Scenario

01. Insufficient Analysis or Research
02. Insufficient Prior Research
03. Influences of diverted vessel
04. Organizational Problems
05. Inflexible Management Structure
06. Insufficient Information Transfer
07. Planning and Design
08. Poor Planning
09. Cleanng of diverted vessel
10. Bad Event
11. Chemical Phenomenon
12. Viscosity Increase
13. Failure
14. Fracture/Damage
15. Loosen of Joint Part
16. Secondary Damage
17. External Damage
18. Leakage

Leakage of hydraulic oil of an agitator caused due to increase in reaction fluid viscosity from contamination of a catalyst in a polystyrene polymerization reactor
Case Details

Knowledge Comment:
It is very difficult to clean a diverted vessel thoroughly, especially remaining of ultra small amount of impuriies is required.

Field Chemicals and Plants
Author YOSHINAGA, Jun (Graduate School of New Frontier Sciences, The University of Tokyo)
TAMURA, Masamitsu (Center for Risk Management and Safety Sciences, Yokohama National University)