太原化工硫酸烧伤事故案例

Contributing Factors促成因素: 1.考虑不全面，底部导淋阀打开放净硫酸，但未考虑流量计上部管道有堵塞促成事故的发生。 Considering incomplete. Although they opened drain valve to release residual material, they didn’t consider the block of top pipeline ,which lead to incident. 2.未配戴防护用品（防护罩、护目镜） Not wearing protective equipment (protective mask, goggles).
硫酸烧伤 H2SO4 burn Intentional behavior 故意的行为 The employee understood the procedures but made decision to not adhere to it员工知道制度、规定，但没 有遵守
没有穿戴适当的PPE，培训和检查不够 Without suitable PPE, No enough training and checking
SAFETY ALERT 安全警示
Site企业名称:蓝星化工有限责任公司 Bluestar Chemical Co.LTD
Incident resulted in事故导致: 丧失劳动时间Lost Time
Description: 事故描述: 2010年8月6日10时， TDI车间污水处理岗位发现硫酸转子流量计损坏。操作工A先生、B先生进行拆除更 换处理工作。他们放尽导淋阀排完残余硫酸后，拆流量计上端法兰时，法兰处喷出硫酸造成二人烧伤。由于 法兰垫片是采用橡胶板制作，通径较小，长时间使用垫片膨胀将通径堵塞，在排放残料时流量计上部硫酸流 下不来，至使管道内存有物料，在拆除螺栓后移动流量计时硫酸喷出，造成事故的发生。二人被送医院治疗 ，A先生留院继续治疗，B先生医疗处理后回家休养。 August 6th about 10 am, sewage treatment’s operators of TDI workshop found the H2SO4 rotor meter was damaged. The operators, Mr. A and Mr. B brought their tools to replace the instrument. The operators opened drain valve and released residual material. When they dismantled rotor meter’s up flange, the H2SO4 ejected, which contribute to two operators burned. The block of rotor meter on the flange is the cause of incident. The flange gasket ,which has smaller diameter hole is made of rubble. For a long time in H2SO4 the gasket expanded, blocking material flowing down. After removal of the bolts of the meter the material ejected. Two employees were sent to hospital. Mr. A was advised to stay in hospital to continue treatment, while Mr. B went home to rest.
Root Causes根本原因: 1.作业前未进行危险识别； No hazard identification before operation (SWRFra Baidu bibliotek； 2.未配戴防护用品（防护罩、护目镜） Not wearing protective equipment (protective mask, goggles). Corrective Actions采取的措施: 1.加强操作工的安全培训，特别是PPE的培训。 To strengthen the safety training, especially the PPE training. 2.硫酸、双氧水管线法兰不准用橡胶垫，改用耐酸垫片. For rubber gasket is not allowed to use in the H2SO4 and Hydrogen peroxide substituting for acid-proof gasket.
Root Cause Analysis Chart
The employee fails to recognize safety hazard in performing his tasks员工在执行任务时，没 有认识到危险
Unintentional behavior 不是有意的行为
没有做SWR分析 No SWR before
SAFETY ALERT安全警示
Related Photos: ( Photo of area that incident occurred, illustration on how it occurred, etc) 相关的照片：（事故发生区域的照片，解释事故是怎样发生的等）
转子流量计上法兰 the up flange of the rotor meter
Key Learning‘s: 从中学到了什么 1.在作业时要认识到管道内物料的危险。 Well known the danger of internal material in the pipeline when operating. 2.在作业时要穿戴好劳动防护用品。 Wearing PPE when operating.