 |
01. |
Insufficient Analysis or Research |
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02. |
Insufficient Prior Research |
|
03. |
Danger of Material |
|
04. |
Poor Value Perception |
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05. |
Poor Safety Awareness |
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06. |
Inadequate Risk Recognition |
|
07. |
Planning and Design |
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08. |
Poor Planning |
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09. |
Poor Process Design |
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10. |
Bad Event |
|
11. |
Chemical Phenomenon |
|
12. |
Concentration |
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13. |
Bad Event |
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14. |
Mechanical Event |
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15. |
Blockage |
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16. |
Secondary Damage |
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17. |
External Damage |
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18. |
Explosion |
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19. |
Bodily Harm |
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20. |
Death |
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21. |
22 person died |
|
22. |
Bodily Harm |
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23. |
Injury |
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24. |
363 person injured |
|
25. |
Damage to Society |
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26. |
Social Systems Failure |
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27. |
142 buildings damaged |
|
|
|
Explosion of ammonium nitrate caused due to superfluous concentration at an ammonium sulfate recovery process
|
 |
Knowledge Comment: |
|
At newly development process, concentration of very small amount of dangerous impurities may be failed to notice. |
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