Scenario

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
Case Details

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.

Field Chemicals and Plants
Author ARAI, Mitsuru (Environmental Science Center, The University of Tokyo)
TAMURA, Masamitsu (Center for Risk Management and Safety Sciences, Yokohama National University)