2016年2月23日21时30分左右，某管桩公司无证吊车司机郭某和某物流有限公司拖挂车司机刘某在某管桩公司第三堆放场进行管桩卸吊作业，由于管桩两端不平衡，导致管桩脱钩，从拖挂车上坠落地面压到帮忙挂钩的司机刘某的头部，致刘某当场所死亡。
At about 21:30 on February 23, 2016, Guo, an unlicensed crane driver of a pipe pile company, and Liu, a trailer driver of a logistics company, carried out pipe pile unloading and hoisting operations in the third stacking yard of a pipe pile company.
（一）现场调查 (1) On-site investigation
发生事故的起重机属于双吊钩通用桥式起重机，双小车、双升降机构，在起重机2个吊钩上仍悬挂着索具，该索具为3组吊链及吊钩（自制专用吊钩）。起重机下方停靠1辆平板运输车（车头号牌为粤T14510、拖挂车号牌为粤T0974挂），车上存放有6根管桩（长约13m）。发生事故时所吊卸的管桩（长约13m，直径500mm，重量约为3t）已坠落在平板运输车右侧的行车道上，该管桩已有明显裂纹，平板运输车尾部右侧的行车道上有明显的血迹（为救出事故受害人已移动了坠落的管桩）。
The crane where the accident occurred belongs to the double hook general overhead crane, double trolley, double lifting mechanism, and the rigging is still suspended on the two hooks of the crane, and the rigging is 3 groups of chains and hooks (self-made special hooks). There is 1 flatbed transport truck (the front plate is Guangdong T14510 and the trailer number plate is Guangdong T0974) parked under the crane, and 6 pipe piles (about 13m long) are stored on the vehicle. At the time of the accident, the pipe pile (about 13m long, 500mm in diameter, and about 3t in weight) had fallen on the right lane of the flatbed truck, and the pipe pile had obvious cracks, and there were obvious blood stains on the right side of the rear of the flatbed truck (the fallen pipe pile had been moved to rescue the accident victim).
事故设备为通用桥式起重机，出厂编号为S115118，规格型号为QE16(8+8)-25.5-A6，额定起重量为（8+8）t，起升高度为12m，起升速度为13.3m/min，大车运行速度为89 m/min，小车运行速度为43.8 m/min。事故起重机已办理了使用登记并在检验有效期内使用。
The accident equipment is a general overhead crane, the factory number is S115118, the specifications and models are QE16 (8 + 8) -25.5-A6, the rated lifting capacity is (8 + 8) t, the lifting height is 12m, the lifting speed is 13.3m/min, the trolley running speed is 89 m/min, and the trolley running speed is 43.8 m/min. The accident crane has been registered for use and used within the validity period of the inspection.
（二）事故原因分析 (2) Analysis of the cause of the accident
（1）管桩公司员工郭某（普工）无证上岗，擅自操作起重机进行管桩装卸作业，在操作中未能及时发现挂钩未到位的不正常状态且未等刘某走到安全区域便开始起吊管桩，导致在起吊过程索具脱钩、管桩坠落酿成事故。
(1) Guo (general worker), an employee of the pipe pile company, worked without a license, operated the crane without authorization to carry out the pipe pile loading and unloading operation, failed to find the abnormal state of the hook not in place in time during the operation, and began to lift the pipe pile without waiting for Liu to walk to the safe area, resulting in the decoupling of the rigging and the fall of the pipe pile during the lifting process.
（2）物流公司司机李某，违规擅自进行管桩挂钩作业，因未经过司索作业（挂钩）岗前培训、未掌握挂钩操作要领，操作不当（挂钩未到位）。
(2) Li, the driver of the logistics company, carried out the pipe pile hook operation without authorization in violation of regulations, because he did not go through the pre-job training of the operation (hook) of the company, did not master the essentials of the hook operation, and the operation was improper (the hook was not in place).
物流公司刘某安全意识淡薄，自我保护意识不强，在起重机升降过程未按规定站在安全区域，管桩坠落时躲避不及被碾压致死。
Liu, a logistics company, has a weak sense of safety and self-protection, and does not stand in the safety area according to the regulations during the crane lifting process, and is crushed to death when the pipe pile falls.
（一）事故单位应建立健全起重机械安全管理制度，制定并严格执行起重机操作规程。加强对起重机械作业现场的监督检查，杜绝无证上岗、违章操作等行为。
(1) The accident unit shall establish and improve the safety management system of lifting machinery, formulate and strictly implement the crane operation procedures. Strengthen the supervision and inspection of the lifting machinery operation site, and put an end to unlicensed work, illegal operation and other behaviors.
（二）事故单位应加强对起重机械相关作业人员的安全教育、安全培训和管理，尤其要重视新员工的安全教育和技能培训，要加强外协单位员工进厂安全培训工作。
(2) The accident unit should strengthen the safety education, safety training and management of the relevant operators of lifting machinery, especially pay attention to the safety education and skill training of new employees, and strengthen the safety training of employees of the outsourcing unit entering the factory.
（三）事故单位应加强对特种设备的经常性检查和经常性维护保养，及时消除安全隐患。
(3) The accident unit shall strengthen the regular inspection and maintenance of special equipment to eliminate potential safety hazards in a timely manner.
