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01. |
Poor Value Perception |
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02. |
Poor Safety Awareness |
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03. |
Inadequate Risk Recognition |
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04. |
Organizational Problems |
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05. |
Inflexible Management Structure |
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06. |
Insufficient Education/Training |
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07. |
Insufficient Analysis or Research |
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08. |
Insufficient Practice |
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09. |
Lack of Imagination |
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10. |
Planning and Design |
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11. |
Poor Planning |
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12. |
Poor Design |
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13. |
Usage |
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14. |
Operation/Use |
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15. |
Process Waste Water |
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16. |
Gas Accumulation during Work |
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17. |
Bad Event |
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18. |
Chemical Phenomenon |
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19. |
Heat Generation/ Ignition |
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20. |
Secondary Damage |
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21. |
External Damage |
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22. |
Fire |
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23. |
Loss to Organization |
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24. |
Economic Loss |
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25. |
Direct Monetary Damage 23 million yen |
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Sudden fire due to contamination of unexpected impurities during neutralization work at a waste water storage tank
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Knowledge Comment: |
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They considered the countermeasure against the dissoluted flammable gases in the waste water, but final check was not sufficient. |
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