氯碱分厂丧失劳动时间事故 v 最终版

SAFETY ALERT 安全警示,Contributing Factors促成因素: 1、泵出口与管道连接处由于的振动引起螺栓的松动；At the connection between pump discharge and pipe, the bolts were loose by the vibration. 2、无法兰口的防护罩；There was no protective cover for the flange. 3、人员在此区域作业；There were people working in that area.,Site企业名称:江西星火有机硅厂,M先生点泵站的位置 Position of Mr. M who was starting up pump,H1先生站在的位置 Mr. H1s position,漏酸的法兰 Flange where leaked,被硫酸碳化的工作服 Carbonized work clothes,事故现场照片site picture,事故现场照片site picture,硫酸泄漏法兰处，拆下的法兰垫片，完好无损。The flange gasket removed from the acid leakage flange. It is in good condition.,受伤人员照片pictures of injured people,SAFETY ALERT 安全警示,Root Causes根本原因:,The tool we used 参考右边的附表,SAFETY ALERT 安全警示,Corrective Actions采取的措施:,注：1、请各位领导在填写时尽量详细，表格不够可以再续一页，不要出现“立即、迅速如何如何”等字眼；2、在完成时间一栏请注明详细的改善措施的完成时间节点；3、请将改善措施具体落实到人；4、备注一栏请注明该项整改措施的完成程度。,完成finished,正在进行on-going,未按期完成或未开始not started or not finish before deadline,SAFETY ALERT 安全警示,Corrective Actions采取的措施:,注：1、请各位领导在填写时尽量详细，表格不够可以再续一页，不要出现“立即、迅速如何如何”等字眼；2、在完成时间一栏请注明详细的改善措施的完成时间节点；3、请将改善措施具体落实到人；4、备注一栏请注明该项整改措施的完成程度。,完成finished,正在进行on-going,未按期完成或未开始not started or not finish before deadline,根本原因分析表 Root Cause Analysis Chart,3 worker in C&A branch and 1 worker in Maint Center injured by strong sulfuric acid,No protection cover on flange,No related national industry standard,No request in design,No hazard identified,Leakage on gasket,No pressure test,Bolts on flange loosened,Gasket selection and quality issue,PPE failure,Operation mistake,Wrong selection on flange connection,Pipe and pump PN not match,Not wearing acid and soda protection clothes,Not wearing facial mask,Not wearing acid and soda protection shoes,No SOP or SOP not updated,Not operated based on SOP,Gap,Gap,Evidence: 1. According to the pipe testing regulation, the seal situation on leaked flange cannot be tested. 2. Through the pump test on Sep 5 of 2012, the pressure reached 0.3MPa (according to pipe property list, the design work pressure is 0.3MPa) 3. April 6 of 2013, the 32 hours linked testing proved the system was normal. 4. No extra action after April 6.,Evidence: There is SOP provided: XHC/WI-JD-04520-2010 LJBF type pump SOP, but it was not reviewed on time. It was expired.,Evidence: acid and soda protection shoes confirmed on site.,Have policy but not implemented,Not identified the risks during commissioning.,Lack inspection on working clothes,GAP,GAP,Note: Pipe normal work pressure is 0.54PMa. The pipe design level is 1.6MPa. It meets the requirement.,Caused by vibration,Not standard bolts,Not fasten the bolts during installation,No spring gasket used,No regulation requirement,Pump vibration,The ground bolts were not installed properly.,Not accurate position during the installation.,Evidence: The installation record on Oct 26 of 2011 shows the position is qualified.,Gap,If there was other work on the pump after the inspection.,Explanation: There is no evidence.,The requirement is 8 M16 bolts on flange. On site there were 4 M12 bolts.,The supplier didnt deliver the right pump according to design (HG20592-2009 technical requirements),The installation company didnt report when finding the flange non-conformance.,根本原因分析表 Root Cause Analysis Chart,Evidence: No requirement for normal operation.,GAP,Explanation: There is deviation on center to center distance of discharge flange and standard flanges bolt hole.,Evidence: No pressure sign on the gasket replaced.,