BHS过滤器掉落事故调查审核辩析.ppt

Proprietary - To Be Maintained in Confidence * 2012/04/20 BU5 BHS Filter Falling Incident Investigation Review BU5 BHS过滤器掉落事故调查审核 Apr. 20, 2012 2012年4月20日 Presenter:主持人： SC Wang BS Chang Reveiwer审核者 James Yim Edlyn Moy Dong Jiyang BRIEF ACCOUNT OF INCIDENT事故简述 On Mar.18, 2012: At approximately 16:50 on Mar. 18th, when TM-401 (New BU5 BHS No-Dry Rotary Pressure Filter) was under lifting above the roof of PTA centrifuge house, suddenly one crane sling was loosened from its connector, and that caused the other sling broken and the crane fly jib collapsed. Accordingly, TM-401 fell from 29m high to the 4th floor (15m high) and damaged one centrifuge which was located on the 4th floor. Fortunately, no one was injured. 2012年3月18日： 3月18日16：50左右，当TM-401（新的BU5 BHS 编号 － 干燥旋转压力过滤器）在PTA离心机房屋顶上方吊装时，突然一根吊车吊索从其连接头上松掉，造成另一根吊索断裂，吊车副臂倒塌。于是，TM-401从29米高处掉落到第四层（15米高），损坏一只位于第四层的离心机。幸运的是，无人受伤。 What Went Wrong出了什么问题 CRITICAL FACTORS:关键因素： A: One sling of 500T crane was loosened from its connector, and that caused the other sling broken and the crane fly jib collapsed. 500吨吊车的一根吊索从其连接头上松掉，造成另一根吊索断裂，吊车副臂倒塌。 B: Risk assessment of BHS filter lifting plan was insufficient. BHS过滤器吊装计划风险评估不充分。 Hazards Crane sling broken Hazard Realization BHS filter fell from 29m high to 4th floor (15m high) KHP does not have the selection process for project contractor’s subcontractor crane company. KHP project team and BU5 team only reviewed the lifting plan, but didn‘t review sling maintenance records and identify the potential risks of the old type crane made in 1982. One sling of 500Tcrane was loosened from its connector. Crane company did not purchase slings with its connector from the original maker (Gottwald). They replaced slings with connectors by a local maker on Aug.3, 2011. The quality and manufacturing process for sling connection are questionable. KHP did not assign one Lifting