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01. |
Carelessness |
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02. |
Insufficient Precaution |
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03. |
Carelessness of Operator |
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04. |
Organizational Problems |
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05. |
Inflexible Management Structure |
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06. |
Insufficient Information Transfer |
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07. |
Poor Value Perception |
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08. |
Poor Safety Awareness |
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09. |
Inadequate Risk Recognition |
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10. |
Malicious Act |
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11. |
Rule Violation |
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12. |
Safety Rule Violation |
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13. |
Planning and Design |
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14. |
Poor Planning |
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15. |
Poor Design |
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16. |
Secondary Damage |
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17. |
External Damage |
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18. |
Fire |
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19. |
Bodily Harm |
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20. |
Injury |
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21. |
2 person injured |
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Fire at a fin-fan cooler due to contamination of hydrogen by mishandling of a valve during turnaround shutdown maintenance at an atmospheric distillation unit
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Knowledge Comment: |
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Process pipings and utility pipings are not connected easily. You must take precise care to beginning of flammables supply when adjacent plant is under construction. |
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