Kebakaran di Pabrik Baja | Major accident at iron and steel plant


Major accident at iron and steel plant


No Danger for Kremikovtzi Steel Mill after Nearby Explosion ...

In January 2004, a major industrial accident occurred at Kremikovtzi, Bulgaria’s largest iron and steel plant, with three workers killed and 22 more hospitalised. An investigation subsequently highlighted major health and safety problems at the site. The tragedy focused attention on the widespread failure by companies to implement health and safety legislation, with trade unions calling for new measures to ensure the law’s effective application.

Kremikovtzi is Bulgaria’s largest plant involved in the extraction and primary processing of ferrous metals. The facility is situated on a site of 15 square kilometres east of the capital Sofia. Before privatisation, the company had more than 15,000 employees, but after a series of structural changes there are now 7,950 workers. A number of allied and maintenance activities are organised as separate enterprises. The plant undertakes the full cycle of production – extraction of iron ore, ‘agglomeration’, production of cast iron and steel etc. The company also extracts coke and produces electricity, heating and oxygen.

Kremikovtzi is regarded as having various inherited and new problems, notable old equipment and technologies and considerable investment shortages caused by old company debts. The plant is one of the main sources of environmental problems in the region. The working conditions at the plant are reported to be one of the main factors causing tension between management and employees, and have been raised by trade unions. However, the company has been making efforts to meet the basic requirements of health and safety legislation. For example:

  • there is an occupational safety service with good capacity;
  • the company has its own occupational health service;
  • there are health and safety committees at company and workshop level;
  • there is a process of identifying and evaluating risks; and
  • internal health and safety regulations are regarded as being soundly based.

Major accident

At about 16.30 on 10 January 2004, the operator of monitoring equipment at Kremikovtzi’s water-power department reported that the pressure in the water pipeline supplying the blast furnace’s gas-purifying machinery was falling. A breakdown team was sent to the scene and started repairs to the pipeline, though without coordinating its action with the operational management of the blast furnace and the firm’s ‘gas-rescue’ service. At about 17.00, gases from the blast furnace, containing a high level of carbon monoxide, started to escape from the broken pipe. Twelve firefighters were sent in, without being given sufficient information on the concentration of carbon monoxide. More gases then started leaking due to a rapid decrease in the water level and the elimination of the machinery’s ‘water barrier’. As a result of this series of human errors, the noxious gases killed three people, including one firefighter. Another 22 suffered various levels of poisoning and were hospitalised.

Reasons identified

An investigation of the circumstances and the reasons for the accident drew several important conclusions. First, the gas escape could have been stopped if there had been good coordination between the actions of the breakdown team, the specialists at the blast furnace and the gas-rescue service. There were two spare water pipelines that could have supplied water for the gas-purifying machinery and maintained a sufficient water barrier. With regard to the situation after the gas escaped, the investigation found that,

  • the rescue unit’s actions and equipment (including breathing equipment) was inadequate;
  • the parts of the blast furnace where there was a danger of gas leaks did not have an automatic warning system;
  • there were serious gaps in the education and training of the main technical workers responsible for the gas-purifying system;
  • the necessary technical inspections of the condition of the firefighters’ breathing equipment had not been undertaken; and
  • important labour inspectorate instructions on technical supervision and internal communications, as well as on equipment to cool and purify blast furnace gases had not been implemented.

The investigation concluded that:

  • important legal provisions had been only formally implemented.
  • the risk evaluation was formal and imperfect;
  • the management ignored points raised by trade unions;
  • there was a lack of reliable information, communication and coordination systems; and
  • there was a lack of coordination between various services and the external companies working at the site.

After the tragedy

Following its investigation of the reasons for the accident, the labour inspectorate imposed a fine on 16 officers of the company. The inquest continues and a criminal prosecution of officers may follow. At the request of trade unions, the company’s executive director imposed disciplinary penalties, including the dismissal of employees who had violated health and safety instructions. The labour inspectorate has issued more than 20 instructions to address legal violations and omissions in the organisation and management of health and safety activities at the site.

At the initiative of the Confederation of Independent Trade Unions in Bulgaria (CITUB), a number of extraordinary joint meetings have been held, involving trade union leaders, company management and the Kremikovtzi working conditions committee. CITUB also insisted on a special meeting of the National Working Conditions Council to discuss the tragedy. A number of concrete actions at national level were discussed at this meeting, aimed at the real implementation of the health and safety and working conditions legislation. These include:

  • stronger control of high-risk production activities;
  • increasing the capacity of the chief labour inspectorate;
  • development of a special labour inspection law;
  • enforcing a differentiated employer’s insurance contribution for work accidents and occupational illnesses by 1 January 2005;
  • the introduction of economic incentives (eg tax and credit relief) to stimulate investments in improving working conditions;
  • the introduction of special obligatory work accident insurance for particularly high-risk occupations and activities; and
  • improving the training of working conditions committees and groups, managers and company officers, and trade union officials working in the field of health and safety at work.


In the context of the Kremikovtzi tragedy, a number of conclusions can be drawn with regard to the general state of working conditions in Bulgarian enterprises. The Bulgarian legislation in the field of health and safety and working conditions has been fully harmonised with the EU norms and criteria, but its implementation is taking time

The harmonisation of Bulgarian legislation with EU norms has put enterprises in a difficult situation. They are largely technologically undeveloped, their equipment is old, and there are financing and investment deficits and a lack of economic incentives for investment in working conditions and the innovation of production as a whole. Companies’ markets have become narrower and there is a lack of markets for whole branches of activity. This has been accompanied by mass redundancies, ‘groundless’ restructuring and the elimination of whole areas of production. Strict cost-saving regimes have been introduced which have affected heating, air-conditioning and cleaning equipment, lighting installations and other equipment that have a direct effect on working conditions. Unfortunately, nowadays the working conditions in many Bulgarian enterprises have been downgraded. The new health and safety legislation provided for a six-year period for its application by enterprises and workplaces, but during this period they have not been able to do so.

A number of companies have made an attempt to respond to the main legal regulations on health and safety. However these regulations have been those with an organisational and managing character, requiring considerable management efforts but less in the way of investment resources. A real change in working conditions has not happened in most enterprises. This is a process that requires a different type of effort and resources and a different time schedule. New ‘non-traditional’ approaches should be found. The state and the social partners should develop their capacity and resources to influence the implementation of the health and safety legislation. (Todor Todorov, Institute for Social and Trade Union Research)

Dalam konteks tragedi Kremikovtzi, sejumlah kesimpulan dapat ditarik sehubungan dengan keadaan umum kondisi kerja di perusahaan-perusahaan Bulgaria. Undang-undang Bulgaria di bidang kesehatan dan keselamatan dan kondisi kerja telah sepenuhnya diselaraskan dengan norma dan kriteria UE, tetapi implementasinya membutuhkan waktu.

Harmonisasi undang-undang Bulgaria dengan norma UE telah menempatkan perusahaan dalam situasi yang sulit. Mereka sebagian besar tidak berkembang secara teknologi, peralatan mereka sudah tua, dan ada defisit keuangan dan investasi serta kurangnya insentif ekonomi untuk investasi dalam kondisi kerja dan inovasi produksi secara keseluruhan. Pasar perusahaan menjadi lebih sempit dan ada kekurangan pasar untuk seluruh cabang kegiatan. Ini telah disertai dengan redundansi massal, restrukturisasi ‘tanpa dasar’ dan penghapusan seluruh area produksi. Rezim penghematan biaya yang ketat telah diperkenalkan yang telah mempengaruhi pemanasan, AC dan peralatan pembersihan, instalasi penerangan dan peralatan lainnya yang memiliki efek langsung pada kondisi kerja. Sayangnya, saat ini kondisi kerja di banyak perusahaan Bulgaria telah diturunkan. Undang-undang kesehatan dan keselamatan yang baru menetapkan periode enam tahun untuk penerapannya oleh perusahaan dan tempat kerja, tetapi selama periode ini mereka belum dapat melakukannya.

Sejumlah perusahaan telah berupaya untuk menanggapi peraturan hukum utama tentang kesehatan dan keselamatan. Namun peraturan ini memiliki karakter organisasi dan pengelolaan yang membutuhkan upaya manajemen yang besar tetapi kurang dalam hal sumber daya investasi. Perubahan nyata dalam kondisi kerja belum terjadi di sebagian besar perusahaan. Proses ini membutuhkan jenis upaya dan sumber daya yang berbeda serta jadwal waktu yang berbeda. Pendekatan ‘non-tradisional’ baru harus ditemukan. Negara dan mitra sosial harus mengembangkan kapasitas dan sumber dayanya untuk memengaruhi pelaksanaan undang-undang kesehatan dan keselamatan. (Todor Todorov, Lembaga Penelitian Sosial dan Serikat Buruh)


WDA Online Training | Mengelola Akseptasi Risiko Pabrik Baja dan Solusi Asuransi dan Reasuransi-nya(Steel Manufacturer’s Risk and Insurance) | Rabu, 03 Februari 2021 | 09:00 s/d 12:00

WDA Online Training | Mengelola Akseptasi Risiko Pabrik Baja dan Solusi Asuransi dan Reasuransi-nya(Steel Manufacturer’s Risk and Insurance) | Rabu, 03 Februari 2021 | 09:00 s/d 12:00

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