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China Accident Investigation
Report No. CN-MEM-2013-06-03
2013
Fire Fire Explosion Explosion Toxic release Toxic
吉林宝源丰禽业'6·3'特别重大火灾爆炸事故（2013，121 死）
吉林宝源丰禽业有限公司，长春市德惠市（国务院事故调查报告转发）
Related equipment → piping (piping)
121Fatalities
76Injuries
ExplosionMechanism code ELP
⌗Failure Mode · ISO 14224 Mapping
Damage mechanism (recorded in KB)
ExplosionELP
ISO functional code (as recorded)
ISO 14224:2016 functional failure code
ELP · External leakage - process
ISO ELP — External leakage - process.
1What Happened
主厂房电气线路短路引燃可燃物，火势蔓延至氨设备/氨管道→高温致氨设备物理爆炸、大量氨气泄漏介入燃烧
2Root Cause
违规将保温材料由岩棉换易燃聚氨酯；未安全培训/演练；安全出口锁闭；氨制冷系统物理爆炸
3Reliability Lessons (from investigation root cause)
- The 'Root Cause' above is the core lesson of this accident; not split further.
4Associated Failure Mechanisms (Keywords)
氨 制冷 电气短路 氨管道 物理爆炸 泄漏 聚氨酯保温 安全出口锁闭 氨气中毒
About the Failure-Mode Code (click to expand)
The recorded code ELP is an ISO 14224:2016 functional failure code (describes what the equipment failed to do). The damage mechanism (how it failed) is shown in the Mapping block above. The two are distinct dimensions in ISO 14224.
5Evidence Source (transparent)
Authority：国务院事故调查组（地方政府转发）
Official Report：www.ypzf.gov.cn ↗
Data Verification：verified_url_ypzf_gov_cn_2026-08-07
↗Related Failure Modes · Traceability
This accident is not yet linked to a specific FM traceability card.