导致此次偏差发生的根本原因是杨国富误打开气动阀，由于其工作时间不长缺乏

The root cause of this deviation is that Yang Guofu opened the pneumatic valve by mistake. Due to its short working time and lack of awareness of the consequences of forced opening of the pneumatic valve, the pneumatic valve was not closed in time; Xu Xiuzhi did not check the pneumatic valve first when opening the manual valve. In the switch state, by default, the pneumatic valve is normally closed, which causes the ammonia valve to be fully opened, and the ammonia flows directly into the tank, causing the pH to rise rapidly and exceed the process range. At the same time, H3-MPD-10206-01 04 edition of the "1,4-butane disulfonate adenosylmethionine fermentation post operating procedures" lacks the description of ammonia automatic control operation. <br><br>The pH of the 205 seed tank of adenosylmethionine 1,4-butanesulfonate exceeded the process range from 04:30 to 09:50 on December 14, 2019, and the duration lasted about 6 hours, and in December 2019 At 08:30 on the 14th, the OD600 was only 2.82, which was much lower than the normal batch. Because the pH is high for a long time (about 9), the growth of the bacteria is severely inhibited, and even death and autolysis can not meet the requirements of transplantation. In order to prevent the influence of this deviation from being further expanded, the batch of 205 cans was inverted. The production of the next step is not carried out, and there is no corresponding finished product. The 9001-191203 batch of 308 cans of fermentation medium has been sterilized and kept under pressure on December 13, 2019. In the case of second-level seeds, it avoids the risk of bacterial infection at the later stage, and is also treated by pouring. The automatic pneumatic valve for ammonia water in the secondary seed tank of adenosylmethionine 1,4-butanedisulfonate lacks a label and cannot prompt the operator to confirm the valve switch status in time. The 1,4-butane disulfonate adenosine methionine fermentation post operating procedures lack a description of the ammonia-based automatic control operation and cannot play a guiding role, and need to be upgraded. <br><br>CP-TZ-API-D-TZ-API-12AD-19004-20001: Invert cans for 205 and 308 cans. <br>CP-TZ-API-D-TZ-API-12AD-19004-20002: For the automatic control of ammonia water in the secondary seed tank of adenosylmethionine 1,4-butanedisulfonate, the normally open flag is added to the upper pneumatic valve, and the lower pneumatic valve is increased to Closed sign.<br>CP-TZ-API-D-TZ-API-12AD-19004-20003: upgraded version H3-MPD-10206-01 1,4-butane disulfonate adenosine methionine fermentation post operation rules (version 04), adding ammonia Description of self-control operation. And train all personnel in Building Y10 of Workshop 109, and take this deviation as a case to emphasize the hazard of forced opening of the pneumatic valve and the ammonia valve must be confirmed to be normally closed before the automatic control operation of ammonia.

The root cause of this deviation is That Yang Guofu mistakenly opened the pneumatic valve, because its working time is not long lack of awareness of the consequences of the pneumatic valve forced to open, did not close the pneumatic valve in time; At the same time H3-MPD-10206-04 version of "1,4-butyl sulfonate adenosine methionine fermentation post operating procedures" lack of ammonia self-control operation description. <br><br>The pH of the 205 seed tank of 1,4-disulphate adenosine methionine was out of the process range between 0430 and 0950 hours on 14 December 2019 and lasted approximately 6 hours, and at 0830 hours on 14 December 2019, OD600 was only 2.82, much lower than the usual batch. Because pH for a long time higher (9 or so), the growth of the bacteria is severely inhibited, or even die self-soluble, can not meet the migration requirements, in order to prevent the impact of this deviation further expanded, so the batch of 205 cans for reverse tank treatment, not the next process of production, no corresponding finished products. And 9001-191203 batches of 308 cans of fermentation medium, because on December 13, 2019 has been sterilized, pressure-protected standby, in the case of secondary seeds, to avoid the risk of late-stage geriatric infection, but also to do inverted tank treatment. 1,4-disulplysulpin ethine secondary seed tank ammonia self-control pneumatic valve lack of identification, can not promptly remind the operator to confirm the valve switch status. 1,4-butyl sulfonate adenosine methionine fermentation post operating procedures lack of ammonia self-control operation description, can not play a guiding role, need to upgrade.<br><br>CP-TZ-API-D-TZ-API-12AD-19004-20001: Pour 205 and 308 cans.<br>CP-TZ-API-D-TZ-API-12AD-19004-20002: For 1,4-dyfolasulfonocosin adenoid anoineform secondary seed tank ammonia self-control on the pneumatic valve increases the normal open logo, the lower pneumatic valve increases the normal closure mark.<br>CP-TZ-API-D-TZ-API-12AD-19004-20003: Ascending H3-MPD-10206-01 1, 4-disulpylate adenine coric acid fermentation post operating procedures (04), add a description of the operation of ammonia self-control. And 109 workshop Y10 all personnel training, and this deviation as a case to emphasize the pneumatic valve forced to open the hazard and ammonia self-control operation before the first to confirm that the pneumatic valve is normally closed.

The root cause of this deviation is that Yang Guofu mistakenly opened the pneumatic valve. Due to his short working time and lack of awareness of the consequences of the forced opening of the pneumatic valve, he did not close the pneumatic valve in time. Xu Xiuzhi did not check the opening and closing status of the pneumatic valve before opening the manual valve, and he defaulted that the pneumatic valve was normally closed based on experience, which led to the opening of all the ammonia valves and the direct flow of ammonia into the tank, Causes the pH to rise rapidly and beyond the process range. At the same time, h3-mpd-10206-01 04 edition of the operating procedures for adenosylmethionine 1,4-butanedisulfonate fermentation Posts lacks the description of automatic operation of ammonia water.<br>The pH of 205 seed tank of ademetionine 1,4-butanedisulfonate exceeded the process range from 04:30 to 09:50 on December 14, 2019, lasting for about 6 hours, and at 08:30 on December 14, 2019, the OD600 was only 2.82, which was much lower than the normal batch. Due to the high pH value (about 9) for a long time, the growth of the bacteria was severely inhibited, even died and autolysed, which could not meet the requirements of seed transfer. In order to prevent the further expansion of the impact of this deviation, the batch of 205 tanks were inverted, without the next process production, and no corresponding finished products. In the case of secondary seeds, the 308 tank fermentation medium of batch 9001-191203 has been sterilized and kept for standby on December 13, 2019, so as to avoid the risk of bacteria infection in the later stage, and it is also inverted. The automatic control pneumatic valve of ammonia water in the 1,4-butanedisulfonic acid ademetionine secondary seed tank is lack of identification, so it is unable to prompt the operator to confirm the opening and closing status of the valve. There is no description of ammonia automatic control operation in the operation procedure of 1,4-butanedisulfonic acid ademetionine fermentation post, which can not play a guiding role and needs to be upgraded.<br>Cp-tz-api-d-tz-api-12ad-19004-20001: pour 205 and 308 tanks.<br>Cp-tz-api-d-tz-api-12ad-19004-20002: add the normally open mark to the upper pneumatic valve of the ammonia automatic control system of the 1,4-butanedisulfonic acid ademetionine secondary seed tank, and add the normally closed mark to the lower pneumatic valve.<br>Cp-tz-api-d-tz-api-12ad-19004-20003: upgraded h3-mpd-10206-01 operation procedures for 1,4-butanedisulfonic acid adenosylmethionine fermentation post (version 04), added the description of automatic operation of ammonia water. All personnel in building Y10 of workshop 109 were trained, and the deviation was taken as an example to emphasize the harm of forced opening of pneumatic valve and to confirm that the lower pneumatic valve is normally closed before automatic control operation of ammonia water.<br>