4.28 accident, urgent!
Essential version of the 4.28 major reflection materials
Reflection materials on learning from the "4.28" accident
In order to deeply learn the lessons from the "4.28" particularly major accident on the Jiaoji Line of Jinan Bureau , a major safety inspection and major reflection activity was carried out along the entire road. This move was like a deafening alarm bell ringing in our ears.
Through the lessons of the "4.28" accident and comparing my own work reality, I deeply feel that there is still a certain gap between my current work status and the leadership requirements. In terms of foundation, management, control, etc., it has not fully kept up with the pace of railway development. In terms of ideology, style and work attitude, there is still a certain distance from the new situation and new standards. Below, based on the lessons learned from the "4.28" accident, this article Based on the principle of "deep reflection, careful investigation, and real improvement," we should seriously reflect on our work over the past year.
1. The warning from the "4.28" particularly serious accident
This accident is a typical multi-layered hidden danger, multi-faceted loss of control, and management errors. More than 70 fresh lives were lost in an instant, hundreds of disabled passengers are suffering, and railway transportation equipment was severely damaged. All this was only caused by serious omissions in the transmission of the slow speed limit order during construction. Serious lessons have warned us that the shift in safety first thinking will inevitably weaken safety awareness, weak basic safety management will allow accidents to take advantage of, and the "fault" in the safety level-by-level responsibility system will inevitably prevent the implementation of various effective measures. , It goes without saying that if all effective measures are not truly implemented and a unanimous voice cannot be reached, safe production cannot be guaranteed.
2. Compare the "4.28" accident and reflect on your own ideological understanding
The occurrence of the "4.28" particularly serious accident is by no means accidental. The accident is caused by a weak sense of responsibility and is caused by ideological It is caused by weak concepts. Through reflection, I realized that as the safety management mechanism of the new system continues to be improved and improved, the safety ideological understanding under the new situation and new tasks needs to be continuously improved. The old concepts and old safety ideological understanding have been I do not adapt to the safety management requirements under the new system. From my perspective, I still have certain deviations in my ideological concepts. First, they are satisfied with the status quo and do not learn deeply from the lessons of others. In the long-term safe and stable environment, they are mentally paralyzed. Over the past year, the workshop has been relatively stable in terms of safety, and the faults of responsible driving equipment have been eliminated throughout the year. In addition, the workload has decreased. , the safety factor is relatively high, I have developed a stable situation in a certain procedure, and I have not always rooted the idea of safety first in my heart. The idea of "not seeking merit, but seeking no faults" still remains in my mind, so I The ideological concept of "treating other people's affairs as one's own, and treating nothing as nothing but nothing" has not been truly established; secondly, the ideas of selfishness and humanism have not been eradicated, and there is not much effort in strictly solving and handling the "two violations" issue. In particular, when dealing with problems that arise among individual management cadres and work squad leaders, they avoid the most important issues and ignore the trivial matters, and their methods are not tough enough. For example, on April 17, when inspecting the reflection on the second anniversary of the "4.15" major accident at the Nancha workplace, two teams did not carry out activities in a timely manner. I only asked the deputy director and foreman of the workplace to reorganize the reflection, but did not Including in the assessment, I have the behavior of relaxing my mind. Through this big reflection, I must quickly change my ideological concepts, eliminate my paralyzing and careless thoughts, maintain a high degree of sensitivity, perform my responsibilities well, and grasp all the work. good.
3. Combined with the "4.28" accident, reflect on the ability to lead freely
Combined with the lessons of the "4.28" accident, compare your own work responsibilities with the "six in place" and " Reflecting on the "six individuals", there are still problems such as low standards and unrealistic work styles. The level-by-level responsibility system has not been fully implemented, which mainly reflects the following aspects:
First, safety is the first priority Insufficient substantive understanding.
This is the root cause of all transportation safety problems. As far as I am concerned, as the first person responsible for safety production in the workshop, I lack a substantive understanding of safety first. There is a bias. One of the manifestations is the lack of deep understanding of the connotation of safety first thought. The "first position" of focusing on safety has shifted; the "energy" of focusing on safety has been sidelined; the "standard" of focusing on safety has been relaxed; the "investment" on focusing on safety has been reduced; The "safety first education" has been neglected, resulting in frequent problems. Although the work was arranged, the measures were not specific, and the research and follow-up were not timely. Although the importance of safety was emphasized, there was an ideological problem of focusing on driving and neglecting people. Subjectively, there is dependence and the idea of dependence, that is, reliance on the deputy position. If there is a driving situation or accident time adjustment, it is not fully experienced personally. Therefore, although precautionary measures are taken in terms of safety, repeated and low-level mistakes evolve. It becomes a mistake that cannot be understood by others. With the adjustment of the layout structure, I cannot study it subjectively, just general research and general layout. In particular, the dynamics of thoughts were underestimated and the issues of personality and sexual orientation were not truly fully connected, thus causing the gourd to rise. Therefore, my ideas are not really positioned in the entire implementation process. In early March this year, when I went to the Yichun workplace to inspect the work, I found that the basic management work was poor. Many forms and books were not standardized and filled out in a confusing manner. Standing still reveals that my work style is still unrealistic, and I have not yet sunk in and truly penetrated into the scene.
It is precisely because of misplaced understanding, misplaced attention, and misplaced thinking that blind spots appear in safety management. The second manifestation is that safety ideological education is not in place. The main reason is that I ideologically believe that safety ideological education is the main task of the party and mass organizations, and I myself have not invested much energy. Although some educational methods and means were adopted during critical periods of production safety and seasonal changes, they were not highly targeted and did not really penetrate the minds and hearts of employees. The educational effect was like a castle in the air. Especially when I go to the front line to educate employees face-to-face, I often lecture on the matter, or use discipline instead of teaching, and punishment instead of teaching. As a result, there is a phenomenon of being in a hurry in terms of safety awareness and behavior. , in terms of measures and methods to ensure safety, problems have arisen that are not implemented in place.
Secondly, in terms of safety management, there are main problems such as lax management, failure to grasp key points, imperfect systems and methods, and inadequate assessment and incentives.
1． The intensity is not strong, the management is not strict, and the system is relatively weak. Overall, a lot of thought and measures have been taken, but the implementation results are not good. Especially in terms of management strength, "two violations" continue for a long time and are repeatedly banned. Repeated violations occur continuously. We cannot seize the key to control and intensify efforts to make rectifications. We often deal with the matter on a case-by-case basis and do not do much to manage the process, resulting in " "Two violations" continued one after another. Lax management is manifested in accommodating thoughts, being satisfied with past standards, thinking that some things have no consequences, and cannot treat small things as big things. We cannot treat small things as big things according to the high standards and strict requirements set by the section chief. Treating nothing as something important, and treating other people's affairs as one's own to strictly manage. The result is that if the top is relaxed, the bottom will fail, and safety hazards and problems cannot be eliminated in time. For example, on January 30 this year, train 17092 originating from the Nancha operating yard ran to Shenshu Station and braked. Through analysis, it was found that the lessons learned from others were not learned.
2． Not paying attention to the rules of exploration and not good at grasping the key points. For example, after the original station repairs were transferred to the operational workshop, I did not adjust the safety management ideas according to the changes in maintenance tasks. Instead, I followed the past methods and methods and was unable to provide regular guidance and monitoring for station repairs. To strengthen safety management, they did not fully understand the situation of weak positions, and failed to accurately study and explore the rules and deep-seated problems of safety management after the adjustment of the production layout, resulting in some inertial violations and maintenance quality problems that could not be solved. Effective control.
Third, there are dead ends in on-site inspection control.
1． The roles of management cadres and work squad leaders are effectively grasped, and many requests are made but few are checked and implemented. For example, the deputy director is required to inspect the material allocation every month, but when the leaders of the section and the monitoring team inspected, they still found that the material reserve was not in good condition, and problems such as lack of accessories and incomplete varieties were exposed again.
2． The intensity of in-depth on-site spot inspections and monitoring is not balanced enough. In daily work, we only focus on spot inspections and monitoring of the train inspection front line. We only rely on the Haolianghe Loading and Unloading Maintenance Station and the Fifth Battalion Inspection Team, the deputy director in charge and members of the safety team to monitor, so that I don’t have a comprehensive understanding of the actual situation of the remote teams and groups.
3. The documents, telegrams, notifications, etc. issued by superiors were signed and approved in a timely manner, but the inspection and implementation were not timely enough. As a result, the relevant requirements were not implemented in the team and the expected results were not achieved.
4. Reflect on management loopholes in light of the “4.28” accident
1. Safety management is stable but risky. Since the beginning of this year, we have received 203 pieces of various types of safety information, including 170 cases of double violations and missed inspections and repairs, accounting for 83.7% of the total number of information. The problems exposed show that our standards in safety management are not yet high. High, the measures are not realistic, the methods are not strong, and the work style is not strong. Every problem may bring immeasurable consequences to safety production if it coincides with it. I believe that the accident is caused by a weak sense of responsibility and a lack of maintenance. Details are caused by poor work, and the root cause is management errors. The lessons of the "4.28" accident remind us once again that safety must be implemented in execution. No matter how high the understanding is and how detailed the prediction is, it will not be implemented in action. Just talking on paper, if we do not strictly manage and strengthen the rectification of two violations and operating disciplines, then the "4.28" accident will inevitably happen again.
2． Labor safety is not taken seriously. It can be said that over the past year, Duan has always put labor safety work at the forefront of all work, and has introduced many regulations, systems and measures related to labor safety. The workshop can also increase the education and management of labor safety in accordance with Duan's requirements. and control.
However, there are big gaps in implementation. For example, the workshop clearly formulated on-site control measures for shift handover time and lunch time, but our monitoring cadres, technical guidance and work team leaders did not implement them seriously. In April alone, I For two consecutive days, we randomly inspected the on-site control and monitoring conditions of cadres working on the night shift. The guidance team and foremen were not present at the scene. Effective regulations were completely empty words for individual cadres. Judging from the labor safety information that occurred, the inspections were not implemented. We go together and return together, we do not dress according to regulations on rainy days, the foreman does not confirm the status of the derailment device, problems such as line intrusion during operation and single-post personnel dozing on duty and missing work are more prominent. In terms of station maintenance, wheel stops and electric welding are not carried out as required. Problems such as not wearing goggles while working and not being protected when working at high heights are quite prominent, and these problems all happen under our noses. Why do they happen repeatedly and continuously? I think there are three main reasons: First, there is a lack of responsibility and taking things inappropriately. , cadres are used to seeing it, and employees are used to doing it. This malignant tumor is still growing due to fluke mentality and paralysis; secondly, there is a lack of self-protection awareness. "The whip will not hurt until it hits you." They are not aware of the harm caused by their own violations; third, there is a lack of working methods of supervision, education and reminders. Every month, I participate in 4 to 5 class roll call meetings and group preview meetings, and regularly check the team foreman's log. Whether it is a class roll call meeting or a group preview meeting, individual foremans and foremen only have a clear understanding of labor safety work Limited to the study of documents and telegrams, daily reminders and supervision are not done well. I am unable to seriously put forward some requirements for personal safety according to weather changes and seasonal changes, and fail to follow the dangerous points, key points and weak points of labor safety determined by the workshop. To control, catch, and manage, this is why labor safety information continues to occur. Through this reflection, from my own perspective, I must change my work style, assume the responsibility of the first manager, seriously rectify labor discipline, deepen labor safety inspection activities, pay close attention to the implementation of safety measures and card control measures, and ensure personal safety. Safety.
3. There is a big gap in quality control. First, there is a gap in the implementation of the eight key safety issues and the "six-word" measures during the inspection. Mainly manifested in the daily work, individual employees have deficiencies in the implementation of operating standards, especially the failure to inspect the brake parts, brake piping and coupler parts in the middle of the vehicle, not rocking the pipe according to regulations, and the brake shoe is folded to the limit. Problems such as failure to replace damaged vehicles, failure to bind couplers as required, and simplified wind test procedures often occur. The phenomenon of simplified repairs and counter-repairs has not yet been eliminated. Second, there are still some shortcomings in the station repair worksite in comparison with the "Six Key Problems" requirements, such as: bicycle testing is not carried out according to regulations, and accessory repairs are not strictly controlled. Mainly because the blanking dimensions and lathe repairs do not meet the requirements of the drawings. In order to address these problems , the workshop will increase the control of on-site maintenance operations and strictly implement the "three inspections and one inspection" system to ensure that the quality of maintenance meets standards.
4. The quality of personnel is not balanced enough. First, the new standards and new requirements for 70T new cars are not fully understood, especially the ability to judge and deal with faults of some new cars is not yet proficient. Second, individual employees did not fully grasp the revised part of the regulations, and individual teams were unable to make full use of their off-duty time to organize employees to learn technical business. In particular, some older employees became tired of learning technical business, which led to poor technical and professional standards. decline. Third, some employees lack actual troubleshooting experience, especially those who dare not handle some large-scale faults and difficult faults. Through these problems, we have increased training on new technologies, new rules, new types of faults, and difficult faults in accordance with the overall requirements of the Duan Education Section, generally improved the technical and professional level of employees, and ensured that employees can adapt to the needs of real work as soon as possible.
4. Emergency response capabilities and accident investigation drills are not fully grasped. In our daily work, we always regard accident investigation and emergency fault handling as an important task. Especially in accident investigation, the team of elite and capable personnel is not enough, and high-level accident investigation experts are not widespread enough. The emergency response capabilities of employees have not yet fully reached the standard. Therefore, we will increase training in accident investigation drills and emergency fault handling capabilities. We will fully launch this work in the second quarter.
Fifth, reflect on the role of workshop cadres in light of the "4.28" accident
First, the team leader level has lax self-requirements and self-restraint. Mainly manifested in the lack of careful spot checks and checks on on-site operations. They only focus on spot checks around the vehicle. They are unable to control the seasonal characteristics, vehicle model characteristics and personnel characteristics. They also do not pay attention to spot checks on the internal parts of the vehicle. In addition, they do not pay attention to the foreman’s log. There are also phenomena of not being timely and not serious in filling in the form, and there are good-hearted and coping practices in itself.
Second, there is a lack of control and loss of control at the technical guidance level. Sometimes, when dealing with the problems discovered, they are not able to save face due to human feelings, and do not put themselves in the right position. At the same time, the night shift time, shift handover time, and noon meal time are not well controlled. Even if they go to the site for random inspections, they still fail. It's just a show for others to see, and there is no focus on strengthening the control of the internal status of the vehicle and labor safety. In particular, individual members of the technical guidance group have not completed the rationing. Since the winter transportation, 4 people have not completed the random inspection and rationing. This year we have The technical guidance group made readjustments and transferred a person who was not suitable to work in the technical guidance group to other positions. This year, we will intensify efforts to rectify the team of cadres above the work squad leader. We will never tolerate those who are incompetent, irresponsible, and dare not take responsibility.
Third, there is still a gap in the implementation of the "six in place" by workshop monitoring cadres. There is still a long way to go before the requirement of "getting into the scene" put forward by Duan Zhi to the cadres, which can be summarized as "five emphasis and five neglect". That means emphasizing train inspections and neglecting station repairs; emphasizing fleets and neglecting logistics; emphasizing long-term and heavy-duty traffic and neglecting small operations; emphasizing personal driving and neglecting equipment and materials; emphasizing spot checks of employees and neglecting the monitoring of cadres; especially after the winter transportation, Some cadres subjectively developed lax thoughts and failed to grasp the key points during on-site monitoring. For example, the workshop clearly clarifies that the handover time of on-duty cadres and monitoring cadres must be on-site monitoring, and the on-duty director must be on-site monitoring during lunch time, but there is a big gap in implementation. The on-duty director is not available for on-site monitoring, and the on-duty cadres are also busy with other tasks. Regarding work, we believe that failing to implement the standards after setting them is a dereliction of duty and responsibility. In accordance with the Duan Chang’s No. 1 Order, we have re-formulated on-site monitoring standards for cadres at all levels, re-refined the work rations, and will punish those who cannot complete the work rations conscientiously. Incorporated into the assessment of the level-by-level responsibility system, those who fail to complete realistic quantification for three consecutive months will be dealt with strictly.
6. Combined with the "4.28" accident, determine the next work measures
Combined with the "4.28" accident lessons, focus on safety reflection and inspection activities, in order to further consolidate the actual safety and stability of the workshop situation, focus on the following aspects.
1． We will do a good job in safety management and deepen the annual activities with a solid style. Focusing on the Kazakhstan Allianz [2008] No. 1 document and the workshop promotion plan, we must achieve "clear goals, assigned responsibilities to people, and orderly advancement", and regard the realization of the annual goal of deepening safety management as the starting point and foothold of our excellence work to ensure Achieve a safe year.
2． Carry out special safety activities with a serious attitude. Combined with safety reflection and inspection activities, we will intensify the investigation of potential safety hazards, and rectify the problems, hidden dangers and weak links that exist in actual safety on a regular basis, assigning people, responsibilities and quality to ensure that the problems rectified are timely. To solve the problem of cancellation, the workshop will deploy, inspect, hold accountable, and assess the special rectification work of production safety together with the safety work every month to ensure the effective advancement of the special rectification work of production safety and the safety reflection and inspection activities.
3. We must do a good job in labor safety work with a rigid attitude. Pay close attention to the implementation of rules and regulations and card control measures, focus on personal safety work "I would rather listen to the scolding than listen to the cry", and at the same time strengthen the management and guarantee, focusing on the same departure and return for train inspection, safety protection, employee clothing, and work walking , alcohol testing system, pre-shift breaks, daily education, single-post work, study and implementation of text notifications, etc. are strictly controlled, and key controls are placed on station repair and drop-off operations, electrical welding operations, safety protection, and high-stepping operations, etc. Strengthen motor vehicle management and education, reminders, and supervision of car drivers to ensure traffic safety and consolidate personal safety and stability.
4. We will carry out eight security research activities with firm conviction. To promote the effective implementation of standardized operations, we will carry out eight safety research activities throughout the entire year, highlight the seasons, seize key points, and comprehensively tackle key problems, and combine safety research activities with the implementation of standardized operations, the implementation of "six-character" measures, vehicle Troubleshooting is organically combined and advanced simultaneously to ensure that train quality reaches standards and achieve key research goals.
5. Effective means should be used to provide technical and business training. To comprehensively improve the technical and professional quality of cadres and workers, on the basis of daily training, focus on skills training from four aspects. The first is to hold a new technology and new standard job information meeting and the "Four Rules" lottery competition; the second is to hold an accident simulation drill every month; the third is to hold a rapid repair technology demonstration competition; the fourth is to regularly hold physical fault observations training. On this basis, in order to encourage employees to be enthusiastic about learning technical business, we will increase rewards and assessments, and truly implement into actions the difference between learning and not learning, and the difference between practicing and not practicing.
6. Grasp the role of cadres with a pragmatic style. Pay close attention to the implementation of the level-by-level responsibility system, combined with the "six in place" proposed by Duan Chang Zhi and the Duan Chang's No. 1 Order, we will adopt four methods to encourage cadres at all levels to play their roles.
First, we rely on the implementation of the "six in place" to measure whether cadres have truly penetrated into the scene, whether they really play a role, and whether they can truly discover or solve problems. We will measure the implementation of the "six in place" It should be used as an important basis for the assessment of cadres’ level-by-level responsibility system.
The second is to rely on Duan Chang’s No. 1 Order and the realistic quality of work to measure whether cadres have truly sunk to the bottom and penetrated into the scene. We will combine Duan Chang’s No. 1 Order with the spring melt season and the adjustment of the train operation chart. , re-formulate realistic rations for the work of cadres at all levels to ensure that each cadre can play his role on the spot, be invested in the scene, and solve problems on the spot. No centralized meetings will be organized in the workshop unless there are special circumstances, and cadres will not be allowed to ask for leave without special circumstances. Cadres are not allowed to remotely control production in the office, and cadres who cannot complete quantitative and realistic work in a balanced manner will be included in the assessment of the level-by-level responsibility system.
The third is to rely on the implementation of standards to measure the daily performance and behavior of cadres.
This year we will carry out three competition evaluation activities, namely: monthly cadre role analysis and evaluation, safety competition evaluation among various workplaces, and workplace team safety competition evaluation. Each evaluation activity will be uniformly evaluated by the workshop safety leadership group to ensure that Cadres and workplace cadres all participate in the activities, receive the same rewards and punishments, and make public announcements regularly. The purpose is to allow each manager to not only clarify his or her responsibilities, but also to personally participate and organize, and truly put down his or her airs and take action. shoulder the responsibility, do their respective jobs well, do it solidly, and achieve results.
Through this major safety reflection and inspection activity, we firmly believe that under the correct leadership of the section and section party committees, and with the help and guidance of organizations at all levels in the section, we have the courage to face the problems and better We are determined to solve and rectify existing problems, and "be prepared for danger in times of peace and recognize hidden dangers." In the future work, we will better give full play to our own advantages, form joint forces, overcome difficulties, ensure safety, and contribute to the harmonious development of Harbin vehicles. Make unremitting efforts.
Information source: China Railway No. 1 Forum - China Railway Forum