 |
01. |
Insufficient Analysis or Research |
 |
02. |
Insufficient Prior Research |
 |
03. |
Effect of very small amount product |
 |
04. |
Poor Value Perception |
 |
05. |
Poor Safety Awareness |
 |
06. |
Inadequate Safety Countermeasure |
 |
07. |
Planning and Design |
 |
08. |
Poor Planning |
 |
09. |
Poor Design |
 |
10. |
Usage |
 |
11. |
Maintenance/Repair |
 |
12. |
Insufficient Inspection |
 |
13. |
Failure |
 |
14. |
Fracture/Damage |
 |
15. |
Crack |
 |
16. |
Secondary Damage |
 |
17. |
External Damage |
 |
18. |
Explosion |
 |
19. |
Bodily Harm |
 |
20. |
Injury |
 |
21. |
3 person injured |
 |
22. |
Loss to Organization |
 |
23. |
Economic Loss |
 |
24. |
Direct Monetary Damage 24 million yen |
|
|
 |

Explosion caused due to a leakage of a heat medium (nitrate) through a crack in the reactor at a phthalic anhydride manufacturing plant
|
 |
Knowledge Comment: |
 |
It is overlooked that contamination danger material was generated from the heat medium and a reaction product. The cruck occurred at the place where the leakage was mandatory inhibited to avoid the contamination. |
|
|
|
|