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01. |
Poor Value Perception |
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02. |
Poor Safety Awareness |
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03. |
Mal Safety Management/Education |
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04. |
Carelessness |
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05. |
Insufficient Understanding |
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06. |
Insufficient Recognition of Risk |
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07. |
Usage |
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08. |
Maintenance/Repair |
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09. |
Poor Planning of Repair |
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10. |
Incorrect Reaction |
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11. |
Poor Communication |
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12. |
No Communiction |
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13. |
Secondary Damage |
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14. |
External Damage |
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15. |
Leakage |
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16. |
Bodily Harm |
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17. |
Death |
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18. |
4 person died |
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19. |
Bodily Harm |
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20. |
Sickness |
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21. |
44 Person Poisoning |
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Leakage of hydrogen sulfide gas caused due to overlapping of some errors during shutdown maintenance for off-site piping at a refinery
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Knowledge Comment: |
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A repair work in which a sepatation was done by cosing only one remote valve resulted a catastrophe when the driving air of the valve failed. |
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