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01. |
Poor Value Perception |
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02. |
Poor Safety Awareness |
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03. |
Insufficient Recognition of Risk |
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04. |
Organizational Problems |
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05. |
Poor Management |
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06. |
Slackness of Management |
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07. |
Planning and Design |
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08. |
Poor Planning |
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09. |
Insufficient Schedule Management at Shutdown |
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10. |
Non-Regular Operation |
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11. |
Change in Operation |
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12. |
Operation Differ from Direction |
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13. |
Failure |
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14. |
Deformation |
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15. |
Shrinkage of Piping/Heat Exchanger |
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16. |
Secondary Damage |
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17. |
External Damage |
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18. |
Fire |
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Leakage and fire of fuel oil from a flange between a heat exchanger and piping during shutdown operation at a vacuum gas oil hydrodesulfurization unit
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Knowledge Comment: |
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Metals must shrink at temperature dropping, so rapid temperature drop has to be avoided. |
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