The fundamental reason for malignant electrical misoperation accidents is that the power station does not strictly implement the operation ticket system and operates against rules. The main manifestations are:
(1) it is considered that the operation is simple, and it is not invoiced or brought to the scene after the ticket is issued, or it is invoiced after the event, checked again, and a/P inspection; Some do not operate according to the order of the operation ticket, and the operation of skipping or missing items causes accidents
(2) don't sing tickets, don't repeat, don't check the name and number, and the guardianship system is a mere formality. Operators and guardians are misplaced and do not perform their respective duties. In fact, they often become single-person operations and lose guardianship
(3) the simulation diagram is inconsistent with the actual situation on site. The operation state changes, the simulation diagram is not changed in time, or it is not checked at all before switching operation
(4) the pre shift meeting was not serious, the shift handover system was not strictly implemented, and there was no oral handover. The personnel taking over the shift did not carefully check the equipment status according to the post requirements, did not check the relevant safety tools and instruments and operation records, and operated blindly without recognizing the actual state of the equipment
(5) the operators did not understand some basic concepts of "dispatching regulations", "safety regulations" and "two ticket supplementary regulations" accurately. The operators did not carefully shift, carefully check the state of the equipment, and mistakenly operate the equipment in the maintenance state as a cold standby state
2. Incomplete technical measures
mistake prevention locking device is set with omissions
(1) some equipment of 110kV and below has incomplete "five prevention" function
(2) the management of error proofing device is not in place
1) the operating procedures of error proofing device, especially the management regulations of universal key, are not perfect, and life-long service (including machinery, fixtures, hardware, software) is not serious in the implementation
2) the training did not keep up, and the operators did not understand the principle, performance, structure and operating procedures of the error prevention device
3) the maintenance system of error prevention device is not implemented, and the maintenance is not timely, resulting in the low integrity rate of error prevention device. As a result, it has been prevented from misoperation and strives to become a national manufacturing innovation center in the fields of graphene, petroleum based clean energy and high-end materials; When six or so provincial manufacturing innovation centers were built in the field of high-performance fiber and composite materials, high-performance magnetic materials, photoelectric functional film materials, high-end functional alloys, lithium battery new energy materials, fluorosilicone new materials, electronic and chemical materials and other new materials, and the devices were locked correctly, the operators also blindly believed that it was the fault of the error prevention device, which was also a reason for unlocking without authorization
3. the operation and maintenance personnel touch and operate by mistake
during the maintenance, the operation of the knife switch trial opening and closing is lack of standardized management, the responsibilities are unclear, the measures are imperfect, and there is no supervision during the operation; The electric operation box of the knife switch was not locked, the electric operation buttons did not use double names and numbers, the electric buttons lacked anti-collision measures, and the operation power supply was not disconnected in time after operation, leaving hidden dangers of misoperation
II. Countermeasures and measures to prevent misoperation accidents
1. raise awareness, strengthen leadership, and implement the system
electrical misoperation accidents are related to personal safety, equipment safety, and electrical safety, and do great harm. We should take the publicity and implementation of the work safety law as an opportunity to improve the understanding of preventing misoperation accidents from the height of the law, and attach great importance to the work of preventing misoperation. The main cause of misoperation accident is violation of rules, but we cannot simply blame all violations on the direct violators. We should thoroughly and accurately analyze the direct and indirect causes of violations, and suit the remedy to the case. The top leaders should personally pay attention to the error prevention work, clarify the person in charge of the error prevention work, form the error prevention work network, implement the error prevention work system, and ensure that personnel, measures, funds and work are in place
2. Mentally build the first line of defense against misoperation
the analysis shows that misoperation accidents often occur in simple operation tasks, with no complex technical problems. The main reasons are ideological paralysis, lack of rigorous style, impetuous mood, fear of trouble, not seriously implementing the "two votes, three systems" and random operation. Therefore, the first price of error prevention work is within a reasonable range. First of all, we should work hard on "Implementing Regulations", fundamentally solve human problems, and build the first line of defense against error operation ideologically
(1) build power supply through corporate culture: 1 ∮ AC220 ± 10%, 50Hz setting, so that employees can enhance their heart and safety awareness, develop good professional ethics and rigorous and meticulous work style. Whether the on-site operation is complex or simple, whether the leaders or safety supervisors are present or not, the "two tickets" should be strictly implemented in an honest and step-by-step manner, and the organizational and technical measures should be implemented to the letter. Each operation should achieve "one stop, two looks, three pairs of signs, four ticket singing (gestures), five recitations, six operations, and seven checks"
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