Scenario

01. Organizational Problems
02. Poor Management
03. Slackness of Management
04. Poor Value Perception
05. Poor Safety Awareness
06. Inadequate Risk Recognition
07. Carelessness
08. Insufficient Precaution
09. Carelessness of Operator
10. Usage
11. Operation/Use
12. Usage of Equipment/Material
13. Incorrect Reaction
14. Poor Communication
15. Malfunction
16. Poor Hardware
17. Machine Not Move
18. Bad Event
19. Chemical Phenomenon
20. Burning
21. Secondary Damage
22. External Damage
23. Fire
24. Loss to Organization
25. Economic Loss
26. Direct Manetary Damage 12million yen

Fire at a quenching oil bath caused due to short circuit at a spring manufacturing factory
Case Details

Knowledge Comment:
If a cause of a trouble could not be solved in a small trouble, a large trouble might occur.

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)