| Case Name |
A fire occurred on re-startup after an emergency shutdown of a body painting robot for automobiles |
| Pictograph |
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| Date |
April 13, 1989 |
| Place |
Zama, Kanagawa, Japan |
| Location |
Automobile factory |
| Overview |
On April 13th, 1989, a spray painting line of an automobile factory stopped due to a high-voltage failure. The high-voltage error was reset without sufficient checking. Then, ignition occurred when spray-painting restarted. It was not taken into account that toluene and other light hydrocarbons, which ignite very easily, are used in spray painting booths. |
| Incident |
The painting line for automobiles stopped during coating operation due to a high-voltage failure. The high-voltage error was reset on the control panel, and the line started operation again. At that time, a small flame was generated from the blowing gun on the left side of the automated painting robot in the first stage of the third booth, and the fire spread to the third booth, fourth booth, and mixing pump rooms, etc. |
| Processing |
Consumption and usage |
| Substance |
Lacquer thinner (main part; toluene) |
| Type of Accident |
Fire |
| Sequence |
About 00:00 on April 13th, 1989. A fire occurred.
It was difficult to approach and check the booth because of the special structure of the paint booth in the factory. The fire spread vertically, because coating material adhered to the booths. There were many blind spots, and fire-extinguishing activity was very difficult.
03:40. The fire was extinguished. |
| Cause |
On restart, investigation into the reason for the line stopping was insufficient. The ignition cause was considered to be static electric sparks. |
| Response |
The equipment was stopped urgently. |
| Countermeasures |
Investigation into causes and treatment are carried out when mechanical troubles arise. Training and education on initial fire fighting activities are carried out. |
| Knowledge Comment |
In the case of trouble, automatic cut-off devices must not be reset until confirmation and countermeasures are completed. |
| Background |
There was insufficient recognition of handling a dangerous material, and restarting was done without checking the situation. A lack of recognition of managers and education for workers handling dangerous materials are considered to be the true causes of the accident. |
| Reason for Adding to DB |
Example of fire caused due to high-voltage failure in a paint booth |
| Scenario |
| Primary Scenario
|
Poor Value Perception, Poor Safety Awareness, Inadequate Risk Recognition, Organizational Problems, Inflexible Management Structure, Insufficient Education/Training, Carelessness, Insufficient Precaution, Carelessness of Operator, Malicious Act, Rule Violation, Safety Rule Violation, Secondary Damage, External Damage, Fire, Loss to Organization, Economic Loss, Direct Monetary Damage 130million yen
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| Sources |
Fire and Disaster Management Agency. Major cases of accidents. Fire occurring from spray nozzle of painting robot that finishes the body. Accident cases of dangerous materials. pp.31, 262-263.
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| Physical Damage |
A paint booth mixing chamber and attached facilities of about 2200 square meters were destroyed by fire (including a top coating booth, top coating oven, conveyor, automated painting machine, paint blending room). Lacquer thinner, lacquer, melamine alkyd were damaged. |
| Financial Cost |
¥ 131 million (Accident cases of dangerous materials) |
| Field |
Chemicals and Plants
|
| Author |
DOBASHI, Ritsu (School of Engineering, The University of Tokyo)
TAMURA, Masamitsu (Center for Risk Management and Safety Sciences, Yokohama National University)
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