has been talked about for a long time. This accident once again sounded the alarm bell of safety production, revealing that there are still shortcomings and weaknesses in safety production work in our area. Work safety should not be sloppy or careless. We should continue to strengthen the leadership responsibility of the Party committee and government, the responsibility of department supervision, the responsibility of township territorial management, and the responsibility of the main body of the enterprise, and perform our duties in a down-to-earth manner. We should implement the work from the following aspects: First, we should strengthen the education and training of safety production, improve the safety production awareness of enterprise managers and various front-line employees, and achieve the purpose of standardizing the management of safety production operations and strengthening self-protection; Second, it is necessary to organize and carry out special rectification of key industries in the area of industry and trade, strengthen the inspection, guidance and supervision of safe production, urge enterprises to strictly implement the main responsibility of safe production, and strictly standardize the procedure management of enterprises for special operations such as limited space, dust, hot work, hoisting, etc; Third, guide and urge all enterprises to comprehensively investigate and clarify the problems in safety production, strengthen the effectiveness of rectification, and comprehensively improve the level of safety production management; Fourth, strengthen the management of emergency rescue plans, strictly require key enterprises in the region to prepare emergency rescue plans according to regulations, strengthen emergency drills, and improve emergency response capabilities; Fifthly, we should learn the lessons of this accident, draw inferences from other cases, strengthen publicity, and ensure that "the whole region receives education when the first factory accident occurs", so as to prevent similar accidents.
（2） Rectification and preventive measures
The accident has learned a profound lesson and caused some casualties. In order to learn the lesson carefully and effectively prevent and reduce the occurrence of similar accidents, the following corrective and preventive measures are proposed:
1. The office of the district safety committee should quickly organize an accident warning meeting, report the investigation and handling of the accident to the whole district, deeply analyze the causes of the accident, summarize the lessons of the accident, ensure that the accident occurs in one enterprise and the whole district is educated, especially for the relevant industries and production and operation entities involved in limited space operations, strictly carry out accident warning education.
2. Siyuan Water Resources should organize relevant personnel to hold an accident summary meeting, and learn from the accident experience and lessons in accordance with the principle of "four not letting go". First, we should improve the management system for special operations such as confined space, and strictly manage the operation process; The second is to strengthen the effect of safety production education and training to ensure that safety production education and training are integrated into the mind; Third, revise and improve the company's emergency rescue plan, and carry out emergency drills in combination with the company's actual situation; Fourth, we should develop a practical rectification plan to eliminate potential safety hazards and prevent production safety accidents.
3. The Party Committee and Government of Henggouqiao Town should strengthen the performance of their duties, strictly implement the leadership responsibilities of the Party and government and territorial management responsibilities for work safety, increase the deployment of work safety, improve the implementation depth of work safety, enhance the breadth of work safety supervision and inspection, and comprehensively improve the level of work safety management in the town.
Xian'an District Emergency Management Bureau
March 27, 2023
