BEIJING, July 30 (Xinhua)-Recently, the website of the State Railway Administration released an announcement on the investigation and handling of the K596 passenger train collision with the operator on the "6.4" Lanzhou-Xinjiang line, which pointed out the suggestions for handling the units and personnel responsible for the accident: 21 people were given disciplinary sanctions, and the judicial organs have taken compulsory measures against 3 people.
The details are announced as follows:
I. Basic information of the accident
1. Overview of the accident
At 5: 18 on June 4th, 2021, Jinchang Workshop of Wuwei Works Section of China Railway Lanzhou Bureau Group Co., Ltd. carried out line mechanical maintenance work on the down line between Yushi and Jinchang Station of Lanzhou-Xinjiang Railway. Due to the temporary failure of tamping the stabilizing car, when the person in charge of the operation organized the workers to transfer to cross the railway line, the cross-line personnel collided with K596 passenger train, resulting in 9 deaths.
2. Overview of the accident unit
China Railway Lanzhou Bureau Group Co., Ltd. has 16 trunk lines including Baolan High-speed Railway, Lanxin Passenger Dedicated Line, Yinxi High-speed Railway, Longhai High-speed Railway and Lanxin High-speed Railway, and 4 other branch lines, with a business mileage of 6,052 kilometers and 41 transport stations. Wuwei Works Section is its subordinate transportation station, and the line in the accident zone is maintained by Jinchang Line Workshop, a workshop under Wuwei Works Section.
3. The accident happened
According to the maintenance plan, there are two tamping stabilization vehicles working together in this maintenance operation, and the mechanical maintenance operation is carried out from east to west from K361+850 and K364+500 respectively.
At 2: 54 on June 4th, Zhang, deputy director of Jinchang Line Workshop in Wuwei Works Section, as the operation leader, organized the workshop participants to hold a preparatory meeting for maintenance operation, and deployed the maintenance operation organization plan and division of labor. A total of 5 employees and 18 laborers from Wuwei Works Section participated in the mechanical maintenance operation at K361+850, and Zhou was appointed as the shift leader. Because the operation area is in the curve and poor communication area, the protector responsible for the protection of the operators is adjusted to the middle protector, and the protector responsible for the emergency group is adjusted to the protector responsible for the protection of the operators.
At 4: 20 on June 4, according to the registration request of the station liaison officer of Wuwei Works Section, station attendant of Jade Station applied to the train dispatcher, who issued a dispatching order, blocked the downlink between Jinchang Station and Jade Station from the time of receiving the order, and allowed Wuwei Works Section to carry out line mechanical maintenance at K360+000 to K368+000, and the maintenance was completed at 7: 22.
At 4: 38 on June 4th, Zhang, the person in charge of the operation, led the workers to enter the protective net from the operation door on the side of K361+900 uplink, crossed the uplink and downlink, and walked along the shoulder to the K361+850 operation site.
At 4: 48 on June 4th, the tamping stabilizing car was moved from Jade Station to K361+850 according to the operation plan.
At 5: 04 on June 4, the tamping stabilized vehicle failed to continue its operation due to the oil leakage of the accumulator.
At 05: 09 on June 4th, the resident liaison officer informed the on-site guard that the passenger train K596 was predicted to pass the Jade Station at 05: 10.
At 5: 15 on June 4th, Wang, the site protector of tamping stabilizing vehicle, confirmed that he had received the approaching information of passenger train K596 twice.
At 5: 16 on June 4th, it was confirmed that the fault of the tamping stabilization vehicle could not be repaired and the operation could not be continued. The person in charge of the operation, Zhang, issued an instruction for the operators to transfer to the operation site K364+500, arranged for the shift leader, Zhou, to lead 15 operators to cross the uplink and downlink lines, and went out of the protective net from the operation gate K361+900 to take a bus to K364+500 to participate in the operation. Wang, the protector who originally followed the tamping stabilization vehicle for mobile protection, was appointed to be responsible for the transfer and crossover After that, the protector Wang and the shift leader Zhou led 15 workers to the shoulder of the road at the 5-meter position (K361+820) on the east side of the faulty tamping stabilization vehicle. During the preparation for crossing the line, the person in charge of the operation, Zhang, urged the crossing line three times.
At 5: 18 on June 4, Wang, who was in charge of the protection of the operators, was still jointly controlling the position of the K596 passenger train with the middle protector. In the case that the middle protector did not answer, he did not issue an order prohibiting crossing the line and did not stop the personnel from crossing the line. Zhou, the shift leader, blindly organized the cross-line personnel to cross the line without confirming whether the train passed. Because the lookout line was blocked by the faulty tamping and stabilizing vehicle, the crossing personnel did not see the approaching K596 passenger train before crossing the line. During crossing the uplink, they collided with the passing K596 passenger train, and nine workers died on the spot. Three workers have crossed the uplink, and the other three workers were blocked by the shift leader Zhou.
Second, the emergency response
After the accident, the co-driver of K596 passenger train, the vehicle attendant and the police immediately got off the train to check the scene of the accident. The driver immediately reported to Jinchang Station and called 120 and 110 for rescue and alarm. After receiving the report, the station immediately organized the police officers of Jinchang station police station and other relevant personnel to rush to the scene of the accident to carry out rescue work for the collision personnel. Confirmed by 120 medical staff, 9 people were killed and others were not injured. After on-site disposal, K596 passenger train started at 6: 43.
After receiving the accident report, China Railway Lanzhou Bureau Group Co., Ltd., the main person in charge led the relevant personnel to the scene of the accident for emergency and after-treatment work.
After receiving the accident report, China National Railway Group Co., Ltd. immediately rushed to the emergency command center to direct emergency rescue, and assigned a deputy general manager to lead a team to rush to the scene of the accident to guide Lanzhou Bureau Group Co., Ltd. to carry out emergency rescue, after-care treatment, safety and stability, and cooperate with accident investigation.
The main person in charge of Lanzhou Railway Public Security Bureau rushed to the scene of the accident, organized and dispatched 120 police officers, set up 8 working groups, and devoted themselves to on-site maintenance, exploration and after-treatment work.
After receiving the accident report, Lanzhou Railway Supervision and Administration Bureau immediately launched the emergency plan, and the main person in charge led the relevant personnel to the scene of the accident to guide the accident rescue, and set up an accident investigation team to carry out the accident investigation.
The Gansu Provincial Party Committee and the provincial government attached great importance to it, and assigned provincial government leaders to rush to the scene to guide Jinchang Municipal Party Committee and Wuwei Municipal Party Committee and Municipal Government to fully cooperate with the railway department to carry out the aftermath and family comfort and condolences.
The emergency management department sent personnel to the scene of the accident to guide the emergency treatment and accident investigation.
Iii. Casualties caused by the accident
Nine workers were killed and no one was injured in the accident.
Four, the cause and nature of the accident, responsibility identification
1. The direct cause of the accident
During the maintenance operation, the tamping stabilizing car broke down, and the direct causes of the accident were blind command, incomplete joint control, field protection failure and illegal crossing of the line during the transition and crossing of the line.
(1) The foremen violate Article 54 of the Law of People’s Republic of China (PRC) on Work Safety, Article 5 of the Regulations on Railway Safety Management and Article 3.2.2 of the Rules for the Safety Management of Railway Works (TZY [2014] No.272) "When crossing a bridge, crossing or crossing a line, they should ‘ Hand-to-hand, eye-to-eye, mouth-to-mouth ’ , do ‘ One stop, two looks, three passes ’ , it is forbidden to cross the line ",Article 6 of Labor Safety Card Control Measures for General Speed Railway of Public Works Department of Lanzhou Bureau Group Company (Gong ‘an Letter [2020] No.66):" It is forbidden to cross the line blindly without confirming the arrival of cars on this line or adjacent lines ",and Article 68:" Before the operators get on the road and cross the line, they should choose a place with good lookout conditions to cross the line ".When leading the operators to cross the line, there are no regulations.
(2) On-site guards violated Article 54 of the Law of People’s Republic of China (PRC) on Work Safety, Article 5 of the Regulations on Railway Safety Management and Article 24 of the Labor Safety Card Control Measures for General-speed Railways in the Public Works Department of Lanzhou Bureau Group Corporation (Gong ‘an Letter [2020] No.66): "The guards should concentrate on their work, look carefully, correctly display and use signal spare parts, and accurately grasp the train operation. Timely and clearly inform all the operation leaders and foremen of the advance notice of each train heading for the operation site, supervise the operators (machines and tools) to get off the train in time when starting, and so on. When knowing that the K596 train is approaching and the joint control has not been answered and confirmed to be safe, it has not issued an instruction to prohibit crossing the line and has not prevented the crossing personnel from crossing the line.
(3) The person in charge of the operation violates Article 54 of the Law of People’s Republic of China (PRC) on Safety in Production, Article 5 of the Regulations on Railway Safety Management and Article 19 of the Measures for the Safety Management of Railway Business Lines (Tieyun [2012] No.280): "The main duties of the person in charge of the construction are: to be responsible for organizing and directing the construction site, directing the on-site construction, arranging construction protection and confirming the conditions for releasing the train; Responsible for summarizing and analyzing the construction organization, progress and safety, and being responsible for the safety of the construction site ",etc., did not arrange safety precautions for crossing the line, did not comply with the on-site protection regulations, and blindly urged the transition personnel to cross the line.
2. Identification of the nature and responsibility of the accident
According to Article 11 of the Regulations on Emergency Rescue and Investigation and Handling of Railway Traffic Accidents (Order No.501 of the State Council) and Articles 10 and 49 of the Rules on Investigation and Handling of Railway Traffic Accidents (Order No.30 of the Ministry of Railways), this accident is a serious accident of railway traffic, and China Railway Lanzhou Bureau Group Co., Ltd. takes full responsibility.
V. Suggestions on handling the units and personnel responsible for the accident
1. Persons whose judicial organs have taken compulsory measures (3 persons)
Three people, including Zhou, the operator, Wang, the site protector, and Zhang, the person in charge of the operation, have been arrested according to law.
2. Give disciplinary action personnel (21 people)
(1) The secretary of the Party Committee and the chairman of China Railway Lanzhou Bureau Group Co., Ltd. were given administrative demerits.
(2) The deputy secretary of the Party Committee and the general manager of China Railway Lanzhou Bureau Group Co., Ltd. were given administrative demerits.
(3) The deputy general manager in charge of public works of China Railway Lanzhou Bureau Group Co., Ltd. was severely warned by the party.
(4) The deputy director in charge of overall work of the Public Works Department of China Railway Lanzhou Bureau Group Co., Ltd. was ordered to resign, and the administrative record was severely punished.
(5) The director of China Railway Lanzhou Bureau Group Co., Ltd., who is in charge of this maintenance operation, was removed from office and the administrative record was severely punished.
(6) The chief of the Safety and Quality Section of the Ministry of Works of China Railway Lanzhou Bureau Group Co., Ltd. was dismissed and the administrative record was greater than the punishment.
(7) The deputy chief of the Safety and Quality Section of the Ministry of Works of China Railway Lanzhou Bureau Group Co., Ltd., who is in charge of labor safety and protection, was dismissed and the administrative record was given greater punishment.
(8) The chief of the line section of the Ministry of Works of China Railway Lanzhou Bureau Group Co., Ltd. was dismissed, the probation period was terminated, and the administrative record was severely punished.
(9) The deputy secretary and section chief of the Party Committee of Wuwei Works Section of China Railway Lanzhou Bureau Group Co., Ltd. were removed from office, and the administrative record was severely punished.
(10) The party secretary and deputy section chief of Wuwei Works Section of China Railway Lanzhou Bureau Group Co., Ltd. were removed from office, and the administrative record was severely punished.
(11) The deputy section chief in charge of line maintenance in Wuwei Works Section of China Railway Lanzhou Bureau Group Co., Ltd. terminated the probation period and was severely warned by the party.
(12) The administrative record of the deputy section chief in charge of labor safety and protection in Wuwei Works Section of China Railway Lanzhou Bureau Group Co., Ltd. was severely punished.
(13) The chief of the security section of Wuwei Works Section of China Railway Lanzhou Bureau Group Co., Ltd. was dismissed from his post.
(14) The administrative record of the assistant engineer in charge of the safety section of Wuwei Works Section of China Railway Lanzhou Bureau Group Co., Ltd. was severely punished.
(15) The head of the line section of Wuwei Works Section of China Railway Lanzhou Bureau Group Co., Ltd. was dismissed.
(16) The administrative record of the deputy section chief of the line section of Wuwei Works Section of China Railway Lanzhou Bureau Group Co., Ltd. was severely punished.
(17) The line section of Wuwei Works Section of China Railway Lanzhou Bureau Group Co., Ltd. is responsible for the administrative demerit of the line maintenance engineer.
(18) The director of Jinchang Line Workshop in Wuwei Works Section of China Railway Lanzhou Bureau Group Co., Ltd. was dismissed.
(19) The General Party Branch Secretary of Jinchang Line Workshop in Wuwei Works Section of China Railway Lanzhou Bureau Group Co., Ltd. was dismissed.
(20) The deputy director in charge of Jinchang Line Workshop in Wuwei Works Section of China Railway Lanzhou Bureau Group Co., Ltd. was dismissed.
(21) The deputy section chief in charge of equipment of Lanzhou Works Machinery Section of China Railway Lanzhou Bureau Group Co., Ltd. was given an administrative demerit.
3. Suggestions on the handling of the unit
Instructed China Railway Lanzhou Bureau Group Co., Ltd. to make an in-depth inspection to China National Railway Group Co., Ltd.
Six, the problems exposed by the accident
1. The field operation standards are not implemented in place.The basic operation system of Wuwei Works Section is not implemented. First, the on-site protection personnel and foremen have a weak sense of safety, fail to implement the operating standards thoroughly, and fail to perform their duties as required. Second, the person in charge of the operation did not direct the operation according to the existing plan, and illegally changed the plan temporarily and changed the protection and shift personnel. Third, the abnormal emergency response was not in place. When the tamping stabilizing vehicle broke down and organized the transition and cross-line operation, the emergency response plan and safety precautions were not formulated.
2. On-site operation safety risk control is not in place.Wuwei Works Section did not carry out safety risk prediction in combination with the actual situation of the job site. First, no targeted measures have been formulated for the need to cross the uplink without working doors in the downlink. Second, the card control measures are not formulated in combination with the problem that the construction site is in a continuous curve section and the line of sight of safety protection is limited. Third, there are loopholes in the construction protection scheme, the joint control link is too complicated, the information transmission is lengthy, the intercom channel is busy, there are key traffic information missing, and the transmission chain is unstable.
3. Maintenance operation management is not in place.The relevant departments of China Railway Lanzhou Bureau Group Co., Ltd. and Wuwei Works Section failed to implement the maintenance operation standards of the business line organized by the workshop, and the on-site control was not in place, and the business guidance, supervision and inspection were not in place. Wuwei Works Section failed to organize safety education and training for laborers involved in the operation as required.
Seven, accident prevention and rectification measures.
In order to draw a profound lesson from the accident, draw inferences from others, effectively prevent and resolutely curb similar accidents, the following rectification measures and suggestions are put forward for China Railway Lanzhou Bureau Group Co., Ltd.:
1. Firmly establish the safety concept of safety first and life first.
We must conscientiously implement the spirit of the important exposition and instructions of the Supreme Leader General Secretary on safety production, adhere to the people first and life first, adhere to the red line consciousness and bottom line thinking, firmly establish the concept of safe development, effectively improve the political position, deeply understand the grim situation facing the current railway safety work, implement the main responsibility of safety production, strengthen risk judgment and hidden danger investigation and management, quickly reverse the passive situation of safety production, and resolutely curb the occurrence of similar accidents.
2. Deeply draw lessons from the accident and immediately carry out special rectification of business line construction.
It is necessary to draw a profound lesson from the accident, immediately organize the special rectification of the construction safety of business lines, benchmark the regulations in the whole process from the aspects of construction organization and leadership, construction scheme review, construction plan preparation and approval, safety agreement signing, personnel training, etc., comprehensively investigate the problems such as non-implementation of on-site operation standards, irregular organization, non-implementation of protective measures, illegal entry and exit during operation, strengthen the on-site supervision and control of cadres, give play to the role of scientific and technological means such as remote monitoring, increase supervision and assessment, and compact safety responsibilities.
3. Strengthen the construction safety infrastructure and improve the construction safety prevention ability.
In view of the problems exposed by the accident, scientifically analyze and judge the weak links in railway safety management, and make up for the shortcomings of on-site safety management by strengthening the means of "civil air defense, physical defense and technical defense" to improve the ability of on-site safety management and control. It is necessary to strictly carry out training for construction workers and management personnel in business lines in different levels and grades, strengthen the management and training of labor and employment, establish and improve the responsibility system of "self-control, mutual control and other control" for operation safety, and strengthen the safety monitoring and control of construction operations in key time periods, key lots and key links to ensure traffic, personal and construction safety.
4. Strengthen the daily management of business line construction and improve the rules and regulations.
It is necessary to improve the construction safety management system of business lines, implement the professional management responsibility of business line construction, improve the construction safety risk prevention and pre-judgment mechanism and abnormal emergency response mechanism, analyze and judge potential risks according to different construction characteristics, formulate emergency response plans, improve emergency response and risk prevention capabilities, and ensure safety.