Investigation report yetsaona yemakemikari

Investigation report yetsaona yemakemikari

Webhusaiti yepamutemo yeguangxi Zhuang Autonomous Region emergency Management department yakaburitsa Investigation Report panjodzi yeMoto Yakakura muBeihai LNG Co., LTD musi waNovember 2, 2020. Sekureva kweshumo, vanhu vanomwe vakafa, vanhu 2 vakakuvara zvakaipisisa uye vakananga. kurasikirwa kwehupfumi kwaiva 20.293 mamiriyoni yuan.

Chikonzero chekukurumidza chetsaona

Munguva yekuitwa kwechikamu chechipiri chepurojekiti, vharuvhu yekuzviparadzanisa inovhurwa, uye iyo LNG (yakanyungudutswa gasi rechisikigo) mune yakaderera-kumanikidza kunze kwekutapurirana manifold inoburitswa kubva pakachekwa pombi muromo, uye musanganiswa weLNG atomized air mass. uye mhepo inogadzira kupisa kana simba rekupisa rinobvira.

Chikonzero chisina kunanga chetsaona

Nzira isina kunaka yekuzviparadzanisa nevharuvhu, injinjini yezviridzwa kwete zvinoenderana neyakavharirwa chimbo chekuongorora uye kubvumidzwa maitiro uye maitirwo ekushanda, kupisa mamiriro ekushanda akasimbisa kuti kusakwana, kusakwana kwekuchengetedza njodzi yekuziva uye kutonga, "varidzi vebhizinesi madiki makondirakiti makuru" maitiro ekugadzira vashandi anoita. iyo yakachengeteka yekugadzira manejimendi manejimendi ekuita haisviki pachinzvimbo chakagadzwa, manejimendi ekondirakiti haasvike panzvimbo yakatarwa, nezvimwe.

Mushumo wekuferefeta wakataura

Mangwanani ezuva iroro, mainjiniya einjiniya Lai Xiaolin haana kuita nhevedzano yemaitiro akadai seyekutevera kuongorora uye kusimbiswa kwechiridzwa chinovharira tikiti rekushanda, asi akapinda muchiteshi cheinjiniya uye akashanda ega pasina kutariswa kwevamwe mainjiniya emidziyo.

Na 11:44 maminetsi nemasekonzi makumi mana nemasere, Lai Xiaolin akashandisa iyo SIS system kuvhara nechisimba vharafu 0301-XV-2001.Pakarepo, valve 0301-XV-2001 yakavhurwa uye LNG yakatanga kupfapfaidza.Pa 11:45 maminitsi 00 seconds, valve yakazaruka zvakakwana.Masekonzi gumi mushure mejekiseni reLNG, moto wakaputika pachikuva pamberi peTK-02 tangi yekuchengetedza.Paive nevanhu vasere, kusanganisira Liang, pachikuva pamberi peTK-02 tangi yekuchengetera uye munhu 1, Kusanganisira Tian, ​​pamusoro petangi apo LNG yakaputika mumoto.

Chirevo chakadaro

Mutsaona iyi, sinopec Zhongyuan Petroleum Bureau Natural Gas Technology service Center, Beihai LNG Kambani, Sinopec Gumi Kuvaka, Henan Hongyu, Sichuan Yitong, Sinopec Guangzhou Engineering, Qingdao Transocean vane zvisiri pamutemo uye zvisiri pamutemo mamiriro.Pakati pavo, Natural Gasi Tekinoroji Service Center yeZhongyuan Petroleum Bureau yeSinopec yakatyora mirau yekutonga yemidziyo yekudzivirira inovharira sisitimu uye haina kunyatsoita nzira yekubvumidzwa yekuvharira chiridzwa zvinoenderana nemirairo.Muinjiniya wezviridzwa Lai Xiaolin akaita zvekumanikidzira kuvharirana kuvhiyiwa kusati kwapera mvumo yetikiti yekuvharisa uye pakanga pasina muchengeti.

Boka renyanzvi dzemakemikari HSE dzerimwe basa rakanyanya kukurukura nezvetsaona yacho.Mushure mekuona kutaura kwenyanzvi imwe neimwe, ndakadzidza zvakawanda.Heino ongororo uye pfupiso:
1.Njodzi iyi yakaitika pasina kuparadzaniswa kunobudirira kwemasimba ane ngozi.Paive nematambudziko mune logic yeESD emergency shutdown system muSIS system, uye kupomba kweplate bofu kwakatadza kuita basa.Zvinotonyanya kukosha, usavimba ne "system" zvakanyanya, chero system ine mukana wekutadza.LOTOTO(Kukiya/kutaga/ bvunzo)nekubatana kwenyama pazvinogoneka.Simbiso uye kubvumidzwa kuchaitwa zvinoenderana nemvumo nebasa revashandi vemaneja pamatanho ese.

2.Haana nzira yemvumo inoshanda yekuita basa rine njodzi, uye haana kuita pre-work security assessment (JSA) isati yatanga basa.Zvinoenderana nekuongorora kwakasimba uye maitiro ekubvumidza ekuita zvine njodzi, munyoreri uye maneja anofanira kunyatsoita ongororo yekuchengetedzwa isati yaitwa, uye mvumo inofanira kuenda kunzvimbo inosimbiswa isati yatenderwa.

3.Chirevo chekuongorora njodzi chinoratidzika sechinyatsochenjerera, uye kunyange pfungwa nemaminitsi zvakanyatsojeka: pa11: 20, rutivi rwuri pedyo netangi rakagurwa, uye pa11: 40, sei uchikurudzira kubata chiridzwa. interlocking work ticket?Chechipiri, vharafu iyi inofanira kunge iri yakaderera mvura pamwero wekucheka-kure vharafu.Yakavharwa rini uye sei?Kwete vanhu vazhinji havana kunzwisisa vharafu yakavharwa kukurudzira injiniya kuvhara vharafu zvakare.Mibvunzo yakawanda pamusoro pezvakawanda, asi hapana kutarisa, hapana tambo.Zvakaoma kunzwisisa.