The relevant person in charge of the accident investigation team of the State Council answered reporters' questions on the investigation of major fire accidents in Beijing Changfeng Hospital

Beijing, 10 Oct (Xinhua) -- A few days ago, the executive meeting of the State Council examined and approved the investigation report on the "25 April" major fire accident at Beijing Fengtai Changfeng Hospital. The reporter interviewed the relevant person in charge of the accident investigation team on the hot issues of social concern in the investigation of the accident.

Reporter: How is the State Council accident investigation team formed? What is the process of the investigation?

A: After the accident, the CPC Central Committee and the State Council attached great importance to it. On April 4, the Beijing Municipal People's Government set up an accident investigation team to carry out the investigation, and the State Council Safety Committee supervised the investigation and handling of the accident. In view of the serious nature and bad impact of the accident, in accordance with relevant laws and regulations, with the approval of the State Council, the "21.4" fire accident investigation team of Beijing Fengtai Changfeng Hospital of the State Council, led by the Ministry of Emergency Management and attended by the Ministry of Public Security, the Ministry of Housing and Urban-Rural Development, the National Health Commission, the State Fire Rescue Bureau, the All-China Federation of Trade Unions and the Beijing Municipal People's Government, was established to investigate the accident on the basis of the preliminary work of Beijing.

The accident investigation team conscientiously implemented the spirit of General Secretary Xi Jinping's important instructions and the decision-making and deployment of the Party Central Committee and the State Council, and in accordance with the principles of scientific rigor, compliance with laws and regulations, seeking truth from facts and attaching importance to practical results, through on-site inspection, investigation and evidence collection, video analysis, testing and identification, simulation experiments, expert demonstration, etc., found out the accident history, causes, casualties, direct economic losses and relevant units, identified the problems and responsibilities existing in local party committees and governments, relevant departments and units, and summarized and analyzed the main lessons of the accident. Suggestions for rectification and preventive measures were proposed.

The investigation determined that this was a major production safety liability accident caused by the illegal implementation of renovation projects by the hospital where the incident occurred, poor construction safety management, chaotic daily management, long-term existence of fire hazards, illegal operation of construction units, lack of on-site safety management, coupled with ineffective emergency handling, and non-implementation of the responsibilities of the local party committee government and relevant departments.

Reporter: What is the main cause of the accident? Why are there so many casualties?

Answer: Through video analysis, on-site inspection, detection and identification and simulation experiment analysis, the accident investigation team determined that the direct cause of the accident was the construction site of Beijing Changfeng Hospital Renovation Project, and the construction unit carried out self-leveling ground construction and door frame installation and cutting cross operations in violation of regulations, the flammable and explosive components in the epoxy resin primer material volatilized and formed an explosive gas mixture, and the spark generated by the angle grinder cutting the metal purification plate was deflagged; The ignition of combustible materials near the site, the open flame and high-temperature smoke generated ignited the wooden decoration materials in the building, some fire separation did not play a role, and the fixed fire fighting facilities failed, resulting in the expansion of the fire and the spread of a large amount of smoke; In addition, the initial treatment was ineffective, and the evacuation and transfer of patients on high-floor floors could not be effectively organized, resulting in major casualties.

The accident investigation team analyzed the causes of the fire, the spread of the fire, and the causes of casualties one by one. In terms of the cause of the fire, at the construction site of the ICU renovation project on the third floor of the south annex building of Beijing Changfeng Hospital, the operators carried out self-leveling ground construction and the installation and cutting of the purification door frame, and crossed operations in violation of regulations; The flammable and explosive components in the epoxy resin primer material applied by self-leveling ground construction volatilize, coupled with the fact that the site is not effectively ventilated, forming an explosive gas mixture, and the concentration reaches the lower explosion limit; The spark generated by the angle grinder cutting the metal purification plate causes deflagration in the case of an explosive gas mixture and ignites the combustible material stacked under the ramp outside the northwest gate. In terms of the cause of the spread of the fire, after the deflagration occurred, the operator did not extinguish all the many fire points formed at the scene and did not call the police at the first time, and the hospital staff did not call the police as soon as they discovered the fire, did not effectively organize the initial fire fighting, fixed fire fighting facilities failed, the automatic sprinkler system and the fire hydrant system pipe network had no water, and failed to effectively control the fire; The ramp and hospital passage walls are made of wooden decoration materials, and the construction area and non-construction area are not separated by non-combustible materials in accordance with regulations, resulting in the spread of open flames into the main building of the East Building; Some pipeline shafts are not fireproof plugged and no fire doors are installed, some stairwell fire door closers are damaged and cannot be closed normally, the normally closed fire door of the stairwell on the east side of the fifth floor of the north passage is not kept closed, and the gypsum board partition wall above the fire door of the stairwell on the west side of the sixth floor of the south passage is burned through, resulting in the spread of smoke. In terms of the causes of casualties, the failure to timely evacuate and inhale smoke containing carbon monoxide are the main reasons for a large number of casualties. The hospital where the fire occurred in the early stage of the fire did not activate the emergency plan, and did not effectively organize the evacuation and transfer of trapped people; The ward setting is unreasonable, and the hospital where the incident occurred concentrated patients who could not take care of themselves or had limited mobility on the seventh and eighth floors, and most of the patients did not have the ability to escape independently; It is difficult for critically ill patients to move, the passage in the building is narrow, the transfer conditions are poor, and it is difficult to rescue and transfer.

Reporter: What violations of laws and regulations did the hospitals and relevant units involved have?

A: The investigation found that the hospital and construction unit involved had many violations of laws and regulations.

There are mainly the following aspects: First, the main responsibility of the hospital is seriously not implemented. Changfeng Hospital Company violated the regulations on the management of medical institutions, failed to register the number of beds as required, and the ratio of medical care did not comply with the regulations. The width of the public walkway of the inpatient department is 1.4 meters, which is significantly less than the minimum 2.1 meters required by the specification; the statutory obligations of building construction and the safety management duties of the construction site have not been fulfilled, and the 2017 renovation and renovation construction projects carried out since 38 have not applied for construction permits from relevant departments or applied to streets and townships for construction registration procedures in accordance with regulations, and illegal fire and cross-operation at the ICU renovation project site have not been discovered and stopped; Failure to perform the main responsibility of fire safety in accordance with regulations, failure to meet the defined standards but failure to declare key units of fire safety, failure to regularly organize maintenance of fire fighting facilities and equipment, automatic fire alarm system, automatic sprinkler system, and indoor fire hydrant system are not kept intact and effective. The second is the illegal cross-operation of the construction unit. Zhongyuan Xincheng Company lacked safety management at the construction site, and the operators used angle grinders to carry out cutting operations without going through the fire approval procedures for open flame operations in violation of regulations, without supervision on site, and without cleaning up the combustible materials on site; Failure to formulate fire safety measures for flammable and explosive materials, and illegal seasoning in the workplace; Epoxy resin self-leveling floor construction and purification door installation cross operation; Failure to maintain the qualification and licensing conditions for construction enterprises, and failure to establish a safety production management organization and allocate full-time safety production management personnel in accordance with regulations.

Reporter: What problems exist in the local party committee government and relevant departments in this accident?

A: The accident investigation team identified problems in the implementation of the responsibilities of local party committees and governments and relevant departments.

First, local party committees and governments have a weak awareness of preventing and resolving major risks. Fengtai District of Beijing Municipality did not conscientiously perform the responsibility of territorial management of safe production, did not pay enough attention to the capacity building of grassroots safety supervision in streets and townships, ranked first from the bottom in the city's safety production and fire protection work assessment in 2022, did not effectively organize and carry out special inspections of fire safety at construction sites, and did not report accident information in a timely manner, and reported casualties slowly. Beijing's concept of safety development is not firm enough, and the relevant departments have not seriously implemented the responsibility of safe production and fire safety management in key places such as local medical institutions and construction sites, and have not effectively urged and guided the Fengtai District Party Committee and District Government to strictly implement the responsibility of local safety production management. Second, the shortcomings of administrative approval and safety management of medical and health institutions are obvious. The Fengtai District Health Commission did not strictly perform the verification and management duties of medical institutions, did not supervise Beijing Changfeng Hospital for a long time in accordance with the regulations to apply for the registration of the change of the number of beds, staffing did not meet the requirements, etc., failed to perform the industry supervision and management duties of Beijing Changfeng Hospital ICU renovation project without construction permit, did not check and found hidden dangers of fire protection problems in the project, and did not report the accident casualties information to the Fengtai District Party Committee, District Government and District Emergency Response Office through official channels. The Beijing Municipal Health Commission did not conscientiously perform its safety supervision duties of "managing the industry must manage safety", and neglected to monitor and control the Fengtai District Health Commission's ineffective performance of industry safety supervision duties; The guidance and implementation of the group inspection of the fire safety group of Beijing medical institutions and the special inspection requirements for fire safety at construction sites of construction projects are ineffective, and the rectification of hidden dangers is not effectively promoted. Third, there are loopholes in the safety supervision and management of construction projects. The Fengtai District Housing and Urban-Rural Development Committee did not conscientiously perform its duties of industry safety supervision, and did not supervise construction projects that did not have a construction permit; Failure to provide effective business guidance and service cooperation for construction projects below the limit transferred to sub-district and township management; The failure to obtain a construction permit for the ICU renovation project of Beijing Changfeng Hospital above the quota shall not be investigated and dealt with in accordance with laws and regulations. The Beijing Municipal Housing and Urban-Rural Development Commission is ineffective in implementing the special inspection requirements for fire safety at construction sites; The qualification of construction enterprises was not dynamically supervised as required, and the construction unit was not monitored and managed to maintain the conditions for secondary qualification and licensing in the construction industry. Fourth, the fire safety risk prevention and control network is not strict. The local fire department did not seriously perform its fire supervision and management duties, and the daily fire supervision and inspection and special rectification of fire safety were not solid. When the Fengtai District Fire Rescue Detachment (formerly the Fengtai District Public Security Fire Detachment) carried out fire control acceptance of the internal decoration project of the east building of Beijing Changfeng Hospital in 2012, it issued an acceptance assessment conclusion in violation of regulations without checking the integrity of pipeline shaft plugging, failing to evaluate the fire prevention of the internal decoration of the building, and without using a special power supply circuit for fire fighting electrical equipment; For a long time, Beijing Changfeng Hospital has not been identified as a key unit of fire safety. The guidance of the Beijing Municipal Fire Rescue Corps to implement the group inspection of the fire safety group of Beijing medical institutions and the special inspection of fire safety at the construction site of construction projects was ineffective, and the rectification of hidden dangers was not effectively promoted. In addition, the accident investigation team of the State Council also found that the Fengtai Branch of the Beijing Municipal Commission of Planning and Natural Resources did not conscientiously perform its duties to stop and investigate illegal construction, and failed to timely discover and investigate the illegal acts of some buildings of Beijing Changfeng Hospital without applying for construction project planning permits; The Fengtai District Emergency Response Office officially reported 4 hours and 24 minutes after receiving the accident information for the first time, violating the relevant regulations of Beijing on emergency duty work.

Reporter: What profound lessons have been exposed by this accident?

A: The lessons of this accident are very profound, and it has exposed many outstanding problems and obvious shortcomings in local fire safety.

First, the awareness of preventing and resolving major risks is weak. Some leading cadres have insufficient understanding of the major risks existing in their own areas, fail to discover and effectively prevent and control major risks in a timely manner, do not take the lessons of others as their own lessons, and do not pay enough attention to the problems of illegal fire or electric welding operations exposed by related serious and extraordinarily serious fire accidents. The fundamental reason for these problems lies in the fact that the study and implementation of General Secretary Xi Jinping's important expositions on preventing and resolving major risks are not serious and profound, and there is no serious study and investigation of hidden risks in the region in light of actual conditions. Second, the administrative approval and safety management of the medical and health industry are not strict. Since 1998, the health department of Fengtai District has verified the hospital 18 times, and the number of beds has doubled but the registration has not been changed, and the ratio of medical care does not meet the requirements, etc., the results of each verification are qualified; Emphasis was placed on safety work, but the safety production section was actually abolished; Fire safety inspections of medical and health institutions were not carried out regularly, and major problems found in the fire inspection of the hospital in the past three years were not supervised and rectified. Third, there are shortcomings in construction project planning and construction safety supervision. The Beijing Municipal Housing and Urban-Rural Development Department has neglected to supervise the maintenance of qualification conditions of construction enterprises, and the dynamic investigation and clean-up of enterprises that do not meet the conditions lags behind. Beijing Municipality has set its own "limits" for the construction management of construction projects, failing to actively supervise and manage construction projects above the quota that have not applied for construction permits, and excluding construction projects that do not meet the conditions for applying for construction permits from the scope of supervision, "only legal, regardless of illegality"; The safety management of construction projects below the quota is lax, and the training, guidance, coordination and supervision of the territory are not kept up, resulting in the grassroots being unable to catch up and not managing well. The urban and rural planning department of Beijing Municipality has not performed its duties to stop and investigate illegal construction in place, failed to effectively guide the local government and its relevant departments in the investigation and handling of illegal construction, and cannot detect or control the conduct of new construction and expansion without planning procedures in its jurisdiction. Fourth, fire control supervision and inspection and special rectification are not deep. The local fire department did not seriously perform its fire safety supervision duties, and in 3, the hospital had met the definition standards of key fire safety units, and it was only in 2009 that it was identified as a key unit for supervision; After being identified as a key unit, the quality and efficiency of fire supervision and inspection are still not high, and hidden dangers such as fire protection facilities and fire power supply are not discovered and urged to be rectified in a timely manner. In the special inspection of fire safety at the construction site of construction projects deployed by the city, the Beijing Municipal Fire Rescue Corps failed to effectively guide the Fengtai District Fire Rescue Detachment to strictly implement the fire supervision and inspection duties. Fifth, the initial emergency response capacity is insufficient. In this accident, the self-leveling floor and purification engineering operators were all temporary employees, who went to work directly without any construction disclosure and safety education and training, and the illegal cross-operation caused a fire, and the operators did not call the police as soon as possible. Hospital duty personnel, management personnel and medical staff did not call the police as soon as the fire was discovered, and the hospital did not effectively organize initial fire fighting and personnel evacuation. At the same time, the accident also exposed the problems of some government departments and units such as the reporting of accident information, especially the untimely and irregular reporting of casualty information.

Reporter: The nature of this accident is serious and the impact is bad, in order to further learn lessons and prevent such accidents from happening again, what are the suggestions for rectification and preventive measures?

A: In order to profoundly learn the lessons of the accident, draw inferences from one example, and resolutely prevent and curb the occurrence of serious and extraordinarily serious accidents, the accident investigation team put forward suggestions for rectification and preventive measures in five aspects:

First, earnestly shoulder the political responsibility of preventing and defusing major risks. Leading cadres at all levels should combine the study and implementation of Xi Jinping's Thought on Socialism with Chinese Characteristics for a New Era theme education, comprehensively and deeply study and understand General Secretary Xi Jinping's important expositions on safe production, adhere to the supremacy of the people and the supremacy of life, firmly establish the concept of safe development, and further enhance the political, ideological and action consciousness of preventing and resolving major risks. All regions, departments, and units should effectively improve the quality of investigation and rectification of hidden risks, effectively improve the strong willingness and ability level to discover and solve problems, further tighten and compact the main responsibility of enterprises, department supervision responsibilities, and local leaders, establish a long-term mechanism for security risk prevention, and resolutely guard the bottom line of safety red lines. The second is to focus on making up for the shortcomings of safety management in medical and health institutions. Health departments at all levels should strengthen the safety management of the medical and health industry, urge all types of medical and health institutions to strictly implement the regulations on safe production and fire safety management, strengthen the hierarchical management and control of safety risks and the investigation and management of hidden dangers, and organize and carry out special investigation and rectification of safe production and fire safety in medical and health institutions. Strictly enforce the registration verification and administrative examination and approval of medical and health institutions, organize and carry out verification of the lawful practice of medical and healthcare institutions, strictly investigate acts such as failing to make truthful declarations, practicing beyond the scope of permits, and carrying out integrated medical and nursing care services in violation of regulations. Supervise and urge medical and health institutions to give overall consideration to the prevention and treatment of hospital infection and the emergency evacuation and transfer of patients, and guide all types of medical and health institutions to formulate special fire extinguishing plans and emergency evacuation plans. The third is to resolutely plug the loopholes in the safety supervision and management of construction projects. Housing and urban-rural construction departments at all levels should increase the dynamic supervision after qualification approval, strictly manage construction permits for construction projects, strengthen the safety management of construction sites, especially construction hot operations, and promptly discover and eliminate hidden dangers of accidents. Urban and rural planning and other departments should increase the intensity of inspection and disposal of illegal construction, and implement "zero tolerance" for new illegal construction. The fourth is to comprehensively weave a dense fire safety risk prevention and control network. All regions should further consolidate the fire safety management responsibilities of industry departments in accordance with the requirements of "three pipes and three musts", and implement standardized management of industry fire safety; Clarify regulatory responsibilities in a timely manner for cross-functional functions and new business formats and new risks. Promote the construction of emergency stations and fire stations in streets and townships, give play to the prevention and mass management forces of public security police stations, communities, grids, and other groups, and effectively strengthen the fire safety management of small places and small units. Fire departments at all levels should strictly perform their duties of fire supervision and management, promote the transformation of public fire safety governance mode to pre-prevention, and effectively improve the quality and efficiency of fire supervision and inspection. Fifth, accelerate the improvement of grassroots front-line emergency response capabilities and levels. All regions should further strengthen the organization, guidance, supervision and inspection of emergency preparedness such as emergency plans, drills, and training of all kinds of enterprises and institutions. Strengthen safety education and emergency training for front-line workers at the grassroots level, carry out in-depth practical training and emergency drills, and ensure familiarity with the on-site disposal plan of the workplace. Strengthen the construction of emergency response culture, strengthen the popularization of emergency science, effectively enhance the public's awareness of safety, and ensure that everyone pays attention to safety and everyone will respond to emergencies.