金昌奔馬農用化工股份有限公司 “11.3” 中毒和窒息事故調查報告

       

2016NIAN11YUE3RI16SHI30FEN,JINCHANGBENMANONGYONGHUAGONGGUFENYOUXIANGONGSIXIASHUDIANLIGONGSI2MINGZHIGONGZAIJINGHUAZUOYEQUCHUCHENGANGWEI2#DIANBUQINEIJIANXIUZUOYESHI,FASHENGYIQIZHONGDUHEZHIXISHIGU,ZAOCHENGYIRENSIWANG,YIRENSHOUSHANG。

一、事故單位基本情況

JINCHANGBENMANONGYONGHUAGONGGUFENYOUXIANGONGSICHENGLIYU1999NIAN12YUE29RI,SHIGANSUJINCHANGHUAXUEGONGYEJITUANYOUXIANGONGSIZIGONGSI,CHIYOU《ANQUANSHENGCHANXUKEZHENG》(BIANHAO:GANWHANXUZHENGZI(0478)HAO),ZHUYAOFUZERENHEGUANLIRENYUANANQUANZIGEQIQUAN,DANWEIDIZHI:JINCHANGSHIYONGCHANGXIANHEXIBAOZHENHEYALU173HAO,JINGJILEIXING:YOUXIANZERENGONGSI。2015NIAN1YUEFENKAISHIDULIYUNYING。XIANYOUZHIGONG820REN,SHEZHIXINGMEI、ZAOQI、JINGHUA、HECHENG、GUOLU、LIANJIANLIUGESHENGCHANZUOYEQUHEDIANLI、YIBIAOLIANGGEZHUANYEHUAGONGSI。ZHUYAOSHENGCHANYEAN、CHUNJIAN、NONGYONGLVHUAAN、TANSUANQINGAN。SHIGUFASHENGSHIGAIQIYECHUYUTINGCHANJIANXIUZHUANGTAI。

二、事故經過和搶救過程

(一)事故發生經過

11YUE3RIXIAWU15SHIZUOYOU,CHENTONGMING、LIUXINGLIANG、WANGYONGGANG、ZHANGZHITAODENGRENZAIDIANLIGONGSIANQUJIANXIUGONGDUANXIUXI,FUGONGCHANGZHANGZHITAOJIEDAOGONGCHANGZHAOXUDEDIANHUA,DIANHUAZHONGANPAICHENTONGMINGHELIUXINGLIANGQUJIANXIUCHUCHENGANGWEI2#DIANBUQI,BINGDAOCAOZUOSHILINGQU《SHOUXIANKONGJIANZUOYEHEZHUNZHENG》,ZHANGZHITAOXIANGCHENTONGMINGHELIUXINGLIANGCHUANDALEZHAOXUDEDEGONGZUOANPAI。15SHI40ZUOYOU,CHENTONGMINGHELIUXINGLIANGDAIGONGJUQU2#DIANBUQIJIANXIU,ZAICAOZUOSHIWEIJIANDAOBANLI《SHOUXIANKONGJIANZUOYEHEZHUNZHENG》DEREN,BIANJINXINGLEDUANDIANQUEREN。CHENTONGMINGDIANHUAXIANGGONGCHANGZHAOXUDEQUERENWEIXIUGANGWEIHOU,SHANGDAO2#DIANBUQITATAI,DAKAIDIBURENKONG,GUANCHAGUZHANGWEIZHIHOU,YOUPADAOSHANGBUPINGTAI,DAKAISHANGBUDERENKONGJINXINGTONGFENG。GUOLEYIHUI,LIUXINGLIANGZAISHANGBURENKONGGUANCHAHOUSHUO“KEYILE”。LIUXINGLIANGTONGGUOSHANGBURENKONGJINRU2#DIANBUQI,CHENTONGMINGBATOUYESHENJINDIANBUQIZHUNBEIJINRU,LIUXINGLIANGZAILIMIANSHUO“BUXING”,CHENTONGMINGJIUYONGSHOULALIUXINGLIANG,ZAILADEGUOCHENGZHONGCHENTONGMINGHUNDAO。CHENTONGMINGXINGLAIHOU,FAXIANZIJIYANGMIANTANGZAIPINGTAISHANG,YONGSHOUJIGEIGONGCHANGZHAOXUDEDADIANHUASHUO:“WOHELIUXINGLIANGBEIMEIQIDALE,KUAILAI”。CHENTONGMINGPAQILAIKANDAOLIUXINGLIANGHUANZAIDIANBUQILI,YOUSHENSHOUQULATA,ZAILADEGUOCHENGZHONGZAICIHUNDAO。

(二)搶救過程

16SHI30FENZUOYOU,ZHAOXUDEJIEDAOCHENTONGMINGQIUJIUDIANHUAHOU,DAIZHANGMINGYI、ZHANGZHITAODENGRENGANWANGSHIFADIDIAN,TONGSHIDIANHUATONGZHIZHANGDEZHISHANGTAJIUREN。ZHANGDEZHIDIYIGEDAODASHIGUXIANCHANG,JIANDAOCHENTONGMINGSHOUBARENKONG,SHENTIFARUAN,HUXIBUSHUNCHANG,LIMIANQITIXIANGWAICHONG,YOUFEICHANGCIBIDEWEIDAO,ZHANGDEZHIBAIKAICHENTONGMINGDESHOUBINGBATALADAOTONGFENGCHU。KANDAOLIUXINGLIANGZAIDIANBUQILILIRENKONGBUYUANCHU,MIANCHAOSHANGTANGZHU,JIUYONGSHOUXIANBATADETUILACHULAI,ZHESHIDIANLIGONGSIDERENDAODAXIANCHANG,HELIJIANGLIUXINGLIANGJIUCHU。16SHI40FENZUOYOU,ZHAOXUDEDAOTAXIAQULAIYANGQIGUANGEICHENTONGMINGHELIUXINGLIANGXIYANG,BINGLUNHUANZUORENGONGHUXIHEXIONGYADETONGSHI,DIANHUAHUJIAOLE120JIJIUCHE。120JIJIUCHEDAODAHOU,XIANHOUJIANGCHENTONGMINGHELIUXINGLIANGSONGWANGJINCHANGSHIDIYIRENMINYIYUANJIUZHI,LIUXINGLIANGQIANGJIUWUXIAOSIWANG。

三、事故發生時間

2016NIAN11YUE3RI16SHI30FEN。

四、事故發生地點

JINCHANGBENMANONGYONGHUAGONGGUFENYOUXIANGONGSICHUCHENGANGWEI2#DIANBUQI。

五、事故類別:

ZHONGDUHEZHIXI

六、事故傷亡人員情況

SHIGUZAOCHENGLIUXINGLIANGSIWANG,CHENTONGMINGSHOUSHANG。LIUXINGLIANG,NAN,HANZU,SHENFENZHENGHAOWEIxxx,JIATINGZHUZHI:GANSUSHENGYONGCHANGXIANHEXIBAOZHENSIMENCUNWUSHE030HAO。CHENTONGMING,NAN,HANZU,SHENFENZHENGHAOWEIxxx,JIATINGZHUZHI:GANSUSHENGYONGCHANGXIANHEXIBAOZHENHEYALUJINHUAXICUN19DONG101HAO。

七、事故直接經濟損失

95WANYUAN

八、事故性質

SHENGCHANANQUANZERENSHIGU

九、事故原因分析

(一)直接原因

JINCHANGBENMANONGYONGHUAGONGGUFENYOUXIANGONGSIDUIZHENGGEMEIQIXITONGJINXINGLEDUOXINGQITIHEKONGQIZHIHUANHOU,GEXITONGJINRUQUANMIANJIANXIUJIEDUAN,DINGBUFANGKONGFAWEIDAKAIGUO,YOUYUDIANBUQIGAOYUMEIQIJUHELUOCIFENGJIJINCHUKOUGUANDAO,BIKONGQIQINGDEMEIQIJUJIZAITADING,SUIZHUSHIJIANDETUIYI,DIANBUQINEIFUJILEDALIANGMEIQI。DIANBUQICHUYUGONGYIDEGAOWEI,JINCHUKOUGUANDAOZHIJINGCU、GUANDAOCHANG、WANTOUDUO、GAODIQIFU,GUANDAONEICANLIUDEMEIQI,SUIZHU3#LUOCIFENGJIRUKOUGUANDAOGENGHUANSHIGONG,QITILIUDONGHOU,LUXUYOUFUJIDAODIANBUQINEI,ZAOCHENGDINGBUMEIQIJUJI。

LIUXINGLIANG、CHENTONGMINGZAIWEIJINGXUKE,WEICAIQURENHEGERENANQUANFANGHUCUOSHI,WEIBANLIRENHEZUOYESHOUXU,MINGZHI2#DIANBUQISHIMEIQIJINGHUACHUCHENSHEBEI,SHUYUSHOUXIANKONGJIANZUOYE,CUNZAIMEIQIFUJIWEIXIANDEQINGKUANGXIA,WEIZHANGMAOXIANJINRU2#DIANBUQINEIZUOYE。

ZONGSHANGSUOSHU,DUISHOUXIANKONGJIANNEIMEIQIZHIHUANBUCHEDI,YUANGONGWEIZHANGMAOXIANZUOYE,SHIDAOZHISHIGUFASHENGDEZHIJIEYUANYIN。

(二)間接原因

1.JINCHANGBENMANONGYONGHUAGONGGUFENYOUXIANGONGSIANQUANSHENGCHANZHUTIZERENLUOSHIBUDAOWEI,ANQUANGUANLIHUNLUAN,DUIXIGUANXINGWEIZHANGMAOXIANZUOYESHIERBUJIAN,SHIDAOZHICICISHIGUFASHENGDEZHUYAOYUANYIN。

2.JINCHANGBENMANONGYONGHUAGONGGUFENYOUXIANGONGSIWEIYANGELUOSHI《YOUXIANKONGJIANANQUANZUOYEWUTIAOGUIDING》DENGGUIZHANGZHIDU。TEZHONGZUOYERENYUANWEIJINGPEIXUN,WEIQUDEXIANGGUANZUOYEZHENGDEQINGKUANGXIAJINXINGTEZHONGZUOYE;ZAIWEISHENPI、WEIPEIBEIGERENFANGZHONGDUZHIXIDENGFANGHUZHUANGBEI、XIANCHANGWEIPEIBEIYINGJIZHUANGBEIDEQINGKUANGXIASHANZIJINRUYOUXIANKONGJIANZUOYE,SHIDAOZHICICISHIGUFASHENGDEZHONGYAOYUANYIN。

3.GANSUJINCHANGHUAXUEGONGYEJITUANYOUXIANGONGSIDUIXIASHUZIGONGSIGUANLIBUDAOWEI,DUIANQUANSHENGCHANGONGZUOZHONGSHICHENGDUBUGOU,ZAIXIASHUHAN10GEZIGONGSIDEQINGKUANGXIA,ZHIPEIBEI2MINGANQUANGUANLIRENYUAN,QIEJIANRENJINCHANGBENMANONGYONGHUAGONGGUFENYOUXIANGONGSIANQUANGUANLIRENYUAN,WUFABAOZHANGDUIQUANGONGSIANQUANGONGZUODEYOUXIAOGUANLI,SHIDAOZHICICISHIGUFASHENGDEYOUYIZHONGYAOYUANYIN。

十、事故責任認定及處理建議

1.LIUXINGLIANG、CHENTONGMINGZAIWEIJINGXUKE,WEICAIQURENHEGERENANQUANFANGHUCUOSHI,WEIBANLIRENHEZUOYESHOUXU,MINGZHI2#DIANBUQISHIMEIQIJINGHUACHUCHENSHEBEI,SHUYUSHOUXIANKONGJIANZUOYE,CUNZAIMEIQIFUJIWEIXIANDEQINGKUANGXIA,WEIZHANGMAOXIANJINRU2#DIANBUQINEIZUOYE,DUICICISHIGUDEFASHENGFUYOUZHUYAOZEREN。JIANYULIUXINGLIANGZAISHIGUZHONGSIWANG,MIANYUZERENZHUIJIU,JIANYIJINCHANGBENMANONGYONGHUAGONGGUFENYOUXIANGONGSIDUICHENTONGMINGDIAOZHENGGONGZUOGANGWEI。

2.ZHANGDEZHI,JINCHANGBENMANONGYONGHUAGONGGUFENYOUXIANGONGSIJINGHUAZUOYEQUGANGCHANG,ZAIDEDAODANGTIANXIAWU2#DIANBUQIJINXINGWEIXIUDEQINGKUANGXIA,ZHUNBEIGONGZUOBUCHONGFEN,FENGXIANYUPANBUGOU,DUICICISHIGUDEFASHENGFUYOUZHONGYAOZEREN。JIANYIJINCHANGBENMANONGYONGHUAGONGGUFENYOUXIANGONGSICANZHAO《ANQUANSHENGCHANLINGYUWEIFAWEIJIXINGWEIZHENGJICHUFENZANXINGGUIDING》GEIYUCHEZHICHUFEN。

3.ZHAOXUDE,JINCHANGBENMANONGYONGHUAGONGGUFENYOUXIANGONGSIDIANLIGONGSIGONGCHANG,ANQUANGUANLIBUDAOWEI,DUIXIGUANXINGWEIZHANGMAOXIANZUOYESHIERBUJIAN,ANPAIWEIJINGGUOZHENGGUIPEIXUN,WEIQUDEXIANGGUANZUOYEZHENGRENYUANCONGSHITEZHONGZUOYE,DUICICISHIGUDEFASHENGFUYOUZHIJIELINGDAOZEREN。JIANYIJINCHANGBENMANONGYONGHUAGONGGUFENYOUXIANGONGSICANZHAO《ANQUANSHENGCHANLINGYUWEIFAWEIJIXINGWEIZHENGJICHUFENZANXINGGUIDING》GEIYUXINGZHENGJIDAGUOCHUFEN。

4.ZHANGZHITAO,JINCHANGBENMANONGYONGHUAGONGGUFENYOUXIANGONGSIDIANLIGONGSIFUGONGCHANG,ANPAIBUJUBEIZIZHIDIANGONGJINRUSHOUXIANKONGJIANZUOYE,ANQUANQUERENBUDAOWEI,FENGXIANSHIBIENENGLIBUQIANG,DUICICISHIGUDEFASHENGFUYOUZHIJIELINGDAOZEREN。JIANYIJINCHANGBENMANONGYONGHUAGONGGUFENYOUXIANGONGSICANZHAO《ANQUANSHENGCHANLINGYUWEIFAWEIJIXINGWEIZHENGJICHUFENZANXINGGUIDING》GEIYUXINGZHENGJIGUOCHUFEN。

5.LUYONGQIANG,JINCHANGBENMANONGYONGHUAGONGGUFENYOUXIANGONGSIJINGHUAZUOYEQUJINGLIJIANSHUJI,DUIZHENGGEMEIQIXITONGJINXINGLEDUOXINGQITIHEKONGQIZHIHUANHOU,WEIJINXINGJUBUSHOUXIANKONGJIANMEIQIZHIHUAN,YEWEIQUYANGFENXI,DUICICISHIGUDEFASHENGFUYOUZHUYAOLINGDAOZEREN。JIANYIJINCHANGBENMANONGYONGHUAGONGGUFENYOUXIANGONGSICANZHAO《ANQUANSHENGCHANLINGYUWEIFAWEIJIXINGWEIZHENGJICHUFENZANXINGGUIDING》GEIYUXINGZHENGCHEZHICHUFEN。

6.CHENMIAN,JINCHANGBENMANONGYONGHUAGONGGUFENYOUXIANGONGSIDIANLIGONGSIJINGLI,ANQUANGUANLIHUNLUAN,DUIXIGUANXINGWEIZHANGMAOXIANZUOYESHIERBUJIAN,DUICICISHIGUDEFASHENGFUYOUZHUYAOLINGDAOZEREN。JIANYIJINCHANGBENMANONGYONGHUAGONGGUFENYOUXIANGONGSICANZHAO《ANQUANSHENGCHANLINGYUWEIFAWEIJIXINGWEIZHENGJICHUFENZANXINGGUIDING》GEIYUXINGZHENGJINGGAOCHUFEN。

7.DUDEHAI,JINCHANGBENMANONGYONGHUAGONGGUFENYOUXIANGONGSIDONGSHICHANG,ZHUTIZERENLUOSHIBUDAOWEI,DUICICISHIGUDEFASHENGFUYOUZHONGYAOLINGDAOZEREN。JIANYIYIJU《ZHONGHUARENMINGONGHEGUOANQUANSHENGCHANFA》DIJIUSHIERTIAOZHIGUIDING,CHUSHANGNIANDUNIANSHOURU30%DEXINGZHENGCHUFA。

8.GANSUJINCHANGHUAXUEGONGYEJITUANYOUXIANGONGSIDUIXIASHUZIGONGSIANQUANGUANLIBUDAOWEI,DUIANQUANSHENGCHANGONGZUOZHONGSHICHENGDUBUGOU,ZAIXIASHUHAN10GEZIGONGSIDEQINGKUANGXIA,ZHIPEIBEI2MINGANQUANGUANLIRENYUAN,QIEJIANRENJINCHANGBENMANONGYONGHUAGONGGUFENYOUXIANGONGSIANQUANGUANLIRENYUAN,WUFABAOZHANGDUIQUANGONGSIANQUANGONGZUODEYOUXIAOGUANLI,DUICICISHIGUDEFASHENGFUYOUZHONGYAOLINGDAOZEREN。JIANYIGANSUJINCHANGHUAXUEGONGYEJITUANYOUXIANGONGSIXIANGSHIZHENGFUZUOCHUSHUMIANJIANCHA。

9.JINCHANGBENMANONGYONGHUAGONGGUFENYOUXIANGONGSIWEICICISHIGUDEZERENDANWEI。YIZHAO《ZHONGHUARENGONGHEGUOANQUANSHENGCHANFA》DIYIBAILINGJIUTIAOGUIDING,JIANYIGEIYUXINGZHENGCHUFA25WANYUAN。

十一、事故防范措施

1.GANSUJINCHANGHUAXUEGONGYEJITUANYOUXIANGONGSIYAOJIAQIANGDUIXIASHUZIGONGSIDEANQUANGUANLI,PEIQIANGANQUANGUANLIRENYUAN,TISHENGGUANLINENGLI,DUCUXIASHUZIGONGSIPEIBEIHELIDEYINGJIJIUYUANZHUANGBEI。

2.GANSUJINCHANGHUAXUEGONGYEJITUANYOUXIANGONGSIYAODUCUXIASHUDANWEIRENZHENGUANCHELUOSHIGUOJIAFALVFAGUIJISHENGWEISHENGZHENGFU、SHIWEISHIZHENGFUGUANYUANQUANSHENGCHANGONGZUOXIANGGUANGUIDINGHEYAOQIU,YANGELUOSHIQIYEANQUANSHENGCHANZHUTIZEREN,CUJINGONGSIANQUANSHENGCHANXINGSHIZHENGTIHAOZHUAN。

3.JINCHANGBENMANONGYONGHUAGONGGUFENYOUXIANGONGSIYAOYANGELUOSHI《YOUXIANKONGJIANANQUANZUOYEWUTIAOGUIDING》DENGGUIZHANGZHIDU,PEIBEIHELIDEYINGJIJIUYUANZHUANGBEI,DUJUEBUKEXUEDEJIUYUANXINGDONG。

4.JINCHANGBENMANONGYONGHUAGONGGUFENYOUXIANGONGSIYAOJISHIXIUDINGANQUANSHENGCHANZERENZHI,JIAQIANGDUIYUANGONGDEJIAOYUPEIXUN,DUJUEWUZHENGSHANGGANG。