兖矿集团有限公司杨村煤矿

兖矿集团有限公司杨村煤矿 兖矿集团有限公司杨村煤矿“4.23”北风井变电所触电事故调查分析报告 2008年4月23日10时10分，杨村煤矿机电工区在北风井变电所供电系统改造施工时，因职工违章打开并误入规程措施规定严禁打开的开关柜，造成1人触电死亡。 死者概况:孙厚忠，1963年4月18日出生，1982年7月参加工作，杨村煤矿机电工区矿井维修电工，电气维修班班长，高级技师，两届集团公司优秀技能人才。 为及时查明事故原因，深刻吸取事故教训，集团公司成立由安监局、机电部等部门有关人员组成的事故调查组，对事故进行调查分析。经过现场勘查、取证，询问有关人员，查阅核实有关技术、管理资料，查明了事故的经过、性质及原因，认定该事故为责任事故。 一、项目概况及实施过程 杨村煤矿南、北风井变电所是保障矿井通风系统安全的要害场所，是矿井“四大运转”系统之一，属一级负荷变电所。两变电所原高压开关柜为GG1-A型开关，均由济宁开关厂生产，南风井变电所配置7台，为95年3月产品;北风井变电所配置6台，为90年9月产品。因开关柜使用年限较长，部分元器件老化，且少油断路器为淘汰产品，不能满足安全运行要求，并已达到报废年限。 为确保通风系统安全，矿于2006年底决定更换上述设备，拟选用low rotor, until rotor of weight by steam end sliding block and Reed end rotor Bay support, in put low rotor of while should in Reed end rotor Bay at added pad sleeper, due to stator has preliminary adjustment finished, so stator within bore exists must Yang degrees, so should note adjustment makes rotor keep and stator within bore concentric, makes rotor not and coil contact. Panasonic lane hook, remove wire rope hoist, wrapped at the rotor excitation-side shoulder arc washer, and move the lifting wire rope to protect mat. Two 5T chain hoist end beam connections and welded to the rotor carriers, length adjusted for field conditions, and at the other end of the stator lifting hook or end cap end lugs connected, as shown in Figure 11.4.3-1. With Lane slightly single head upgrade rotor Reed end, keep rotor level, demolition rotor Bay or support sleepers, then slowly synchronization pull two only chain gourd, makes rotor in steam end sliding block of support Xia along arc skateboard to steam end sliding, this process in the, lane must and rotor of sliding keep synchronization, in rotor of steam end and Reed end are due hand guardianship rotor and stator Zhijian of clearance. Dang by steam end side has nursing ring protection of coil end Department into stator within bore Hou, slightly upgrade rotor Reed end, in rotor ontology following loaded into Central sliding block, its loaded into Hou must very carefully to along axis to for find are, and note observation rotor coupling in wear loaded process in the whether turned, as has should stop wear loaded, needed on Central sliding block location again for find are, while should note in Central sliding block placed yihou only allows steam end sliding block beyond stator within bore, and in Central sliding block and steam end rotor nursing ring Zhijian at least should keep must of distance ( 300MW 76mm, 1000MW is 50mm). When the steam side slider close to steam at the end of the stator bore 与原设备性能基本相同的新型GG1-A型开关13台，询价每台3.5万元， 计划 项目进度计划表范例计划下载计划下载计划下载课程教学计划下载 资金45.5万元，经公司审查批准列入2007年维简计划。 在公司下达正式计划后，杨村煤矿在没有进行正规设计并改变原变电所位置，利用北风井低压配电室闲置空间作为新建6KV变电所的情况下，于2007年6月2日组织设备购置选型技术论证，所选开关柜为新GG1-A型产品。因该产品为内部保护A类产品，故直接选用公司内部东方机电公司为供货厂家。双方商定于2007年7月在杨村煤矿签订技术协议书，由杨村煤矿提供了原变电所供电系统草图。在技术洽谈期间，经双方到拟改造的北风井低压配电室现场测量，因空间尺寸不能满足原 方案 气瓶 现场处置方案 .pdf气瓶 现场处置方案 .doc见习基地管理方案.doc关于群访事件的化解方案建筑工地扬尘治理专项方案下载 要求，由杨村煤矿在东方机电公司所推荐的几种开关柜型中，综合考虑安装空间和计划资金，选定了与原计划型号不同的井下用ZBK1-GG矿用一般型开关柜，并调整为南风井6台，北风井5台，配置数量比原设计各减少1台。2007年9月19日，由东方机电公司依据双方商定意见，绘制了高压开关系统图，经矿签字确认，并签订技术协议书。东方机电公司依据技术协议书，进行开关柜产品二次接线图设计，并于10月16日经矿签字确认。2007年10月23日，物资部和东方机电公司按规定程序签订了《产品买卖合同》。 2008年2月，东方机电公司按产品规格要求进行检验后，送货到矿。杨村煤矿供应科组织机电科、计划科、机电工区进行到货验收。未办理验收手续(为报计划完成，于2007年12月提交出库验收单)。 杨村煤矿将南北风井开关柜更换作为一项工程，列入矿3月份井下辅助(单项)工程作业计划表，计划3月8日-22日施工，以《杨村煤low rotor, until rotor of weight by steam end sliding block and Reed end rotor Bay support, in put low rotor of while should in Reed end rotor Bay at added pad sleeper, due to stator has preliminary adjustment finished, so stator within bore exists must Yang degrees, so should note adjustment makes rotor keep and stator within bore concentric, makes rotor not and coil contact. Panasonic lane hook, remove wire rope hoist, wrapped at the rotor excitation-side shoulder arc washer, and move the lifting wire rope to protect mat. Two 5T chain hoist end beam connections and welded to the rotor carriers, length adjusted for field conditions, and at the other end of the stator lifting hook or end cap end lugs connected, as shown in Figure 11.4.3-1. With Lane slightly single head upgrade rotor Reed end, keep rotor level, demolition rotor Bay or support sleepers, then slowly synchronization pull two only chain gourd, makes rotor in steam end sliding block of support Xia along arc skateboard to steam end sliding, this process in the, lane must and rotor of sliding keep synchronization, in rotor of steam end and Reed end are due hand guardianship rotor and stator Zhijian of clearance. Dang by steam end side has nursing ring protection of coil end Department into stator within bore Hou, slightly upgrade rotor Reed end, in rotor ontology following loaded into Central sliding block, its loaded into Hou must very carefully to along axis to for find are, and note observation rotor coupling in wear loaded process in the whether turned, as has should stop wear loaded, needed on Central sliding block location again for find are, while should note in Central sliding block placed yihou only allows steam end sliding block beyond stator within bore, and in Central sliding block and steam end rotor nursing ring Zhijian at least should keep must of distance ( 300MW 76mm, 1000MW is 50mm). When the steam side slider close to steam at the end of the stator bore 矿2月份工作总结和3月份工作安排》附表形式印发矿属各单位。项目由机电工区负责施工，机电科负责安装过程中质量监督、把关。南风井变电所改造于3月30日完成。因原计划拖后，故将原定3月份完成的北风井变电所改造计划顺延至4月份，并作为重点检修项目列入4月份矿井月度停产检修计划，计划2008年4月26-27日施工，并正式上报机电部。 在实际工作安排中，北风井开关柜更换自4月15日开始施工，17日5台开关柜就位。布置方式为:自南向北按1#-5#的顺序单面排列，其中，1#、2#柜为II回路，4#、5#柜为I回路，3#柜为联络柜。22日11时进行II回路由老系统切换接入新系统，并投入运行。23日上午进行I回路安装切换工作，作业期间北风井为单回路供电。施工计划比上报的重点检修项目计划时间提前，并未按变更规定上报。 二、事故经过 在22日完成II回路供电切换后，4月23日大班，机电工区区长赵广党主持召开班前会，安排班长孙厚忠等5人进行北风井变电所I回路的系统切换工作，并强调认真执行停送电制度，落实好“两票三制”规定，严格按安全技术措施和本工种操作规程施工。按照措施规定，机电工区副区长赵民为项目负责人，孙厚忠为现场安全监护人，副班长李良恒为现场施工负责人，机电科负责现场业务指导并进行电气试验，作业时间为大班。 在23日实际施工过程中，机电工区区长赵广党安排该项目负责人、副区长赵民下井跟班，由赵广党临时代替赵民到北风井变电所施工现low rotor, until rotor of weight by steam end sliding block and Reed end rotor Bay support, in put low rotor of while should in Reed end rotor Bay at added pad sleeper, due to stator has preliminary adjustment finished, so stator within bore exists must Yang degrees, so should note adjustment makes rotor keep and stator within bore concentric, makes rotor not and coil contact. Panasonic lane hook, remove wire rope hoist, wrapped at the rotor excitation-side shoulder arc washer, and move the lifting wire rope to protect mat. Two 5T chain hoist end beam connections and welded to the rotor carriers, length adjusted for field conditions, and at the other end of the stator lifting hook or end cap end lugs connected, as shown in Figure 11.4.3-1. With Lane slightly single head upgrade rotor Reed end, keep rotor level, demolition rotor Bay or support sleepers, then slowly synchronization pull two only chain gourd, makes rotor in steam end sliding block of support Xia along arc skateboard to steam end sliding, this process in the, lane must and rotor of sliding keep synchronization, in rotor of steam end and Reed end are due hand guardianship rotor and stator Zhijian of clearance. Dang by steam end side has nursing ring protection of coil end Department into stator within bore Hou, slightly upgrade rotor Reed end, in rotor ontology following loaded into Central sliding block, its loaded into Hou must very carefully to along axis to for find are, and note observation rotor coupling in wear loaded process in the whether turned, as has should stop wear loaded, needed on Central sliding block location again for find are, while should note in Central sliding block placed yihou only allows steam end sliding block beyond stator within bore, and in Central sliding block and steam end rotor nursing ring Zhijian at least should keep must of distance ( 300MW 76mm, 1000MW is 50mm). When the steam side slider close to steam at the end of the stator bore 场跟班。 8时50分，因迎接“三防”检查，赵广党在现场对孙厚忠、李良恒强调施工安全后，9时离开现场。机电科也因迎接检查，未安排专人到施工现场进行业务指导。 赵广党离开后，孙厚忠等5人继续施工。现场施工负责人李良恒按照工作票要求对原I回路高压柜电缆进行拆除，经机电科进行电缆电气试验合格后，在5#高压柜组织压接I回路负荷电缆，李良恒在5#高压柜内作业，孙新民、陈金川、李伟斌3人在5#高压柜后作业，孙厚忠负责现场安全监护。10时10分，在5#高压柜作业的李良恒等4人听到临近的开关柜前面发出响声，随即前往检查，发现孙厚忠倒在正常作业区外的3#高压柜内，II回路跳闸，北风井停电、风机停车。 李良恒等人立即将孙厚忠拖出高压柜就地实施抢救，并向矿调度室汇报，同时恢复II回路供电，开启风机，并将孙厚忠送矿医院抢救。孙厚忠经抢救无效死亡。 事故发生后，矿及煤业公司、集团公司有关领导、安监局、机电部等部门有关人员迅速赶到事故现场指挥应急处理，并及时向济宁市安监局报告事故有关情况。 三、事故性质 经调查认定，该事故为地面机电责任事故。 四、事故原因 经联合调查组认定，对事故发生的原因分析如下: 1(现场安全监护人未履行现场安全监护职责，违章进入带电区域low rotor, until rotor of weight by steam end sliding block and Reed end rotor Bay support, in put low rotor of while should in Reed end rotor Bay at added pad sleeper, due to stator has preliminary adjustment finished, so stator within bore exists must Yang degrees, so should note adjustment makes rotor keep and stator within bore concentric, makes rotor not and coil contact. Panasonic lane hook, remove wire rope hoist, wrapped at the rotor excitation-side shoulder arc washer, and move the lifting wire rope to protect mat. Two 5T chain hoist end beam connections and welded to the rotor carriers, length adjusted for field conditions, and at the other end of the stator lifting hook or end cap end lugs connected, as shown in Figure 11.4.3-1. With Lane slightly single head upgrade rotor Reed end, keep rotor level, demolition rotor Bay or support sleepers, then slowly synchronization pull two only chain gourd, makes rotor in steam end sliding block of support Xia along arc skateboard to steam end sliding, this process in the, lane must and rotor of sliding keep synchronization, in rotor of steam end and Reed end are due hand guardianship rotor and stator Zhijian of clearance. Dang by steam end side has nursing ring protection of coil end Department into stator within bore Hou, slightly upgrade rotor Reed end, in rotor ontology following loaded into Central sliding block, its loaded into Hou must very carefully to along axis to for find are, and note observation rotor coupling in wear loaded process in the whether turned, as has should stop wear loaded, needed on Central sliding block location again for find are, while should note in Central sliding block placed yihou only allows steam end sliding block beyond stator within bore, and in Central sliding block and steam end rotor nursing ring Zhijian at least should keep must of distance ( 300MW 76mm, 1000MW is 50mm). When the steam side slider close to steam at the end of the stator bore 并打开带电的3#联络柜，误入带电间隔导致触电死亡，是造成事故的直接原因。 施工措施第17条规定，“更换?回路电源时，严禁打开1#、2#、3#高压开关柜前后柜门(带?回路电源)”。 2(没有执行工作票安全措施，未在带电开关与非带电开关之间设置遮栏和警示，导致现场安全防护设施缺失，致使不能有效阻止现场人员误入带电区域，是造成事故的主要原因。 变电所第一种工作票依据《电业安全工作规程》第84条、85条、86条规定，明确要求“在3#、4#开关柜之间装设遮栏，在4#开关柜刀闸手柄上悬挂‘有人工作，禁止合闸’、‘已接地’标示牌”。但现场没有按要求设置遮栏和悬挂相应警示牌，而且错误地在有电的3#联络柜悬挂“已停电”标示牌。 3(在不符合送电切换规定的情况下违规送电，致使?回路安全防护性能达不到规定要求，现场在无安全保障的情况下继续违章作业，是造成事故的又一主要原因。 送电前未对开关柜各种安全防护功能进行检查，不能实现有效安全防护;开关柜后封板部分未安装，开关柜前未铺设绝缘板，变电所正式运行基础设施不符合规定要求。调查中了解到，在22日?回路已送电的情况下，开关柜门仍处于敞开状态，致使?回路违章运行。 4(改造方案存有严重缺陷，开关柜选型不合理，致使源头留下固有隐患，是造成事故的另一主要原因。 方案制定因陋就简，没有考虑保证安全运行的需要，利用原空间low rotor, until rotor of weight by steam end sliding block and Reed end rotor Bay support, in put low rotor of while should in Reed end rotor Bay at added pad sleeper, due to stator has preliminary adjustment finished, so stator within bore exists must Yang degrees, so should note adjustment makes rotor keep and stator within bore concentric, makes rotor not and coil contact. Panasonic lane hook, remove wire rope hoist, wrapped at the rotor excitation-side shoulder arc washer, and move the lifting wire rope to protect mat. Two 5T chain hoist end beam connections and welded to the rotor carriers, length adjusted for field conditions, and at the other end of the stator lifting hook or end cap end lugs connected, as shown in Figure 11.4.3-1. With Lane slightly single head upgrade rotor Reed end, keep rotor level, demolition rotor Bay or support sleepers, then slowly synchronization pull two only chain gourd, makes rotor in steam end sliding block of support Xia along arc skateboard to steam end sliding, this process in the, lane must and rotor of sliding keep synchronization, in rotor of steam end and Reed end are due hand guardianship rotor and stator Zhijian of clearance. Dang by steam end side has nursing ring protection of coil end Department into stator within bore Hou, slightly upgrade rotor Reed end, in rotor ontology following loaded into Central sliding block, its loaded into Hou must very carefully to along axis to for find are, and note observation rotor coupling in wear loaded process in the whether turned, as has should stop wear loaded, needed on Central sliding block location again for find are, while should note in Central sliding block placed yihou only allows steam end sliding block beyond stator within bore, and in Central sliding block and steam end rotor nursing ring Zhijian at least should keep must of distance ( 300MW 76mm, 1000MW is 50mm). When the steam side slider close to steam at the end of the stator bore 尺寸狭小的低压配电室，选用安全可靠性差的一次接线系统方案，缺少1台隔离刀闸柜，改变了原设计方案和原设备型号;对厂家提供的开关柜系统图和二次接线设计图审查把关不严，对存在的技术缺陷未提出任何异议，草率签字确认，致使3#联络柜隔离开关下刀口始终处于带电状态。变电所开关柜操作通道安全距离达不到规程要求(规定不小于1.5米，实际只有1.47米)。开关柜选型不合理，选择了用于井下、防护功能较低、目前矿区已淘汰使用的开关柜。 5(联络柜产品设计有漏项，产品质量管理有漏洞，致使联络柜带电显示和闭锁装置缺失，属不符合国家 标准 excel标准偏差excel标准偏差函数exl标准差函数国标检验抽样标准表免费下载红头文件格式标准下载 规定产品，达不到“五防”功能之一的“防止人员误入带电间隔”规定，也是造成事故的主要原因。 东方机电公司在进行3#联络柜二次接线图设计时，没有考虑设置防止带电误入的DXN-Q型户内高压带电显示装置显示器及闭锁装置，技术审查把关不严，造成安全防护设计漏项。不符合GB 50060-92《3-110kV高压配电装置设计规范》第2.0.4条关于“室内配电装置应设置防止误入带电间隔的闭锁装置”的要求。 产品质量管理存有漏洞。本应由生产技术部门签订的技术协议书，实际由不具备相关技术资质的销售员签订，预算员审核，销售部长审批，致使系统缺陷不能及时发现。同时，产品出厂验收把关不严，尽管产品都按图纸要求检验并出具检验报告和产品合格证，但经现场2次带电开门试验发现，3#联络柜不能实现防带电误入的功能，2#、4#开关柜虽然设置了闭锁装置，但在进线电缆头带电状态下仍能打开前low rotor, until rotor of weight by steam end sliding block and Reed end rotor Bay support, in put low rotor of while should in Reed end rotor Bay at added pad sleeper, due to stator has preliminary adjustment finished, so stator within bore exists must Yang degrees, so should note adjustment makes rotor keep and stator within bore concentric, makes rotor not and coil contact. Panasonic lane hook, remove wire rope hoist, wrapped at the rotor excitation-side shoulder arc washer, and move the lifting wire rope to protect mat. Two 5T chain hoist end beam connections and welded to the rotor carriers, length adjusted for field conditions, and at the other end of the stator lifting hook or end cap end lugs connected, as shown in Figure 11.4.3-1. With Lane slightly single head upgrade rotor Reed end, keep rotor level, demolition rotor Bay or support sleepers, then slowly synchronization pull two only chain gourd, makes rotor in steam end sliding block of support Xia along arc skateboard to steam end sliding, this process in the, lane must and rotor of sliding keep synchronization, in rotor of steam end and Reed end are due hand guardianship rotor and stator Zhijian of clearance. Dang by steam end side has nursing ring protection of coil end Department into stator within bore Hou, slightly upgrade rotor Reed end, in rotor ontology following loaded into Central sliding block, its loaded into Hou must very carefully to along axis to for find are, and note observation rotor coupling in wear loaded process in the whether turned, as has should stop wear loaded, needed on Central sliding block location again for find are, while should note in Central sliding block placed yihou only allows steam end sliding block beyond stator within bore, and in Central sliding block and steam end rotor nursing ring Zhijian at least should keep must of distance ( 300MW 76mm, 1000MW is 50mm). When the steam side slider close to steam at the end of the stator bore 门，达不到设计要求。 6.职工安全技能缺失，安全培训不全面，致使对现场可能引发的危险因素认识不到，不能达到有效自保互保能力，是造成事故的重要原因。 变电所值班人员上岗前未经相关安全操作培训，不掌握新设备操作要领和安全注意事项;施工人员不清楚《电业安全工作规程》相关内容，达不到岗位应知应会要求，致使现场违章作业现象突出。 7(现场安全制度措施执行不严格，安全责任不落实，安全管理混乱，是造成事故的又一重要原因。 (1)变电所第一种工作票制度执行不严格。工作票执行人在未实施工作票内容的情况下，在工作票、操作票上签字;现场施工负责人未对工作票落实情况进行确认，并违规代替安全负责人签字。 (2)现场岗位职责不落实。工作票执行人不履行岗位职责，未按要求设置遮栏、挂警示牌;施工负责人未对现场安全设施进行检查确认，在现场没有采取有效防护和警戒措施的情况下违章组织施工;现场作业人员自主保安意识不强，在干部违章指挥、现场存在明显安全隐患的情况下参与违章作业;现场安全监护人不仅未履行安全监管职责，及时制止现场违章行为，反而违反措施规定误入禁区，现场逐级安全责任不落实，“三位一体”、“手指口述”安全确认制度没有得到执行。 (3)工区安全管理不到位。项目负责人在工程的关键时期被临时安排从事其他工作不在现场;临时替代项目负责人在现场跟班的区长low rotor, until rotor of weight by steam end sliding block and Reed end rotor Bay support, in put low rotor of while should in Reed end rotor Bay at added pad sleeper, due to stator has preliminary adjustment finished, so stator within bore exists must Yang degrees, so should note adjustment makes rotor keep and stator within bore concentric, makes rotor not and coil contact. Panasonic lane hook, remove wire rope hoist, wrapped at the rotor excitation-side shoulder arc washer, and move the lifting wire rope to protect mat. Two 5T chain hoist end beam connections and welded to the rotor carriers, length adjusted for field conditions, and at the other end of the stator lifting hook or end cap end lugs connected, as shown in Figure 11.4.3-1. With Lane slightly single head upgrade rotor Reed end, keep rotor level, demolition rotor Bay or support sleepers, then slowly synchronization pull two only chain gourd, makes rotor in steam end sliding block of support Xia along arc skateboard to steam end sliding, this process in the, lane must and rotor of sliding keep synchronization, in rotor of steam end and Reed end are due hand guardianship rotor and stator Zhijian of clearance. Dang by steam end side has nursing ring protection of coil end Department into stator within bore Hou, slightly upgrade rotor Reed end, in rotor ontology following loaded into Central sliding block, its loaded into Hou must very carefully to along axis to for find are, and note observation rotor coupling in wear loaded process in the whether turned, as has should stop wear loaded, needed on Central sliding block location again for find are, while should note in Central sliding block placed yihou only allows steam end sliding block beyond stator within bore, and in Central sliding block and steam end rotor nursing ring Zhijian at least should keep must of distance ( 300MW 76mm, 1000MW is 50mm). When the steam side slider close to steam at the end of the stator bore 也因其他工作安排而离岗，造成现场施工在关键环节安全管理缺位。特别在?回路带电运行的特殊期间，前后柜门打开的情况下，施工人员脱岗，现场施工管理极其混乱。 8. 重大系统改造项目管理不规范，施工计划不严肃，措施编审不规范，是造成事故的另一重要原因。 (1)项目管理不规范。以维简项目来实施生产系统关键环节技术改造，系统方案未经正规设计和严格论证，未报主管部门审批，违反煤业公司《设备管理办法实施细则(暂行)》(兖煤股生技字〔2002〕41号)第25条“实施主要设备、系统、装置的改造更新计划，应由单位机电总工程师组织技术方案论证，报公司审批”和第8条“四大系统(四大运转系统、供电系统、井下主煤流系统、洗煤系统、储装运系统等)装备的技术论证上报公司”规定。 (2)项目施工安排随意。北风井开关柜更换项目列入4月份矿井重点停产检修计划，未经机电部批准，擅自提前开工，并且不能如实汇报。违反煤业公司《矿井生产系统装备检修管理办法规定》(兖煤股生技字〔2007〕37号)第19条、第37条关于“重点检修项目变更应向公司汇报”的规定。 (3)措施编审程序不规范，审批制度执行不严格。措施会审只有机电科、安监处、机电工区参与，未通知与此工程有关联的部门参加。施工措施从编制、审批到传达、学习均在项目开工的前一天完成，措施编制和传达学习时间仓促。 9. 业务保安责任不落实，安全监管不全面，现场安全监控力度low rotor, until rotor of weight by steam end sliding block and Reed end rotor Bay support, in put low rotor of while should in Reed end rotor Bay at added pad sleeper, due to stator has preliminary adjustment finished, so stator within bore exists must Yang degrees, so should note adjustment makes rotor keep and stator within bore concentric, makes rotor not and coil contact. Panasonic lane hook, remove wire rope hoist, wrapped at the rotor excitation-side shoulder arc washer, and move the lifting wire rope to protect mat. Two 5T chain hoist end beam connections and welded to the rotor carriers, length adjusted for field conditions, and at the other end of the stator lifting hook or end cap end lugs connected, as shown in Figure 11.4.3-1. With Lane slightly single head upgrade rotor Reed end, keep rotor level, demolition rotor Bay or support sleepers, then slowly synchronization pull two only chain gourd, makes rotor in steam end sliding block of support Xia along arc skateboard to steam end sliding, this process in the, lane must and rotor of sliding keep synchronization, in rotor of steam end and Reed end are due hand guardianship rotor and stator Zhijian of clearance. Dang by steam end side has nursing ring protection of coil end Department into stator within bore Hou, slightly upgrade rotor Reed end, in rotor ontology following loaded into Central sliding block, its loaded into Hou must very carefully to along axis to for find are, and note observation rotor coupling in wear loaded process in the whether turned, as has should stop wear loaded, needed on Central sliding block location again for find are, while should note in Central sliding block placed yihou only allows steam end sliding block beyond stator within bore, and in Central sliding block and steam end rotor nursing ring Zhijian at least should keep must of distance ( 300MW 76mm, 1000MW is 50mm). When the steam side slider close to steam at the end of the stator bore 不够，导致现场问 题 快递公司问题件快递公司问题件货款处理关于圆的周长面积重点题型关于解方程组的题及答案关于南海问题 不能及时发现、及时整改，又是造成事故的重要原因。 分管技术负责人及机电科在项目方案制定、技术论证、作业计划编制和设备验收等关键环节技术把关不严，在项目施工的关键时期无专业人员现场跟班，业务指导不力。安监处对地面单项工程和零活作业汇报制度执行情况监督不力，对施工单位漏报行为追究不严格，工作安排不细致，致使施工信息掌握不充分，安全监管存有盲区。机电部对于本专业范围内重要地点的维简计划掌握不全面，工作不主动;在得知检修计划未经审批，擅自提前完成施工的情况下，未能及时追究矿方责任，也未及时到现场查明项目真实进展情况，业务保安责任不落实。 10(安全认识不到位，安全教育不到位，安全管理不全面，领导责任不落实，致使职工安全意识淡薄，现场“三违”、隐患问题突出，也是造成事故的重要原因。矿对涉及矿井重大安全的系统改造，安全风险认识不足，思想重视不够，未能将风井供电系统改造作为重点项目进行重点管理。在项目实施过程中，矿缺乏统筹安排，组织保障不力，经查矿安全办公会、调度早会等会议纪要、记录，无与此项目相关的任何安排和要求，造成安全管理缺位。分管矿长召集的专项协调会，只有机电科、机电工区、水电暖工区、土建工区参加，未通知调度室、安监处等综合管理部门，施工单位在施工期间未按规定向安监处、调度室汇报，区队管理人员、业务部门、矿分管领导在项目施工期间，均未向安监处填写过信息卡，造成安全信息中断，安全管理脱low rotor, until rotor of weight by steam end sliding block and Reed end rotor Bay support, in put low rotor of while should in Reed end rotor Bay at added pad sleeper, due to stator has preliminary adjustment finished, so stator within bore exists must Yang degrees, so should note adjustment makes rotor keep and stator within bore concentric, makes rotor not and coil contact. Panasonic lane hook, remove wire rope hoist, wrapped at the rotor excitation-side shoulder arc washer, and move the lifting wire rope to protect mat. Two 5T chain hoist end beam connections and welded to the rotor carriers, length adjusted for field conditions, and at the other end of the stator lifting hook or end cap end lugs connected, as shown in Figure 11.4.3-1. With Lane slightly single head upgrade rotor Reed end, keep rotor level, demolition rotor Bay or support sleepers, then slowly synchronization pull two only chain gourd, makes rotor in steam end sliding block of support Xia along arc skateboard to steam end sliding, this process in the, lane must and rotor of sliding keep synchronization, in rotor of steam end and Reed end are due hand guardianship rotor and stator Zhijian of clearance. Dang by steam end side has nursing ring protection of coil end Department into stator within bore Hou, slightly upgrade rotor Reed end, in rotor ontology following loaded into Central sliding block, its loaded into Hou must very carefully to along axis to for find are, and note observation rotor coupling in wear loaded process in the whether turned, as has should stop wear loaded, needed on Central sliding block location again for find are, while should note in Central sliding block placed yihou only allows steam end sliding block beyond stator within bore, and in Central sliding block and steam end rotor nursing ring Zhijian at least should keep must of distance ( 300MW 76mm, 1000MW is 50mm). When the steam side slider close to steam at the end of the stator bore 节。施工期间，除分管机电矿长、机电科、机电工区有关人员到过现场外，矿其他领导及安监人员从未到过施工现场，反映了各级安全自觉履责意识不强，安全管理不全面、安全责任不落实，安全第一的思想不能有效落实到干部职工的自觉行动上，致使现场安全得不到有效监管，干部违章指挥、工人违章作业现象十分突出，现场始终带着隐患违章作业。 五、暴露的问题及教训 通过对事故的深入调查和原因剖析，这起事故是一起典型的管理责任事故，性质严重，教训深刻，集中暴露出逐级安全认识不到位、安全管理不全面、制度措施不落实、教育培训不到位，管理干部未尽职，本质安全理念缺失，导致技术管理有漏洞，隐患排查有死角，综合监管有盲区，致使现场安全管理混乱，违章行为突出，源头带有隐患，发生事故成为必然。 (一)安全第一的思想认识不到位，干部职工安全境界不高、警觉不够。干部职工安全境界不高，吸取以往事故教训不深刻，没有时刻保持安全高度警觉，在实现一定安全周期后，逐级安全思想麻痹，安全第一的思想认识没有真正贯穿到实际工作当中。特别是对于事关矿井重大安全系统改造的变电所改造工程重视不够，简单视为设备更换，仅作为一般工程管理，不能正确认识安全投入与资金计划的关系，忽视安全需求，因陋就简，草率行事，因小失大，致使改造工程方案制定随意、计划管理随意、施工安排随意、现场管理混乱。 (二)安全责任落实不到位，安全过程控制存有漏洞。管理干部low rotor, until rotor of weight by steam end sliding block and Reed end rotor Bay support, in put low rotor of while should in Reed end rotor Bay at added pad sleeper, due to stator has preliminary adjustment finished, so stator within bore exists must Yang degrees, so should note adjustment makes rotor keep and stator within bore concentric, makes rotor not and coil contact. Panasonic lane hook, remove wire rope hoist, wrapped at the rotor excitation-side shoulder arc washer, and move the lifting wire rope to protect mat. Two 5T chain hoist end beam connections and welded to the rotor carriers, length adjusted for field conditions, and at the other end of the stator lifting hook or end cap end lugs connected, as shown in Figure 11.4.3-1. With Lane slightly single head upgrade rotor Reed end, keep rotor level, demolition rotor Bay or support sleepers, then slowly synchronization pull two only chain gourd, makes rotor in steam end sliding block of support Xia along arc skateboard to steam end sliding, this process in the, lane must and rotor of sliding keep synchronization, in rotor of steam end and Reed end are due hand guardianship rotor and stator Zhijian of clearance. Dang by steam end side has nursing ring protection of coil end Department into stator within bore Hou, slightly upgrade rotor Reed end, in rotor ontology following loaded into Central sliding block, its loaded into Hou must very carefully to along axis to for find are, and note observation rotor coupling in wear loaded process in the whether turned, as has should stop wear loaded, needed on Central sliding block location again for find are, while should note in Central sliding block placed yihou only allows steam end sliding block beyond stator within bore, and in Central sliding block and steam end rotor nursing ring Zhijian at least should keep must of distance ( 300MW 76mm, 1000MW is 50mm). When the steam side slider close to steam at the end of the stator bore 作风不扎实，履责意识不强，对矿井重大安全系统改造工作不重视，深入现场不够，以包代管，造成对现场安全动态不掌控，对施工过程中安全问题想不到、说不到、做不到、管不到，对施工项目长期存在的混乱管理违规违章行为没有及时发现、及时制止;工作中满足于原则性提出、粗线条安排，大而化之，应付凑付，造成逐级安全责任落实悬空，致使变电所改造工程计划安排、方案设计、设备选型、设备验收、安装调试等各个环节管理失控，导致在治理重大隐患过程中发生事故，不仅没有达到消除隐患目的，反而留下更为严重的新隐患，目前南北风井变电所仍处在带着隐患运行的状态。 (三)制度措施落实不到位，安全执行力不强。贯彻落实集团公司安全 管理制度 档案管理制度下载食品安全管理制度下载三类维修管理制度下载财务管理制度免费下载安全设施管理制度下载 规定不严肃、不到位，长期存在不按计划施工、检修项目安排随意的违规行为，特别是对于本应列为安全重点工程的变电所再造项目，计划管理不严格，计划变更草率，以维简计划实施改造工程，违规擅自施工，且没有及时、如实汇报，规避上级业务部门监管;施工过程中，把规程措施当成开工护照，票证管理不执行，审查确认程序不规范，“三位一体”安全评估检查、“手指口述”安全确认、重大技改、检修项目安全备案等一系列行之有效的安全制度和集团公司安全管理规定没有真正落到施工过程的每个环节，未能真正发挥应有的规范约束作用。 (四)技术管理不到位，业务保安有漏洞。对要害场所供电系统改造项目的安全技术要求和可能存在的安全风险认识不够，致使变电所改造技术论证不严格，重大施工项目无正规设计，导致方案有缺陷，low rotor, until rotor of weight by steam end sliding block and Reed end rotor Bay support, in put low rotor of while should in Reed end rotor Bay at added pad sleeper, due to stator has preliminary adjustment finished, so stator within bore exists must Yang degrees, so should note adjustment makes rotor keep and stator within bore concentric, makes rotor not and coil contact. Panasonic lane hook, remove wire rope hoist, wrapped at the rotor excitation-side shoulder arc washer, and move the lifting wire rope to protect mat. Two 5T chain hoist end beam connections and welded to the rotor carriers, length adjusted for field conditions, and at the other end of the stator lifting hook or end cap end lugs connected, as shown in Figure 11.4.3-1. With Lane slightly single head upgrade rotor Reed end, keep rotor level, demolition rotor Bay or support sleepers, then slowly synchronization pull two only chain gourd, makes rotor in steam end sliding block of support Xia along arc skateboard to steam end sliding, this process in the, lane must and rotor of sliding keep synchronization, in rotor of steam end and Reed end are due hand guardianship rotor and stator Zhijian of clearance. Dang by steam end side has nursing ring protection of coil end Department into stator within bore Hou, slightly upgrade rotor Reed end, in rotor ontology following loaded into Central sliding block, its loaded into Hou must very carefully to along axis to for find are, and note observation rotor coupling in wear loaded process in the whether turned, as has should stop wear loaded, needed on Central sliding block location again for find are, while should note in Central sliding block placed yihou only allows steam end sliding block beyond stator within bore, and in Central sliding block and steam end rotor nursing ring Zhijian at least should keep must of distance ( 300MW 76mm, 1000MW is 50mm). When the steam side slider close to steam at the end of the stator bore 设备选型错误，达不到矿井一级负荷变电所安全要求，没有从技术源头上保障安全。有关业务部门业务保安责任落实不到位，制定的同类制度规定相矛盾、标准不一致、规定不明确;主动深入现场检查指导的自觉性较差，对重大系统改造施工掌握不够，对本专业安全技术审查把关不严，隐患排查不细，没有及时发现现场隐患和施工措施、施工环节中存在的安全缺陷。特别是对违反矿井检修管理规定的行为不分析、不追究，老好人思想严重，致使违规施工没有得到及时制止。 (五)安全教育培训不到位，职工安全意识淡薄、安全技能缺失。安全教育流于形式，安全第一的理念还没有形成干部职工的自觉行动，干部安全责任不落实，职工安全意识淡薄，对施工过程中存在的安全风险认识不足，警觉不够，防范意识不强，始终带着隐患冒险作业，现场职工“十项权利”没有落到实处。职工上岗培训不全面，干部职工对规程、标准不掌握，安全技能缺失，达不到应知应会基本要求，违规违章行为突出。 (六)现场安全管理不到位，动态监管存有死角。各级干部对重点施工项目关键时期、关键环节靠前指挥、跟踪指导力度不够，会议不安排，现场跟班、带班、安全专盯制度不落实，业务指导监管不到位，对现场长期存在的隐患无认识、无制止、无纠正，导致对现场作业动态失去有效监管。安监部门对变电所改造工程不掌控，形成安全监督检查的死角和盲区。 (七)安全管理形式有误区，形式与内容不统一。贯彻落实集团公司安全工作部署不坚决，安全管理重形式、轻落实，重表面、轻实low rotor, until rotor of weight by steam end sliding block and Reed end rotor Bay support, in put low rotor of while should in Reed end rotor Bay at added pad sleeper, due to stator has preliminary adjustment finished, so stator within bore exists must Yang degrees, so should note adjustment makes rotor keep and stator within bore concentric, makes rotor not and coil contact. Panasonic lane hook, remove wire rope hoist, wrapped at the rotor excitation-side shoulder arc washer, and move the lifting wire rope to protect mat. Two 5T chain hoist end beam connections and welded to the rotor carriers, length adjusted for field conditions, and at the other end of the stator lifting hook or end cap end lugs connected, as shown in Figure 11.4.3-1. With Lane slightly single head upgrade rotor Reed end, keep rotor level, demolition rotor Bay or support sleepers, then slowly synchronization pull two only chain gourd, makes rotor in steam end sliding block of support Xia along arc skateboard to steam end sliding, this process in the, lane must and rotor of sliding keep synchronization, in rotor of steam end and Reed end are due hand guardianship rotor and stator Zhijian of clearance. Dang by steam end side has nursing ring protection of coil end Department into stator within bore Hou, slightly upgrade rotor Reed end, in rotor ontology following loaded into Central sliding block, its loaded into Hou must very carefully to along axis to for find are, and note observation rotor coupling in wear loaded process in the whether turned, as has should stop wear loaded, needed on Central sliding block location again for find are, while should note in Central sliding block placed yihou only allows steam end sliding block beyond stator within bore, and in Central sliding block and steam end rotor nursing ring Zhijian at least should keep must of distance ( 300MW 76mm, 1000MW is 50mm). When the steam side slider close to steam at the end of the stator bore 质，精细化管理没有真正体现在安全日常管理上，致使以表面掩盖问题，安全认识片面，以为组织健全就发挥了监管作用，以为签订了安全责任书就落实了安全责任，以为没出事故就不存在问题，以为增加了技术装备就能保证安全高保险，以为抓过就等于抓好了，导致安全整体工作停于表层，不深入、不扎实。 (八)产品质量隐患突出，产品设计、生产、检验逐级把关不严格。东方机电公司缺乏安全责任意识，不能正确认识产品质量缺陷给企业带来的风险危害，执行产品质量管理体系标准不严格，忽视产品质量安全，违规签订技术协议，对用户提供有缺陷的技术方案审查不严，产品设计有缺陷，审查程序不规范，层层技术把关不严格， 出厂检验不严细，致使存有严重缺陷的产品进入作业现场。 六、防范措施 (一)深刻吸取事故教训，切实提高安全极端重要性、复杂性、艰巨性的认识。深刻吸取“4.23”事故教训，高度警惕安全工作中存在的问题和不足，时刻保持清醒的安全政治头脑，深入排查安全思想认识上的隐患，坚定安全“四个一切”不动摇，从严落实集团公司安全工作部署及一系列安全制度规定，不走形式，不走过场，真正把安全第一的思想认识贯穿到实际工作当中，注重抓实质、求实效，做到所有工作首先要确保安全工作，所有投入首先要保证安全投入，所有责任首先要落实安全责任，切实做到形式与内容高度统一，严防以形式取代管理的各类安全不良行为。 (二)扎实开展“机电管理集中整治”活动。针对当前机电管理low rotor, until rotor of weight by steam end sliding block and Reed end rotor Bay support, in put low rotor of while should in Reed end rotor Bay at added pad sleeper, due to stator has preliminary adjustment finished, so stator within bore exists must Yang degrees, so should note adjustment makes rotor keep and stator within bore concentric, makes rotor not and coil contact. Panasonic lane hook, remove wire rope hoist, wrapped at the rotor excitation-side shoulder arc washer, and move the lifting wire rope to protect mat. Two 5T chain hoist end beam connections and welded to the rotor carriers, length adjusted for field conditions, and at the other end of the stator lifting hook or end cap end lugs connected, as shown in Figure 11.4.3-1. With Lane slightly single head upgrade rotor Reed end, keep rotor level, demolition rotor Bay or support sleepers, then slowly synchronization pull two only chain gourd, makes rotor in steam end sliding block of support Xia along arc skateboard to steam end sliding, this process in the, lane must and rotor of sliding keep synchronization, in rotor of steam end and Reed end are due hand guardianship rotor and stator Zhijian of clearance. Dang by steam end side has nursing ring protection of coil end Department into stator within bore Hou, slightly upgrade rotor Reed end, in rotor ontology following loaded into Central sliding block, its loaded into Hou must very carefully to along axis to for find are, and note observation rotor coupling in wear loaded process in the whether turned, as has should stop wear loaded, needed on Central sliding block location again for find are, while should note in Central sliding block placed yihou only allows steam end sliding block beyond stator within bore, and in Central sliding block and steam end rotor nursing ring Zhijian at least should keep must of distance ( 300MW 76mm, 1000MW is 50mm). When the steam side slider close to steam at the end of the stator bore 中存在的突出问题，扎实开展“机电管理集中整治”活动，逐级制定活动方案，对照国家、行业标准和相关规定，立足管理源头，从深层次上查管理漏洞、查系统缺陷、查现场死角，从根本上解决机电管理不严、不细、不深、不实的问题。 (三)规范重大技改项目和特殊施工安全技术管理。建立完善重大项目安全评估机制，按照分级管理的原则，严格组织技术论证，严格逐级申报、审批。加强规程措施和施工票证管理，严防规程措施关键环节内容缺项、特殊措施针对性不强、编制传达不及时、会审制度不严格等突出问题，严查票证签批随意、执行不严等违规违章行为。 (四)加强安全教育和技能培训。有针对性的强化安全教育和技能培训，有效提高干部履责意识、履责能力，提高职工自主保安意识，增强安全风险辨识和现场操作技能。严查班组长、业务骨干、技术能手等特殊人员作业行为，严查习惯性违章，严防以经验取代规程、以习惯取代措施、艺高冒险等违章行为。 (五)强化内部生产厂家产品质量安全监管。严格按照国家、行业标准，强化内部产品质量检测检验，严防存有安全技术缺陷的产品进入生产作业现场，严防因产品质量问题带来新的安全隐患。对于内部产品因质量问题造成安全隐患的，一律从严分析、公开曝光;问题严重的，取消内部产品市场保护资格。 (六)加强现场安全监管。严查安全管理漏洞和死角，严查安全不尽职的干部，严查不尽责的安全监督人员，严查制度措施不落实的现象，严查各类“三违”行为，对存有安全问题的单位，严格挂牌督low rotor, until rotor of weight by steam end sliding block and Reed end rotor Bay support, in put low rotor of while should in Reed end rotor Bay at added pad sleeper, due to stator has preliminary adjustment finished, so stator within bore exists must Yang degrees, so should note adjustment makes rotor keep and stator within bore concentric, makes rotor not and coil contact. Panasonic lane hook, remove wire rope hoist, wrapped at the rotor excitation-side shoulder arc washer, and move the lifting wire rope to protect mat. Two 5T chain hoist end beam connections and welded to the rotor carriers, length adjusted for field conditions, and at the other end of the stator lifting hook or end cap end lugs connected, as shown in Figure 11.4.3-1. With Lane slightly single head upgrade rotor Reed end, keep rotor level, demolition rotor Bay or support sleepers, then slowly synchronization pull two only chain gourd, makes rotor in steam end sliding block of support Xia along arc skateboard to steam end sliding, this process in the, lane must and rotor of sliding keep synchronization, in rotor of steam end and Reed end are due hand guardianship rotor and stator Zhijian of clearance. Dang by steam end side has nursing ring protection of coil end Department into stator within bore Hou, slightly upgrade rotor Reed end, in rotor ontology following loaded into Central sliding block, its loaded into Hou must very carefully to along axis to for find are, and note observation rotor coupling in wear loaded process in the whether turned, as has should stop wear loaded, needed on Central sliding block location again for find are, while should note in Central sliding block placed yihou only allows steam end sliding block beyond stator within bore, and in Central sliding block and steam end rotor nursing ring Zhijian at least should keep must of distance ( 300MW 76mm, 1000MW is 50mm). When the steam side slider close to steam at the end of the stator bore 办。严格地面施工安全监控，确保安全监管全面、不留盲区。严格落实业务保安责任，强化业务指导和技术把关，严查专业范围内各种违规行为。加大安全责任追究，对于各类严重“三违”和安全侥幸问题，一律作为事故从严分析，从严处理，坚决遏制各类事故苗头。 针对目前杨村煤矿南北风井变电所存在的系统隐患，由煤业公司列入重大隐患治理计划，严格按照重大隐患治理“五落实”要求立即组织整改，隐患消除之前必须严格制定并落实特殊安全措施，确保系统运行安全。同时，由机电部、东方机电公司联合对矿区在用变电所进行一次拉网式全面排查，对存有类似系统设备缺陷的，一律列入隐患治理计划加快整改，并由各级安监部门严格监督落实。 七、处理意见 1.杨村煤矿机电队维修班班长 孙厚忠 违章打开并误入规程措施规定严禁打开的开关柜，是造成事故的主要原因，鉴于在事故中已经死亡，不再追究责任; 2.杨村煤矿机电队维修班副班长、施工负责人 李良恒 没有按措施要求设置防护隔栏，代人签发工作票，未尽职责，给予撤销副班长职务，开出矿籍，留矿察看一年处分; 3.杨村煤矿北风井扇风机房值班员 任建华 没有按要求挂牌设置警戒线和设置防护隔栏，给予开出矿籍，留矿察看一年处分; 4. 杨村煤矿北风井扇风机房值班员 刘玉连 没有按要求挂牌设置警戒线和设置防护隔栏，没有进行现场安全检查确认，给予开出矿籍，留矿察看一年处分; low rotor, until rotor of weight by steam end sliding block and Reed end rotor Bay support, in put low rotor of while should in Reed end rotor Bay at added pad sleeper, due to stator has preliminary adjustment finished, so stator within bore exists must Yang degrees, so should note adjustment makes rotor keep and stator within bore concentric, makes rotor not and coil contact. Panasonic lane hook, remove wire rope hoist, wrapped at the rotor excitation-side shoulder arc washer, and move the lifting wire rope to protect mat. Two 5T chain hoist end beam connections and welded to the rotor carriers, length adjusted for field conditions, and at the other end of the stator lifting hook or end cap end lugs connected, as shown in Figure 11.4.3-1. With Lane slightly single head upgrade rotor Reed end, keep rotor level, demolition rotor Bay or support sleepers, then slowly synchronization pull two only chain gourd, makes rotor in steam end sliding block of support Xia along arc skateboard to steam end sliding, this process in the, lane must and rotor of sliding keep synchronization, in rotor of steam end and Reed end are due hand guardianship rotor and stator Zhijian of clearance. Dang by steam end side has nursing ring protection of coil end Department into stator within bore Hou, slightly upgrade rotor Reed end, in rotor ontology following loaded into Central sliding block, its loaded into Hou must very carefully to along axis to for find are, and note observation rotor coupling in wear loaded process in the whether turned, as has should stop wear loaded, needed on Central sliding block location again for find are, while should note in Central sliding block placed yihou only allows steam end sliding block beyond stator within bore, and in Central sliding block and steam end rotor nursing ring Zhijian at least should keep must of distance ( 300MW 76mm, 1000MW is 50mm). When the steam side slider close to steam at the end of the stator bore 5. 杨村煤矿机电队副区长 赵民 现场管理不到位，管理混乱，隐患不排查，措施不落实，工人违章不制止，给予撤职处分; 6. 杨村煤矿机电队技术主管 庞锡涛 措施管理不到位，不具备施工条件，安排施工，措施审批覆盖不全面，边传达措施边施工，给予撤职处分; 7. 杨村煤矿机电队队长 赵广党 区队安全管理不到位，不具备施工条件安排施工，没有尽到责任，安全第一的思想淡薄，给予撤职处分; 8. 杨村煤矿机电队党支部书记 王志其安全意识淡薄，安全教育不到位，职工应知应会掌握少，没有尽到教育培训责任，给予撤职处分; 9. 杨村煤矿机电科科长 于如山 组织协调监督管理不到位，现场施工管理混乱不制止，给予行政记大过处分; 10. 杨村煤矿副总工程师 李亚 技术管理失控，技术资料审查设计存在缺陷，给予撤职、解职处分; 11. 杨村煤矿安监处处长 王建户 安全监管不全面，对于矿井薄弱地点、薄弱单位失察，给予行政记过处分; 12. 杨村煤矿机电副矿长 岳朝柱 机电工作管理不到位，施工现场混乱，不具备施工条件提前施工，更改报批的设备，更改后的设备存在严重的设计缺陷，没有防止人员带电误入的闭锁机构，给予撤职处分; 13. 杨村煤矿总工程师 王道广 技术管理不到位，技术改low rotor, until rotor of weight by steam end sliding block and Reed end rotor Bay support, in put low rotor of while should in Reed end rotor Bay at added pad sleeper, due to stator has preliminary adjustment finished, so stator within bore exists must Yang degrees, so should note adjustment makes rotor keep and stator within bore concentric, makes rotor not and coil contact. Panasonic lane hook, remove wire rope hoist, wrapped at the rotor excitation-side shoulder arc washer, and move the lifting wire rope to protect mat. Two 5T chain hoist end beam connections and welded to the rotor carriers, length adjusted for field conditions, and at the other end of the stator lifting hook or end cap end lugs connected, as shown in Figure 11.4.3-1. With Lane slightly single head upgrade rotor Reed end, keep rotor level, demolition rotor Bay or support sleepers, then slowly synchronization pull two only chain gourd, makes rotor in steam end sliding block of support Xia along arc skateboard to steam end sliding, this process in the, lane must and rotor of sliding keep synchronization, in rotor of steam end and Reed end are due hand guardianship rotor and stator Zhijian of clearance. Dang by steam end side has nursing ring protection of coil end Department into stator within bore Hou, slightly upgrade rotor Reed end, in rotor ontology following loaded into Central sliding block, its loaded into Hou must very carefully to along axis to for find are, and note observation rotor coupling in wear loaded process in the whether turned, as has should stop wear loaded, needed on Central sliding block location again for find are, while should note in Central sliding block placed yihou only allows steam end sliding block beyond stator within bore, and in Central sliding block and steam end rotor nursing ring Zhijian at least should keep must of distance ( 300MW 76mm, 1000MW is 50mm). When the steam side slider close to steam at the end of the stator bore 造方案没有经过集团公司审批，给予记过处分; 14. 杨村煤矿矿长 徐瑞峰 安全管理不到位，逐级责任不落实，督促不利，薄弱环节地点失察，给予记过处分; 15. 杨村煤矿党委书记 李庆良职工安全意识淡薄，三乎三惯思想严重，安全教育不到位，给予记过处分; 16.东方机电公司技术主管 史博虎 开关柜设计存在严重缺陷，没有设计防止人员带电误入的闭锁机构，诱发事故，给予记过处分; 17. 东方机电公司设计室主任 张继峰 审查设计没有发现开关柜存在严重的设计缺陷，为用户提供带有隐患的产品，给予记过处分; 18. 东方机电公司总经理 朱乃峰 责任心不强，管理不到位，为用户提供带有隐患的产品，负有领导责任，给予记过处分; 19. 东方机电公司董事长 孙传运 质量意识不高，检验不够为用户提供带有隐患的产品，负有领导责任，责成分析大会做检查; 20.集团公司机电部部长 王惠忠 业务管理不到位，责任追究不到位，监督检查不到位，保安责任不到位，给予警告处分; 21.煤业公司副总经理 曲天智 警觉不高，认识不高，安全监督检查不全面，责成分析大会做检查; 22.集团公司安监局局长 李位民 安全监督检查不到位，覆盖面不全，责任追究落实不到位，责成分析大会做检查; 23.集团公司副总经理、煤业公司总经理 杨德玉 分管集团公low rotor, until rotor of weight by steam end sliding block and Reed end rotor Bay support, in put low rotor of while should in Reed end rotor Bay at added pad sleeper, due to stator has preliminary adjustment finished, so stator within bore exists must Yang degrees, so should note adjustment makes rotor keep and stator within bore concentric, makes rotor not and coil contact. Panasonic lane hook, remove wire rope hoist, wrapped at the rotor excitation-side shoulder arc washer, and move the lifting wire rope to protect mat. Two 5T chain hoist end beam connections and welded to the rotor carriers, length adjusted for field conditions, and at the other end of the stator lifting hook or end cap end lugs connected, as shown in Figure 11.4.3-1. With Lane slightly single head upgrade rotor Reed end, keep rotor level, demolition rotor Bay or support sleepers, then slowly synchronization pull two only chain gourd, makes rotor in steam end sliding block of support Xia along arc skateboard to steam end sliding, this process in the, lane must and rotor of sliding keep synchronization, in rotor of steam end and Reed end are due hand guardianship rotor and stator Zhijian of clearance. Dang by steam end side has nursing ring protection of coil end Department into stator within bore Hou, slightly upgrade rotor Reed end, in rotor ontology following loaded into Central sliding block, its loaded into Hou must very carefully to along axis to for find are, and note observation rotor coupling in wear loaded process in the whether turned, as has should stop wear loaded, needed on Central sliding block location again for find are, while should note in Central sliding block placed yihou only allows steam end sliding block beyond stator within bore, and in Central sliding block and steam end rotor nursing ring Zhijian at least should keep must of distance ( 300MW 76mm, 1000MW is 50mm). When the steam side slider close to steam at the end of the stator bore 司机电工作，安全管理不到位，安全检查存在漏洞，责成分析大会做检查。 八、要求 为了全面接受杨村煤矿“4.23”事故教训，矿党政于5月6日事故分析会后，立即召开了领导班子会议，对接受杨村煤矿事故教训提出如下要求: 1.矿属各单位都要把杨村煤矿的事故当成兴隆庄煤矿的事故来分析、认识，把机电系列事故当成全矿的事故来分析，要把事故原因分析的淋漓至尽，事故的教训要刻骨铭心，采取的措施要行之有效，确保人人不发生事故，队队不发生事故，全矿实现安全生产。 2.各单位、科室要在对杨村矿“4.23”事故分析清楚，教训总结全面的基础上，所有管理干部都要对照本单位实际，写出“4.23”事故教训反思报告，于5月15日前报安监处统计室，矿各分管领导将组织党办、矿办、宣传科、工会、团委、安监处将对各单位写出的报告进行评选，选出优秀报告10篇，最差报告10篇，在6月安全生产月活动中进行研讨。各单位要对存在的问题和隐患，说明白，采取的措施要果断，消除问题、隐患要彻底，确保本单位的安全生产,和正在开展的“说到、想到、做到”大讨论及“百日安全检查活动”相结合。 3.要求各包保小组成员每月至少参加一次区队班前会，分管领导每月至少要参加分管单位的班前会两次，与区队干部职工共同深刻反思包保单位、分管单位管理上的漏洞，措施上的不到位，现场上的缺陷，人员的不安全行为 。 low rotor, until rotor of weight by steam end sliding block and Reed end rotor Bay support, in put low rotor of while should in Reed end rotor Bay at added pad sleeper, due to stator has preliminary adjustment finished, so stator within bore exists must Yang degrees, so should note adjustment makes rotor keep and stator within bore concentric, makes rotor not and coil contact. Panasonic lane hook, remove wire rope hoist, wrapped at the rotor excitation-side shoulder arc washer, and move the lifting wire rope to protect mat. Two 5T chain hoist end beam connections and welded to the rotor carriers, length adjusted for field conditions, and at the other end of the stator lifting hook or end cap end lugs connected, as shown in Figure 11.4.3-1. With Lane slightly single head upgrade rotor Reed end, keep rotor level, demolition rotor Bay or support sleepers, then slowly synchronization pull two only chain gourd, makes rotor in steam end sliding block of support Xia along arc skateboard to steam end sliding, this process in the, lane must and rotor of sliding keep synchronization, in rotor of steam end and Reed end are due hand guardianship rotor and stator Zhijian of clearance. Dang by steam end side has nursing ring protection of coil end Department into stator within bore Hou, slightly upgrade rotor Reed end, in rotor ontology following loaded into Central sliding block, its loaded into Hou must very carefully to along axis to for find are, and note observation rotor coupling in wear loaded process in the whether turned, as has should stop wear loaded, needed on Central sliding block location again for find are, while should note in Central sliding block placed yihou only allows steam end sliding block beyond stator within bore, and in Central sliding block and steam end rotor nursing ring Zhijian at least should keep must of distance ( 300MW 76mm, 1000MW is 50mm). When the steam side slider close to steam at the end of the stator bore 4.从5月7日开始，将在矿各个单位进行杨村煤矿事故就是兴隆庄煤矿事故的大讨论活动，查找我们在规程的规范，责任的落实，岗位操作中存在的问题。看我们的作风转变了没有,思想到位了没有,措施完善了没有,管理到位了没有,集团公司处罚决定引起我们的心灵震撼了没有, 5.各单位没有措施不能擅自施工，地面单位所有的开工场所更换设备、设施时都必须制定专门的措施，提前一周经矿审批，并送交安监处地面科备案。 二〇〇八年五月六日 low rotor, until rotor of weight by steam end sliding block and Reed end rotor Bay support, in put low rotor of while should in Reed end rotor Bay at added pad sleeper, due to stator has preliminary adjustment finished, so stator within bore exists must Yang degrees, so should note adjustment makes rotor keep and stator within bore concentric, makes rotor not and coil contact. Panasonic lane hook, remove wire rope hoist, wrapped at the rotor excitation-side shoulder arc washer, and move the lifting wire rope to protect mat. Two 5T chain hoist end beam connections and welded to the rotor carriers, length adjusted for field conditions, and at the other end of the stator lifting hook or end cap end lugs connected, as shown in Figure 11.4.3-1. With Lane slightly single head upgrade rotor Reed end, keep rotor level, demolition rotor Bay or support sleepers, then slowly synchronization pull two only chain gourd, makes rotor in steam end sliding block of support Xia along arc skateboard to steam end sliding, this process in the, lane must and rotor of sliding keep synchronization, in rotor of steam end and Reed end are due hand guardianship rotor and stator Zhijian of clearance. Dang by steam end side has nursing ring protection of coil end Department into stator within bore Hou, slightly upgrade rotor Reed end, in rotor ontology following loaded into Central sliding block, its loaded into Hou must very carefully to along axis to for find are, and note observation rotor coupling in wear loaded process in the whether turned, as has should stop wear loaded, needed on Central sliding block location again for find are, while should note in Central sliding block placed yihou only allows steam end sliding block beyond stator within bore, and in Central sliding block and steam end rotor nursing ring Zhijian at least should keep must of distance ( 300MW 76mm, 1000MW is 50mm). When the steam side slider close to steam at the end of the stator bore