September, 2014

This is a repeating event

201422SepAll DayLANZHOU COLLAPSE 2014Lanzhou, Gansu (CN)Lessons:Competency,Compliance with Standards,Control of Work,Operating Procedures,Operational Integrity,Operational Readiness,Performance Indicators,Process Knowledge,Risk Assessment,Workforce InvolvementIndustry:MiningCountry:ChinaLanguage:ENLoC:Deterioration Origin: MKOPSC Incident:COLLAPSEHazards:Mechanical/Kinetic/PotentialContributory Factors:Component Malfunction,Organization Inadequate,Organized Procedures,Training/InstructionImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Limestone

Summary

The wall of the kiln collapsed when 3 workers were inspecting the kiln furnace

Proximate causes:
• Inadequate tools, equipment & vehicles
• Inadequate training/knowledge transfer (Lack of understanding the process of the calcination of limestone);
• Lack of work rules/policies/ standards/procedures (lack of standard procedures for inspections);
• Inadequate work rules plan (lack of the pre-start safety review before inspection).


Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: Wikipedia

Origin

MKOPSCMary Kay O'Connor Process Safety Center

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