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01. |
Organizational Problems |
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02. |
Inflexible Management Structure |
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03. |
Insufficient Information Transfer |
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04. |
Misjudgment |
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05. |
Misunderstanding |
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06. |
Insufficient Consideration on Instrument Design |
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07. |
Non-Regular Operation |
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08. |
Emergency Operation |
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09. |
Mis-design of Failure Position |
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10. |
Planning and Design |
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11. |
Poor Planning |
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12. |
Problem in Operation Indication |
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13. |
Bad Event |
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14. |
Chemical Phenomenon |
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15. |
Abnormal Reaction |
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16. |
Secondary Damage |
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17. |
External Damage |
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18. |
Explosion |
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19. |
Loss to Organization |
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20. |
Economic Loss |
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Explosion during preparation for manufacturing pesticide caused due to stopping of cooling water from a failure position setting error at a control valve
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Knowledge Comment: |
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Because the temperature control was not made at an emergency case, it was overheated! |
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