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at about 15:35 on september 7, 2023, a high-pressure gas leak occurred in the gasification workshop of yiding ecological agriculture development co., ltd. in hangjin banner, ordos city, inner mongolia, killing 10 people and injuring 3 people. as of april 2024, the accident caused direct economic losses of 33.9414 million yuan. on september 22, a beijing youth daily reporter noticed that the inner mongolia autonomous region emergency management department website recently published an investigation report on the accident.

a major production safety accident

after investigation, it was determined that the "9.7" major high-pressure gas leakage accident at ordos hangjinqi yiding ecological agriculture development co., ltd. was an illegal change in the position of the remote pressure transmitter of the pressure pipeline, serious blockage at the connection between the main pipeline and the flare pipeline and the pressure measuring device pressure short joint pipe, poor equipment maintenance, illegal command and illegal operation by operating personnel, a large number of personnel gathered on site, and the removal of the valve cover when the medium pressure in the main pipeline was high, resulting in a major production safety responsibility accident caused by the instantaneous leakage and ejection of high-pressure crude synthesis gas in the pipeline.

the investigation report shows that ordos yiding ecological agriculture development co., ltd. was jointly funded by yili clean energy co., ltd. and shandong energy group northwest mining co., ltd., with a main product scale of 300,000 tons/year of synthetic ammonia and 520,000 tons/year of urea. yili clean energy co., ltd. established the kubuqi industrial division to coordinate and manage the safety, production and operation of four companies including yiding company. the staff of the division is composed of some managers of the four companies. yili clean energy co., ltd. is a subsidiary controlled by yili resources group co., ltd.

on august 17, 2023, yiding ecological agriculture development co., ltd. prepared an overall shutdown plan and a single plan for equipment maintenance and reported it to the hangjin banner emergency management bureau. the planned major maintenance time is from august 20 to september 16, and a comprehensive maintenance will be carried out on air separation, thermal power, gasification, purification, and synthetic urea. on august 24, the system was shut down for annual overhaul as planned. before the shutdown, the pressure gauge and pressure transmitter of the accident pipeline were normal. on september 5, yiding company began to put materials into trial operation.

the accident site is located on the southeast side of the enterprise, 114.45 meters away from the office building on the north, 5.1 meters away from the sedimentation tank on the west, 19.45 meters away from the road boundary within the enterprise on the south, and 2.8 meters away from the washing tower on the east.

at 0:36 on september 7, the gasification furnace b was ignited and started. at 4:23 in the morning, coal was added to the gasification furnace b, and the gasification furnace began to heat up and increase pressure. at around 9:22, the outlet pressure of the gasification furnace washing tower showed 3.06mpa and the temperature showed 154.72℃. yang, the deputy director of the fertilizer plant, arranged for personnel to organize the gasification to change the gas supply. at around 11 o'clock, the section chief qi found that the remote pressure transmitter (1210pi0001) showed 0mpa and did not increase the pressure normally. yang arranged for him to open and close the vent valve to confirm the smooth transportation of the raw synthetic gas. qi commanded the personnel to close the vent valve, and the remote pressure transmitter showed a pressure of 3.11mpa. when the vent valve was opened, the pressure would drop rapidly. this was repeated three times. at 12:12:02, the valve was opened for the third time, and the pressure showed 0.03mpa. at 12:37:55, the pressure showed 0mpa. until the accident occurred, the vent valve remained in the open state, and the pressure showed 0mpa. during this period, the on-site personnel li repeatedly touched the vent pipe with his hands to confirm that the temperature was normal. yang arranged for several people to repeatedly open and close the regulating valve (17pv2004) and the accident valve (17mv2017), confirm the status, and find the fault point.

at around 12:00, yang misjudged the fault of the emergency valve, causing interception and preventing the crude synthesis gas from being sent to the conversion process normally. after reporting the situation to liu gang, the director of the fertilizer plant, and zhou, the deputy general manager of the business unit, zhou decided to arrange for the shutdown and maintenance. at 12:33:24, yang returned to the central control room and pressed the stop button, and the gasification system stopped. at 13:31, the outlet pressure of the gasifier scrubber (17pt2013) dropped to 0.25mpa, and nitrogen was purged three times. at 14:10, the pressure value showed 0mpa.

at 15:34, hu, the team leader of the fourth shift of the gasification workshop, and bai, an on-site inspector who were working in other areas, heard on the intercom that yang needed a portable gas detector. they then arrived at the scene and handed the detector to yang. at that time, there were 20 people on the platform.

at 15:35, yang held the accident valve cover and directed the on-site personnel to operate the hydraulic expander 4-5 times. high-pressure gas then gushed out. the personnel operating the valve on site were impacted by the gas and fell to their death after colliding with the north guardrail. the shock wave also injured personnel on the side of the accident valve.

the accident left 10 dead and 3 injured

the accident caused the valve cover, valve stem, and valve plate (total weight 556kg) of the accident valve to be thrown northward at high speed. the horizontal distance of the first landing point was 89.4m, and the horizontal distance of the second landing point was 112.4m. the vertical pole of the fence was broken, and the length of the damaged fence was 7.6m and the height was 1.1m. the electric actuator, handwheel transmission mechanism, and gantry of the accident valve were scattered on the ground in the north direction of the platform. the insulation layer at the lower elbow of the pipeline on the north side of the valve was peeled off by the impact of the airflow, exposing the elbow pipeline surface. the back side (south side) of the accident valve was not damaged by the accident.

the accident caused 10 deaths and 3 injuries. as of april 2024, the accident caused direct economic losses of 33.9414 million yuan.

regarding the reasons for the increase in casualties, the investigation report believes that the platform area at the accident site was less than 30 square meters, 20 workers gathered to dismantle the valve, and many of them were concentrated directly opposite the pressure relief port (valve), causing the casualties to increase.

the investigation report determined that the direct cause of the accident was that the position of the remote pressure transmitter on the accident pipeline was changed in violation of regulations, the connection between the main pipeline and the flare pipeline, as well as the local pressure gauge and the remote pressure transmitter pressure nipple were severely blocked, the local pressure gauge and the remote pressure transmitter displayed distorted, and the operating personnel misjudged and removed the valve cover when the medium pressure in the main pipeline was high, resulting in the instantaneous leakage and gushing out of the high-pressure crude synthesis gas in the pipeline. a large number of operating personnel gathered on site, which led to the expansion of casualties and caused heavy casualties.

there were problems in multiple units and 22 people were held accountable

the investigation report shows that on the basis of the company's early self-rescue, the municipal and flag governments immediately initiated emergency response, and successively established flag-level and municipal-level accident rescue headquarters, forming an overall emergency rescue force. on september 8, the people's government of inner mongolia autonomous region initiated a secondary response to the hazardous chemicals production safety accident, established a rescue headquarters, and achieved safe and orderly material withdrawal and parking, without causing air and water pollution, and without causing secondary disasters. however, due to the death of the relevant person in charge of yiding company in the accident, the initial emergency response was chaotic, and yili clean energy company failed to coordinate the handling of casualties, resulting in slow verification of casualty information, multiple changes in casualties, and long information reporting time. these problems need further improvement and improvement.

the investigation report shows that there are many problems with the relevant units, emergency management departments, market supervision departments, and local governments.

in terms of specific handling suggestions, 6 people were exempted from accountability due to death, and the judicial authorities have taken compulsory measures against 7 people. in addition, 15 people including the safety officer of the equipment manufacturing company, the process engineer and safety engineer of yiding company, the person in charge of the ordos area and the project leader of the china special inspection institute, the safety director, general manager and chairman of yili clean energy company were recommended to be given administrative penalties.

(beijing youth daily reporter li tiezhu)