**After the Accident**
At 6:00 PM on January 13, 2006, Wang ** (a 38-year-old female quality inspector at Jiuquan Iron & Steel (Group) Co., Ltd.'s rolling mill factory) was present when sculptor Zhao ** came to report an issue with the ladle of the casting roll’s working layer. After molten iron was returned to the slag, severe slagging occurred. The quality of the roll was affected, and a site inspection was conducted. At this time, pouring workers from the modeling class—Xue **, Wang **, Fu **, and security **—were slagging the hot metal ladle. Wang ** stood to the east of the pouring cart, observing whether there were any slags in the ladle.
After the slagging process was completed (approximately two minutes later), Xue **, who had already prepared for the pouring, shouted to those nearby: “Everyone move to the side, and pour it.†Wang **, who was standing about 2 meters to the northwest of the ladle, moved to the south safety channel near Xue **, while Wang ** was positioned about 2 meters to the northeast of the pouring truck. At that moment, Wang ** turned around and noticed Wang ** standing on the pouring pipe that was temporarily placed on the south side of the pouring pit.
The pouring pit had eight pouring pipes arranged side by side in an east-west direction. Wang ** was standing facing west to east, on one of these pipes. Each pipe had an outer diameter of 280 mm, a height of 1.4 m, and square flanges measuring 450 x 450 mm at both ends. The upper flange of the casting pipe was 775 mm above the height of the safety protection wall surrounding the pouring pit.
At 6:15 PM, the pouring of molten iron was completed (the process took approximately 30 seconds). Xue X, An, and Wang X pushed the pouring cart along the track, and glass slag scattered from the south side of the centrifuge. At this time, Zhang **, who had just finished filling out the record at the centrifuge console, suddenly heard a scream and then a loud bang. He looked up and saw that Wang ** had disappeared. Before the pouring started, Zhang ** had seen Wang ** standing on the protective wall of the pouring pit, holding the pouring pipe.
Zhang ran over and asked Wang **, “Where is King **?†Then he went to the west side of the pouring pit and looked down, finding Wang’s head facing south on the cold-type iron sheet inside the pit. The pouring pit was 6.5 meters deep, and the cold-type structure was 3.02 meters high, with its top edge 3.5 meters above the pit. Zhang then shouted, “Hurry, someone fell into the pit!†Others rushed to help, and King **, **, and Xue ** successively descended into the pit to lift Wang ** from the cold-type area. A crane was used to pull the bucket and rescue Wang ** from the pouring pit.
At 6:30 PM, Wang Jianping was taken to Jiugang Hospital for emergency treatment but passed away at 12:30 AM on January 14th.
**Accident Category**: Falling from Height
**Direct Economic Loss**: 130,000 yuan
**Cause of the Accident**:
King ** was standing in an improper position, on a 1.4-meter-high pouring pipe, which had a small area and limited space for movement. While observing the pouring process, she accidentally slipped and fell, which was the direct cause of the accident.
**Indirect Causes**:
(1) The large-roller rolls used in the workplace lacked timely resetting of protective railings, creating hidden dangers in the operating environment. No safety warning signs such as “Beware of Falling†were present.
(2) Wang **, Zhang **, and others failed to stop King ** from standing on the pouring pipe during the operation, and did not fulfill their mutual protection responsibilities.
(3) Safety education in workshops and teams was inadequate, leading to weak safety awareness among employees. Management personnel at both levels lacked effective supervision and inspections at the work site.
**Nature of the Accident**: Liability Accident
**Accident Responsibility Division and Treatment Advice**:
(1) Wang **, as a quality inspector, violated regulations by standing on the pouring pit's protective wall, which was extremely dangerous. She was 775 mm higher than the safety wall and observed the pouring process from a narrow, unstable position. Her risky behavior led to the accident. As she died in the incident, no disciplinary action will be taken.
(2) Zou **, director of the rolling mill, failed to manage potential hazards at the site and is responsible for the accident. It is recommended that Jiuquan Iron & Steel (Group) Co., Ltd. impose administrative penalties according to internal regulations.
(3) Liu **, deputy manager, failed to supervise the factory's safety operations and bears leadership responsibility. It is suggested that an administrative warning be issued.
(4) Handan **, manager of the mechanism company, also bears some responsibility and should receive administrative warnings or other measures.
(5) Other responsible individuals will be handled accordingly.
(VI) It is recommended that the Jiashengguan Safety Production Supervision Authority impose administrative penalties on the main person in charge of the mechanism company.
**Precautions**:
(1) The JISCO (Group) Corporation mechanism company must strengthen safety production responsibility, conduct accident reflection activities across the factory, and use this case to educate all employees to enhance hazard identification and safety awareness.
(2) Standing on the safety protection wall of casting pits is strictly prohibited. In special cases, only designated safe walkways may be used.
(3) Three movable cover plates must be installed immediately to close the casting pits. When needed, the relevant cover plate must be lifted.
(4) A thorough investigation of operational site hazards must be conducted, and safety warning signs must be improved in hazardous areas to remind employees to protect themselves.
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