I. accident history
A February morning, a factory maintenance personnel maintenance water source booster pump. Work permit person will stop the pump operation, in the power failure measures, because 380V hand truck type switch operating mechanism card, the switch is not pulled to the "maintenance position", still in the "operation" position. After the licensor and the person in charge of the work confirm it on the spot, after the agreement, hang up the "no closing and no working" sign and start the maintenance work.
During the maintenance, the monitor inspected the switch room and found that the booster pump switch was in the "operation" position. He took down the sign without authorization and tried to open the switch to the "maintenance" position. When pull open close, press "close" button, switch close, have disintegrated booster pump start up a maintenance personnel hurried to dodge, the risk of serious personal injury.
Cause and exposure problems
1. The operator seriously violates the regulations and fails to pull the switch to the "maintenance" position as required by the work ticket. The switch is still in operation
2. The person in charge of the work seriously violates the rules and regulations, knowing that the switch is still in the "running" position, and has not taken measures to prevent the pump body from suddenly rotating, so he/she agrees to start the work and is not responsible for the members of the work team;
3. The operation monitor seriously violates the rules and regulations and conducts electrical operation without authorization in order to fulfill the procedures of operation ticket.