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01. |
Ignorance |
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02. |
Insufficient Knowledge |
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03. |
No Thinking of Reaction Danger at Temperature Rising |
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04. |
Planning and Design |
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05. |
Poor Planning |
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06. |
Careless Temperature Rising Plan |
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07. |
Bad Event |
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08. |
Chemical Phenomenon |
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09. |
Abnormal Reaction |
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10. |
Secondary Damage |
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11. |
External Damage |
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12. |
Explosion |
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13. |
Bodily Harm |
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14. |
Death |
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15. |
2Person Died |
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Rupture of a solvent recovery drum caused by an abnormal reaction due to a temperature rise at a sugar ester manufacturing plant
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Knowledge Comment: |
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It is very dangerous to rise operation temperature without safety study. |
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