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01. |
Ignorance |
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02. |
Insufficient Knowledge |
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03. |
Insufficient Study |
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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. |
Misjudgment |
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08. |
Misunderstanding |
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09. |
Relation between Reaction Progress and Dangerousness |
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10. |
Other Reaction |
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11. |
Regular Operation |
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12. |
Erroneous Operation |
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13. |
Opration without Thinking Timing |
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14. |
Bad Event |
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15. |
Chemical Phenomenon |
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16. |
Abnormal Reaction |
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17. |
Secondary Damage |
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18. |
External Damage |
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19. |
Leakage |
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20. |
Bodily Harm |
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21. |
Injury |
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22. |
4 person burnt |
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Spouting of high-temperature liquid from the reactor due to a hot spot formed on stopping the agitator
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Knowledge Comment: |
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It is very dangerous to stop the agitation on a half way of reaction. Why was the agitation stopped? |
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