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01. |
Organizational Problems |
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02. |
Inflexible Management Structure |
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03. |
Insufficient Education/Training |
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04. |
Misjudgment |
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05. |
Misunderstanding |
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06. |
Mis-Convincement |
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07. |
Planning and Design |
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08. |
Poor Planning |
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09. |
Poor Design |
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10. |
Regular Operation |
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11. |
Erroneous Operation |
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12. |
Mistake Opertion |
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13. |
Bad Event |
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14. |
Chemical Phenomenon |
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15. |
Abnormal Reaction |
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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. |
Injury |
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21. |
6 person injured |
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22. |
Loss to Organization |
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23. |
Economic Loss |
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24. |
Direct Monetary Damage 100 million yen |
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Explosion and fire caused due to simultaneous addition of the whole quantity of additives at a stretch on redistilling vinyl acetate monomer
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Knowledge Comment: |
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The first step is very important at a batch reaction. You should keep the flow rate. |
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