 |
01. |
Misjudgment |
|
02. |
Misperception |
|
03. |
Mis-Convincement |
|
04. |
Ignorance of Procedure |
|
05. |
Insufficient Communication |
|
06. |
Organizational Problems |
|
07. |
Poor Management |
|
08. |
Slackness of Management |
|
09. |
Usage |
|
10. |
Maintenance/Repair |
|
11. |
Start Transfer before Finishing of Repair |
|
12. |
Malicious Act |
|
13. |
Rule Violation |
|
14. |
Safety Rule Violation |
|
15. |
Secondary Damage |
|
16. |
External Damage |
|
17. |
Fire |
|
18. |
Bodily Harm |
|
19. |
Injury |
|
20. |
Loss to Organization |
|
21. |
Economic Loss |
|
22. |
Direct Monetary Damage 110 million yen |
|
23. |
Loss to Organization |
|
24. |
Social Loss |
|
25. |
Closing Oil Terminal |
|
|
|
Fire and complete destruction of an oil terminal due to using pipes before finishing repairs
|
 |
Knowledge Comment: |
|
The beginning of safety is communication and reconfirmation |
|
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