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01. |
Insufficient Analysis or Research |
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02. |
Insufficient Practice |
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03. |
Inadequate Imagination |
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04. |
Ignorance |
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05. |
Insufficient Knowledge |
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06. |
Insufficient Study |
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07. |
Poor Value Perception |
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08. |
Poor Safety Awareness |
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09. |
Insufficient Recognition of Risk |
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10. |
Condensation Reaction |
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11. |
Planning and Design |
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12. |
Poor Planning |
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13. |
Poor Planning of Changing Raw Material |
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14. |
Regular Operation |
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15. |
Erroneous Operation |
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16. |
No Countermeasure against Abnormality |
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17. |
Bad Event |
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18. |
Chemical Phenomenon |
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19. |
Abnormal Reaction |
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20. |
Secondary Damage |
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21. |
External Damage |
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22. |
Explosion/Fire |
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23. |
Bodily Harm |
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24. |
Injury |
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25. |
1 person injured |
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26. |
Loss to Organization |
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27. |
Economic Loss |
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28. |
Plant Burnt up |
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Explosion and fire caused due to a change from sodium salt to potassium salt at a di-cumyl hydroperoxide manufacturing plant
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Knowledge Comment: |
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Even they are the same alkali, the properties of sodium hydroxide and potasium hydroxide are different ech other. Do not replace easily. |
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