Recently, the website of the People's Government of Binxian County, Harbin City, Heilongjiang Province, published the "Investigation Report on General Mechanical Injury Accidents of Binxian Zhongyi Cement Products Co., Ltd. on December 30".
accident investigation team found out the course and cause of the accident, identified the nature and responsibility of the accident, and put forward suggestions and preventive measures through on-site investigation, data access, personnel inquiry and surveillance video access.
After investigation, it was found that the accident was a general accident of production safety responsibility caused by the inadequate production safety management of Zhongyi Cement Products Co., Ltd. in Heilongjiang Province.
1. Basic information
of the accident (1) Units
involved in the accident 1. Heilongjiang Zhongyi Cement Products Co., Ltd.
2. Heilongjiang Zhishi Construction Labor Subcontracting Co., Ltd.
(2) The accident happened and emergency rescue situation
1. The accident happened
at 9:00 a.m. on December 30, 2025. Li Moumou, the workshop director of Heilongjiang Zhongyi Cement Products Co., Ltd. Let Jiang Mou-mou, the leader of the small board team, arrange people to clean up and maintain the mixer in No.8 workshop. The space in the tank is about 5 square meters, the working space is narrow, and two people work alternately. The cleaning was not completed in the morning. After going to work at 13 o'clock in the
afternoon, around 13:10, Jiang asked Zhang (the operator of the mixer that day) to release the residue in the mixer. At 13:10, Zhang shouted under the mixer, "Is there anyone inside? I want to close the switch." At that time, Xu cleaned up the cement residue on the mixer blade with an electric pick in the mixing tank. At about 13:12, Zhang closed the main power supply switch to control the mixing station. At 13:14:22, Zhang started the discharge button of the mixer to discharge the residual material. At that time, there were two people left on the mixer platform, Zhang Mou and Xu Mou. Zhang repeatedly operated the platform button to clean dust bag, put the residual material and other work. At 13:32:42, Zhang pressed the start button of the mixer, and then pressed the emergency stop button. Then Zhang shouted: "People are stirring in the mixer." Jiang, the squad leader, immediately went to the electric control cabinet on the northwest side of the ground to pull down the main switch. Other workers went up to the mixer platform one after another. Jiang and Yang entered the mixer from the discharge port of the mixer and saw Xu stuck on the blades of the mixer, with his eyes closed and his head hanging down.
2. After the emergency rescue
accident, Jiang Mou-mou and Yang Mou-mou immediately entered the mixer from the discharge port of the mixer. When they saw Xu Mou-mou stuck on the blade of the mixer with his eyes closed, Jiang Mou-mou and Yang Mou-mou pulled Xu Mou-mou up and lifted him up. Together with other workers, they pulled Xu Mou-mou out of the discharge port of the mixer. Xu was then placed on the mixer platform and later transported from the platform by forklift. Then So-and-so immediately called Wang So-and-so (the person in charge of Zhongyi Cement Products Company) to say that something had happened, and Xu seemed to have been stirred to death. Wang Mou-mou, the person in charge, asked Li Mou-mou to call the police and report to the county government and the Emergency Management Bureau and inform Xu's family. About 15 minutes, 120 ambulances from the county government, the Public Security Bureau, and the relevant personnel of the Emergency Bureau all arrived at the scene of the accident, and 120 healthcare workers announced Xu's death after giving first aid. Subsequently, Xu's family also arrived at the scene of the accident. With the consent of the family members, the body was sent to the funeral parlor in Binxian County for storage.
(III) Scene
of the accident The scene of the accident is located in the northwest side of the courtyard of Heilongjiang Zhongyi Cement Products Co., Ltd., which is the No.8 production workshop of the company, covering an area of about 1350 square meters. The products produced are 500x500x12 (mm) cement slabs, about 2000 pieces per day. There are two production lines of plate beating machine and plate scraping machine in the workshop. The accident occurred in the mixer of the plate beating machine production line, which is erected in the north and west of the workshop. The mixer operation platform is about 3 from the ground.
II. Casualties and direct economic losses
caused by the accident. The accident resulted in one death and a direct economic loss of about 950,000 yuan.
The deceased Xu Mou, male, with his family address and ID card number, was an employee of Zhongyi Cement Products Co., Ltd. in Heilongjiang Province.
3. The cause
of the accident (1) The direct cause
was confirmed by the accident investigation team that Xu entered the mixing tank to clean up the cement residue in violation of the operating rules; Zhang Mou violated the inspection and maintenance regulations, closed the main power supply switch of the mixer without authorization, and started the starting switch of the mixer by mistake, which was the direct cause of the accident.
(2) Indirect reasons
1. Heilongjiang Zhongyi Cement Products Co., Ltd. is not in place to implement the main responsibility of safety production. The safety production post responsibility system of the whole staff has not been strictly implemented, the hidden danger investigation has not been carried out in full accordance with the company's regulations, the safety management system has not been strictly implemented, and the hidden danger investigation and remediation has not been thorough.
2. The main person in charge and the safety management personnel are deficient in performing their duties. The principal responsible person and safety management personnel fail to implement the dual prevention mechanism of safety risk classification control and hidden danger investigation and management in accordance with the requirements of the Safety Production Law of the People's Republic of China, fail to carry out hidden danger investigation and management in accordance with the regulations, and there are loopholes in the safety production management of the operation site.
3. The company's safety management system is not strictly implemented. The mixer operator and the personnel cleaning the mixing tank did not have a strong sense of safety, did not operate according to the operating procedures, did not implement the work requirements of power off, listing and locking for inspection and maintenance, and closed the main power supply switch without authorization. The workshop director and team leader did not find and stop it in time.
4. Suggestions
on responsibility identification and handling (1) Suggestions on
responsibility identification and handling of accident responsible units Heilongjiang Zhongyi Cement Products Co., Ltd. is not in place to implement the main responsibility of safety production, and has not strictly implemented the responsibility system of safety production for all staff; The implementation of the dual prevention mechanism of safety risk classification control and hidden danger investigation and management is not in place; the safety production education and training of employees is not comprehensive, and the safety supervision of the operation site is not in place, which is responsible for the accident. In violation of the relevant provisions of Article 21, Paragraph 1, Items 3 and 5, Article 28, Paragraph 1 and Article 44, Paragraph 1 of the Safety Production Law of the People's Republic of China, according to the provisions of Article 114, Paragraph 1, Item 1 of the Safety Production Law of the People's Republic of China, it is suggested that the county emergency management Bureau should impose administrative penalties according to law.
(2) Suggestions on
the determination and treatment of the responsibility of the person responsible for the accident 1. Wang Mou-mou, the principal person in charge of Heilongjiang Zhongyi Cement Products Co., Ltd., failed to fully fulfill the main responsibility for production safety, violated the relevant provisions of Article 21 of the Safety Production Law of the People's Republic of China, and was responsible for the management of the accident. It is suggested that the county emergency management Bureau should impose administrative penalties in accordance with the provisions of Article 95, paragraph 1, paragraph 1, of the Safety Production Law of the People's Republic of China.
2. Li Moumou is the workshop director of Heilongjiang Zhongyi Cement Products Co., Ltd. In the on-site safety management work, the implementation of the safety production system was not in place, the hidden dangers of production safety accidents were not timely investigated, and Zhang Shuang's illegal operation was not timely discovered and stopped, which violated the provisions of the second and fifth paragraphs of Article 25 of the Safety Production Law of the People's Republic of China, and was responsible for the management of the accident. It is suggested that the county emergency management Bureau should impose administrative penalties in accordance with the provisions of Article 96 of the Safety Production Law of the People's Republic of China.
3. Jiang Moumou, the team leader of Zhongyi Cement Products Co., Ltd. in Heilongjiang Province, did not investigate the potential safety hazards at the operation site, and did not implement the work requirements of power off, listing and locking for inspection and maintenance. Zhang Mou's illegal operation was not found and stopped in time, and he was responsible for the management of the accident. It is suggested that the County Emergency Management Bureau should impose administrative penalties in accordance with the provisions of Article 45, paragraph 1, of the Measures for Administrative Penalties for Illegal Acts in Production Safety.
4. Zhang Mou, an employee of Zhongyi Cement Products Co., Ltd. in Heilongjiang Province, was the operator of the mixer at that time. After investigation and investigation, the monitoring of the workshop showed that Zhang Mou illegally joined the main power supply gate of the mixer without authorization, and started the mixer by mistake, resulting in Xu Mou's death. According to the provisions of Article 107 of the Safety Production Law of the People's Republic of China, Suspected of the crime of major liability accident, it is suggested that the public security organs investigate.
5. Xu, an employee of Heilongjiang Zhongyi Cement Products Co., Ltd., lacked safety awareness and safety prevention skills. He entered the mixing tank to clean up the cement residue in violation of the operating rules. He was directly responsible for the accident. In view of the death in the accident, it is suggested that he be exempted from accountability.
5. Accident prevention and rectification measures
This accident reflects the problems existing in the safety production management of Zhongyi Cement Products Co., Ltd. in Heilongjiang Province, and the lessons are very profound. We should earnestly draw lessons from accidents and formulate effective rectification measures to prevent the occurrence of production safety accidents in view of the weak links in safety management.
First, Heilongjiang Zhongyi Cement Products Co., Ltd. should hold an all-staff accident warning education meeting to inform all employees of the accident, deeply analyze the causes of the accident, and inform the relevant responsible persons of the handling situation, so as to achieve the purpose of education and warning.
The second is to improve the safety production management organization of the company, improve and implement the safety production responsibility system of the whole staff of the unit, formulate and implement the safety production rules and regulations and operating procedures of the unit, improve and implement the emergency rescue plan for production safety accidents of the unit and organize drills.
The third is to strengthen the safety production education and training of employees, formulate the education and training plan in line with the actual situation of the unit, and carry out the education and training work on time according to the training plan, focusing on the safety production management system formulated by the company and the operation rules of each post, which should be known and strictly observed by all personnel.
Fourth, further standardize the inspection and maintenance of equipment and facilities, improve the level of safety management, and operate, inspect and maintain in strict accordance with equipment instructions and operating rules; It is suggested that enterprises should increase investment in intelligent monitoring and early warning system for key equipment, move forward from "civil air defense to intelligent defense", improve the level of safety production with science and technology, and eliminate accidents in safety production.
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