On July 14th, after obtaining the work permit and dangerous work permit, the fitter's team entered the site, and the operator in the engineering workshop surnamed Chen signed and confirmed the construction and carried out on-site monitoring. On the same day, the fractured axial fan blade was removed and the stainless steel bolts for processing were sent out of the dispatching room.
On July 16th, the processed bolts arrived at the factory. Chen xin, the leader of bench work, led 6 people to work on the top of the cooling tower. 5 of them worked inside the axial flow fan air duct, and 2 of them cooperated and monitored outside the air duct. At the same time, the territorial unit engineering workshop eliminate circulating water post operator liu mou to the site monitoring.
16 PM maintenance workshop director duan just arrived at the next operation, organize fan blade installation operations.
Start the installation process of rain shield at 16:50.
At 16:50, liu Juan left the job site to go to the toilet and returned to the operating room.
Section 17:10 a comrade factory dispatch room peng, request to arrange to do fan test preparation.
17:11 peng a telephone notice engineering workshop operation class requirements to prepare for the test run.
Operator liu mou answered the phone and reported to monitor li xx that the dispatching room was ready to start the fan. Later, the two went to the distribution room together.
When li xiaoying and liu Juan went out of the power distribution room to prepare to start the fan on the top of the cool water tower, they heard the abnormal sound of the cool water tower fan and someone shouted in alarm. They immediately returned to the power distribution room and closed the air switch of the axial flow fan.
< / p > < p > after the accident, duan immediately arranged for the guardian hu, tang ran down the tower of cold water alarm, call 120 for help. At 17:16, the axial flow fan stopped rotating, a section of the immediate organization of personnel rescue.
Li reported the accident to the dispatch room at 17:20, and the dispatch room immediately reported to the dispatching director and the factory director. Factory director fan immediately started an emergency plan, arrangements for the entire plant emergency shutdown.
At 17:30 plant leadership rushed to the scene to organize the rescue, and reported to the northwest sichuan gas mine.
At 17:40, deputy mine manager li dingchuan of northwest sichuan led relevant departments to the scene, organized rescue and rescue, and launched the overall emergency plan of northwest sichuan gas mine emergencies.
Not strictly following the Lockout tagout procedure
On July 16, when maintenance work is completed, at the scene command notices of the workshop director do to start preparing, start-up circulating water operators, after receiving instructions without according to the circulating water device axial flow fan of departure card "operation rules Lockout tagout procedures and job site confirmed cases, illegal closed wind flow distribution shaft main air switch, due to the operation platform on the control box out of control, the axial flow fan starting, causing casualties.
The interface of maintenance operation is fuzzy
The engineering workshop and maintenance workshop did not strictly implement the management requirements of "three processes, two interfaces, one closed loop" and "operation and operation to be controlled" in the refining and purification inspection and maintenance operations of branch company. Before the inspection and maintenance, the engineering workshop and the maintenance workshop only confirmed the on-site process operating conditions, and did not confirm the handover of the power failure status of the axial flow fan. The maintenance work has not been completely completed, and the handover between the engineering workshop and the maintenance workshop has not been implemented yet.