Scenario

01. Poor Value Perception
02. Poor Safety Awareness
03. Poor Recognition of Importance about Structure and Parts
04. Carelessness
05. Insufficient Understanding
06. Insufficient Recognition of Risk
07. Usage
08. Maintenance/Repair
09. Repair
10. Oversight of Secure Deterioration
11. Failure
12. Large-Scale Damage
13. Rapture
14. Secondary Damage
15. External Damage
16. Explosion
17. Bodily Harm
18. Death
19. 10 peson died
20. Bodily Harm
21. Injury
22. 7 person injured
23. Loss to Organization
24. Economic Loss
25. Direct Monetary Damage 2900 million yen

Leakage and explosion at a heat exchanger having a special structure caused due to insufficient maintenance of a vacuum gas oil hydrodesulfurization unit
Case Details

Knowledge Comment:
For special type equipment, you must understand sufficiently the structure and the function of the equipment.

Field Chemicals and Plants
Author KOSEKI, Hirosi (National Research Institute of Fire and Disaster)
TAMURA, Masamitsu (Center for Risk Management and Safety Sciences, Yokohama National University)