Shandong State Administration of Work Safety Approves “3.11” Urea Tower Explosion Investigation Nanhuan Machinery Factory Allegedly Has Direct Responsibility for the Explosion Accident

On June 16, a reporter learned that the Shandong Provincial Safety Supervision Bureau officially approved the investigation report on the "3.11" urea synthesis tower explosion at Pingyin Luxi Chemical Third Fertilizer Factory Co., Ltd., conducted by the Jinan Municipal Government. The report concluded that Nanhua Chemical Machinery Factory bore direct responsibility for the incident. The accident investigation team, formed by the Jinan Municipal Government, determined that the "3.21" explosion was caused by a lack of awareness regarding the severe consequences of a steam leak in the urea synthesis tower at Sinopec Nanjing Chemical Industry Company’s chemical machinery plant. The improper installation and use of a new leak detection hole design allowed steam to enter the laminate plates, leading to more severe outcomes compared to the traditional welded leak detection method. Additionally, there was insufficient communication with users about the risks, resulting in steam leakage between the plates and causing severe stress corrosion, ultimately leading to a major liability accident. The explosion occurred at 21:20 on March 21, 2005, at Pingyin Luxi Chemical Third Fertilizer Factory. It resulted in four deaths, 32 injuries, and approximately 7.8 million yuan in direct economic losses, sparking widespread concern across the fertilizer industry. On March 22, the Jinan Municipal People's Government established an investigation team led by the Jinan City Safety Supervision Bureau, along with representatives from the Quality Supervision Bureau, the Supervision Bureau, the General Trade Union, the Public Security Bureau, and the Pingyin County government. Experts from the Shandong Antai Chemical Pressure Vessel Inspection Center, Jinan Petrochemical Design Institute, and Mingshui Chemical Fertilizer Plant were also invited to participate. The team visited Nanhua Chemical Machinery Factory and the Jiangsu Boiler and Pressure Vessel Safety Testing Center twice to investigate the design, manufacturing, and after-sales service of the R-1102 urea synthesis tower involved in the explosion. In late December 2005, the team submitted a special report to the General Administration of Quality Supervision, Inspection and Quarantine of the People’s Republic of China regarding the investigation, evidence collection, and classification of the incident. According to the report, the accident was caused by the connection of the leak detection pipe to the 16MnR ply plate using a threaded method. During operation, the pipe became loosely sealed or loosened, allowing steam to leak between the tower plates. Alkali ions like sodium concentrated in the leaked steam, causing severe stress corrosion cracking. This led to extensive cracks in the urea tower before the explosion, resulting in a massive release of medium and subsequent explosion. At the time of delivery, the R-1102 urea synthesis tower from Nanhua Chemical Machinery Factory had no looseness in its leak detection hole structure during transportation, installation, or use. However, the company failed to inform the user of the potential dangers, contributing to the accident. As a result, the explosion, which caused significant casualties and property damage, was deemed a quality-related (including manufacturing and service) liability incident. Nanhua Chemical Machinery Factory was directly responsible for the explosion. The former plant manager, now the party secretary, Liu Jinbao, shared leadership responsibility. The chief engineer, Chen Jianjun, altered the structural design of the steam leak detection hole without informing the user due to confidentiality concerns, making him directly responsible for the incident. It is worth noting that similar urea synthesis tower explosions had occurred in the past, but no formal investigation reports had been released. The determination of responsibility for this incident sparked considerable debate within the industry.

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