Scenario

01. Organizational Problems
02. Inflexible Management Structure
03. Insufficient Information Transfer
04. Organizational Problems
05. Poor Staff
06. Poor Experiment of Staff
07. Ignorance
08. Insufficient Knowledge
09. Insufficient Study
10. Diels-Alder Reaction
11. Non-Regular Action
12. Inaction
13. Not Change the Operation Conditions
14. Non-Regular Operation
15. Change in Operation
16. Agitator Stop
17. Malfunction
18. Poor Hardware
19. Mal HeatTransfer
20. Bad Event
21. Chemical Phenomenon
22. Runaway Reaction
23. Extraordinary Pressure Rise
24. Failure
25. Large-Scale Damage
26. Leakage
27. Secondary Damage
28. External Damage
29. Fire
30. Bodily Harm
31. Death
32. 2 Person Died
33. Bodily Harm
34. Injury
35. Serious Injury

Fire caused due to stopping an agitator of a liquid seal-type reactor during a temporary shutdown procedure at an ethylidene norbornene plant
Case Details 100 Selected Cases

Knowledge Comment:
Can you understand what may occur if you stop the agitation on exotheremic reaction with non-catalyst and homogenious?!

Field Chemicals and Plants
Author KOBAYASHI, Mitsuo (Office K)
TAMURA, Masamitsu (Center for Risk Management and Safety Sciences, Yokohama National University)