Chinanews.com, July 30. Recently, the National Railway Administration website issued an announcement on the investigation and handling of railway traffic accidents on the "6.4" Lan-Xin line K596 passenger train collided with operators. The announcement pointed out suggestions for handling the accident and the personnel responsible for the accident. : 21 people were given party disciplinary sanctions, and the judicial organs have taken compulsory measures against 3 people.
The specific announcement is as follows:
1. Basic situation of the accident
1. Overview of the accident
At 5:18 on June 4, 2021, the Jinchang Workshop of the Wuwei Public Works Section of China Railway Lanzhou Bureau Group Co., Ltd. performed mechanical maintenance on the line between Yushi and Jinchang Stations on the Lanxin Line. The work was responsible for the temporary failure of the tamping stabilizer When people were organizing operators to cross the railway line, the cross-line personnel collided with the K596 passenger train, resulting in 9 deaths.
2. Overview of the accident unit
China Railway Lanzhou Bureau Group Co., Ltd. manages 16 trunk lines including Baolan High-speed Railway, Lanxin Passenger Service, Yinxi High-speed Railway, Longhai and Lanxin, and 4 other branch lines, with a business mileage of 6,052 kilometers and 41 transportation stations.
The Wuwei Public Works Depot is its subordinate transportation station section, and the section line where the accident occurred is maintained by the Jinchang Line Workshop, a subsidiary workshop of the Wuwei Public Works Depot.
3. The accident happened
According to the maintenance plan, there are two tamping and stabilizing vehicles for this maintenance operation, starting from K361+850 and K364+500 to carry out mechanical maintenance from east to west.
At 2:54 on June 4th, Zhang, deputy director of the Jinchang line workshop of the Wuwei Public Works Department, as the job leader, organized the workshop participants to hold a maintenance work preparation meeting, deployed the maintenance work organization plan and the division of labor, and a total of 5 Wuwei Public Works Department The employees and 18 laborers participated in the K361+850 mechanical maintenance operations, and Zhou was designated as the shift leader.
Because the operation area is in a curve and poor communication area, the protector responsible for the protection of the operators is adjusted to the intermediate protector, and the protector responsible for the emergency team is adjusted to the protector responsible for the protection of the operating personnel.
At 4:20 on June 4, in accordance with the registration request of the station liaison officer of the Wuwei Public Works Section, the station attendant at Yushi Station applied to the train dispatcher, and the train dispatcher issued a dispatch order to block the distance between Jinchang Station and Yushi Station from the time of the order. Down the line, the Wuwei Public Works Section is permitted to carry out mechanical maintenance work on the line at K360+000 to K368+000, and the maintenance will be completed at 7:22.
At 4:38 on June 4th, the job leader Zhang led the workers into the protective net from the operation door on the K361+900 upstream line, crossed the upstream and downstream lines, and walked along the road shoulder to the K361+850 work site.
At 4:48 on June 4, the tamping and stabilizing vehicle ran from Jade Station to K361+850 according to the operation plan.
At 5:04 on June 4, the tamping and stabilizing vehicle had an accumulator leakage failure, and the operation could not be continued.
At 5:09 on June 4th, the station liaison officer notified the on-site protection personnel that the passenger train K596 had an advance notice at Yushi Station and passed through Yushi Station at 05:10.
At 5:15 on June 4, Wang Mou, a protector at the tamping and stabilizer operation site, confirmed that he received the K596 passenger train approaching information twice.
At 5:16 on June 4th, it was confirmed that the tamping stabilizer had a fault that could not be repaired and the operation could not be continued. The job manager Zhang Mou issued instructions to the operators to transfer to the K364+500 work site, and arranged the shift leader Zhou Mou to lead 15 operators Across the upper and lower lines, go out of the protective net from the K361+900 operation gate and take a car to K364+500 to participate in the operation. The protector Wang, who originally followed the tamping stabilizer for mobile protection, is designated to be responsible for the protection of cross-line operations personnel.
Afterwards, protector Wang and shift leader Zhou led 15 operators to the 5m position (K361+820) on the road shoulder on the east side of the faulty tamping and stabilizing vehicle.
During the preparation to cross the line, the job leader Zhang urged the cross line three times.
At 5:18 on June 4th, Wang, who was responsible for the protection of workers, was still in joint control of the K596 passenger train position with the intermediate protector. When the intermediate protector did not respond, he did not issue an instruction to prohibit crossing the line and did not stop it. People cross the line.
Without confirming whether there is a train passing, Zhou, a shift leader, blindly organized cross-line personnel to cross the line.
Because the line of sight was blocked by the faulty tamping stabilizing vehicle, the cross-line personnel did not see the approaching passenger train K596 before crossing the line. During the process of crossing the upward line, they collided with the passing passenger train K596, and 9 operators died on the spot. , 3 operators have crossed through the upstream line, and the other 3 operators were blocked between the upstream and downstream lines by the shift leader Zhou.
2. Emergency response
After the accident, the assistant driver, train attendant, and police officer of the K596 passenger train immediately got off the train and inspected the scene of the accident.
The driver immediately reported to Jinchang Station and dialed 120 and 110 to request rescue and call the police.
After receiving the report, the station immediately organized public security officers from the Jinchang Station Police Station and other relevant personnel to rush to the scene of the accident to carry out rescue work for the people involved in the collision.
Confirmed by 120 medical staff, 9 people were killed and no other people were injured.
After the on-site disposal, the K596 passenger train drove between sub-zones at 6:43.
After China Railway Lanzhou Bureau Group Co., Ltd. received the accident report, the main person in charge led relevant personnel to the scene of the accident for emergency and after-care 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 form a working group to the accident site to guide Lanzhou Bureau Group Co., Ltd. to carry out emergency rescue, Aftermath handling, safety and stability, and cooperation with accident investigations, etc.
The main person in charge of the Lanzhou Railway Public Security Bureau rushed to the scene of the accident, organized and transferred 120 police officers, established 8 working groups, and devoted all their efforts to on-site maintenance, investigation and aftermath disposal.
After receiving the accident report, the Lanzhou Railway Supervision and Administration Bureau immediately activated the emergency response plan. The main person in charge led the relevant personnel to the accident site to guide the accident rescue, and set up an accident investigation team to carry out accident investigation.
The Gansu Provincial Party Committee and the Provincial Government attached great importance to it and assigned the leaders of the Provincial Government to rush to the scene to guide the Jinchang Municipal Party Committee and the Wuwei Municipal Party Committee and Municipal Government to fully cooperate with the railway department to carry out the aftermath and family reassurance and condolences.
The Emergency Management Department sent personnel to the scene of the accident to guide emergency response and accident investigation.
3. Casualties caused by the accident
The accident caused 9 deaths and no injuries.
Fourth, the cause and nature of the accident, and the determination of responsibility
1. The direct cause of the accident
During the maintenance operation, the tamping and stabilizing vehicle malfunctioned. During the process of transferring and crossing the line, the related personnel blindly commanded, the joint control was incomplete, the on-site protection was ineffective, and the crossing of the line illegally was the direct cause of the accident.
(1) The staff on the shift violated Article 54 of the Work Safety Law of the People's Republic of China, Article 5 of the Railway Safety Management Regulations, and Article 3.2 of the Railway Work Safety Management Rules (Tie Zongyun (2014) No. 272). 2 "When passing bridges, crossings, or crossing lines, you should'hand compare, see, and speak' to achieve'one stop, two see, three passes', and it is strictly forbidden to cross the line", "Lanzhou Bureau Group Corporation Public Works Department Safety Card Control Measures for Express Railways" (Gong’an Han [2020] No. 66) Article 6: "It is strictly forbidden to blindly cross the line without confirming this line or neighboring lines", Article 68: "When the operator is on the road and Before crossing the line, you should choose a place with good viewing conditions to cross the line. When leading the operator to cross the line, it is not confirmed whether there is a train passing, and the operator blindly leads the operator to cross the line in violation of regulations.
(2) On-site protection personnel violated Article 54 of the "Safety Production Law of the People's Republic of China", Article 5 of the "Railway Safety Management Regulations" and "Lanzhou Bureau Group Corporation General Speed Railway Labor Safety Card Control Measures" (Work Safety Letter (2020) No. 66) Article 24: “Protection personnel should concentrate their energy, watch carefully, correctly display and use signal equipment, accurately grasp the train operation situation, and promptly and clearly notify all the person in charge of the operation and the personnel on the shift. Provisions such as the advance notice of the trains heading to the work site, the driving time, and the supervision of the operators (machine tools) to get off the road in time to avoid the traffic", etc., were not issued after knowing that the K596 train was approaching, the joint control did not receive a response again and the safety was confirmed The instruction to prohibit cross-line did not prevent cross-line personnel from crossing the line.
(3) The person in charge of the operation violated Article 54 of the "Safety Production Law of the People's Republic of China", Article 5 of the "Railway Safety Management Regulations" and the "Measures for the Safety Management of Railway Business Line Construction" (Tieyun [2012] No. 280) Article 19: "The main responsibilities of the person in charge of construction: Responsible for the organization and command of the construction site, directing on-site construction, arranging construction protection, and confirming the conditions of the release of the train; Responsible for summarizing and analyzing the construction organization, progress and safety, etc., and responsible for the safety of the construction site ”And other regulations, there are no safety precautions for crossing the line, failing to comply with the on-site protection regulations, and blindly urging the transfer personnel to cross the line.
2. Identification of the nature of the accident and liability
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 Regulations on Investigation and Handling of Railway Traffic Accidents (Order No. 30 of the Ministry of Railways) , The accident was a major railway traffic accident, and China Railway Lanzhou Bureau Group Co., Ltd. took full responsibility.
V. Suggestions for handling the units and personnel responsible for the accident
1. The judicial authorities have taken compulsory measures (3 persons)
Three people, including Zhou, the job leader, Wang, the site protector, and Zhang, the job leader, have been approved for arrest in accordance with the law.
2. Give party disciplinary and political sanctions (21 people)
(1) The party secretary and chairman of the China Railway Lanzhou Bureau Group Co., Ltd. shall be subject to administrative penalties.
(2) The deputy secretary of the party committee and general manager of China Railway Lanzhou Bureau Group Co., Ltd. shall be subject to administrative penalties.
(3) The deputy general manager of China Railway Lanzhou Bureau Group Co., Ltd. in charge of public works has severely warned the punishment within the party.
(4) The deputy director of the Public Works Department of China Railway Lanzhou Bureau Group Co., Ltd. in charge of overall work ordered resignation and administrative sanctions.
(5) The director of the Industrial and Electrical Inspection Institute of China Railway Lanzhou Bureau Group Co., Ltd. in charge of this maintenance operation was removed from his post, and the administrative demerit penalty was imposed.
(6) The chief of the Safety and Quality Section of the Ministry of Works of China Railway Lanzhou Bureau Group Co., Ltd. was removed from his post, and administrative demerit punishment was imposed.
(7) The Deputy Section Chief of the Safety and Quality Section of the Ministry of Public Works of the China Railway Lanzhou Bureau Group Co., Ltd. in charge of labor safety and protection personnel was removed from office, and the administrative demerit penalty was imposed.
(8) The head of the line section of the Ministry of Works of the China Railway Lanzhou Bureau Group Co., Ltd. was removed from his post, terminated the probation period, and imposed administrative penalties.
(9) The deputy secretary of the Party Committee and the head of the Wuwei Construction Section of China Railway Lanzhou Bureau Group Co., Ltd. were removed from office, and the administrative demerit penalty was imposed.
(10) The Secretary of the Party Committee and Deputy Head of the Wuwei Construction Section of China Railway Lanzhou Bureau Group Co., Ltd. was removed from office, and administrative sanctions were recorded for serious demerits.
(11) The deputy head of the line maintenance in the Wuwei Public Works Section of China Railway Lanzhou Bureau Group Co., Ltd. terminated the probation period and severely warned the party.
(12) The deputy head of the labor safety and protection officer of the Wuwei Public Works Section of China Railway Lanzhou Bureau Group Co., Ltd. recorded a major administrative penalty.
(13) The Chief of the Safety Section of the Wuwei Public Works Section of China Railway Lanzhou Bureau Group Co., Ltd. was dismissed from his post.
(14) China Railway Lanzhou Bureau Group Co., Ltd. Wuwei Public Works Section Safety Section Chief Assistant Engineer has been given a major administrative penalty.
(15) Dismissal of the chief of the line section of the Wuwei Public Works Section of China Railway Lanzhou Bureau Group Co., Ltd.
(16) China Railway Lanzhou Bureau Group Co., Ltd. Wuwei Public Works Section Line Section Deputy Chief of Administrative Records has been a serious punishment.
(17) The line section of Wuwei Public Works Section of China Railway Lanzhou Bureau Group Co., Ltd. is responsible for the administrative record of a major demerit for the line maintenance engineer.
(18) Dismissal of the workshop director of Jinchang Line in Wuwei Engineering Section of China Railway Lanzhou Bureau Group Co., Ltd.
(19) The Secretary of the Party Branch of the Jinchang Line Workshop of the Wuwei Engineering Section of China Railway Lanzhou Bureau Group Co., Ltd. was dismissed from his post.
(20) The Deputy Director of the Jinchang Line Workshop in the Wuwei Public Works Section of China Railway Lanzhou Bureau Group Co., Ltd. was dismissed from his post.
(21) The deputy head of equipment in charge of the Lanzhou Industrial Machinery Section of China Railway Lanzhou Bureau Group Co., Ltd. shall be subject to administrative penalties.
3. Suggestions for handling units
Instructed China Railway Lanzhou Bureau Group Co., Ltd. to conduct an in-depth inspection of China National Railway Group Co., Ltd.
6. Problems exposed by the accident
1. The implementation of on-site operation standards is not in place.
The basic operation system of Wuwei Public Works Section is not implemented.
The first is that on-site protection personnel and personnel on shifts have weak safety awareness, incomplete implementation of operating standards, and failure to perform job duties in accordance with regulations.
The second is that the person in charge of the operation does not direct the operation according to the existing plan, and temporarily changes the plan in violation of regulations, exchanges protection and shift personnel.
The third is that the abnormal emergency response is not in place. When the tamping stabilizer breaks down, and the cross-line operation is organized, the emergency response plan and safety precautions are not formulated.
2. Inadequate management and control of on-site safety risks.
The Wuwei Public Works Section did not carry out safety risk prediction based on the actual work site.
One is that no targeted measures have been formulated for the downward line without operation gates and the need to cross the upward line.
The second is that the construction site is not in the continuous curve section, and there is the problem of restricted sight range of safety protection to formulate card control measures.
Third, there are loopholes in the construction protection plan, the joint control link is too complicated, the information transmission is lengthy, the intercom communication channel is busy, there is the leakage of key driving information, and the transmission chain is unstable.
3. Inadequate maintenance management.
The relevant departments of China Railway Lanzhou Bureau Group Co., Ltd. and the Wuwei Public Works Section have failed to implement the maintenance operation standards of the business line organized by the workshop, and the on-site management and control are not in place. The business guidance, supervision and inspection work are not in place.
The Wuwei Public Works Section did not organize safety education and training for laborers involved in the operation in accordance with regulations.
7. Suggestions on accident prevention and rectification measures
In order to draw lessons from the accident, learn from one another, and effectively prevent and resolutely curb similar accidents, the following rectification measures are proposed to China Railway Lanzhou Bureau Group Co., Ltd.:
1. Firmly establish the safety concept of safety first and life supreme
It is necessary to conscientiously implement the spirit of General Secretary Jinping’s important expositions and instructions on production safety, adhere to the people first, life first, adhere to the red line awareness, bottom line thinking, establish the concept of safe development, earnestly improve the political position, and have a deep understanding of the current railway safety work. We will implement the main responsibility for safety production, strengthen risk research and 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 learn the lessons of the accident and immediately carry out special rectification of the business line construction
It is necessary to deeply learn the lessons of the accident and immediately organize and carry out special rectification of business line construction safety, from construction organization leadership, construction plan review, construction plan preparation and approval, safety agreement signing, personnel training, etc. to the whole process of compliance and benchmarking, and comprehensively investigate on-site operations Issues such as non-implementation of standards, non-standard organization, non-implementation of protective measures, and violations of regulations during operations, strengthen on-site monitoring and control of cadres, give full play to the role of scientific and technological means such as remote monitoring, increase supervision and assessment, and consolidate safety responsibilities.
3. Strengthen the construction of safety infrastructure and improve the ability of construction safety prevention
In response to 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 "human defense, physical defense, and technical defense" to improve on-site safety management and control capabilities.
Strictly carry out training for construction operators and management personnel of business lines at different levels and levels, strengthen labor management and training, establish and improve the responsibility system of "self-control, mutual control, and other control" for work safety, and strengthen key time periods, key locations, and key links The construction work safety is monitored and controlled to ensure the safety of driving, personnel and construction.
4. Strengthen the daily management of the business line construction, improve and improve the rules and regulations
It is necessary to improve the construction safety management system of the business line, implement the professional management responsibility for the construction of the business line, improve the construction safety risk prevention and pre-judgment mechanism and the abnormal emergency response mechanism, analyze and judge potential risks according to different construction characteristics, formulate emergency response plans, and improve emergency response And risk prevention capabilities to ensure safety.