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01. |
Ignorance of Procedure |
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02. |
Disregard of Procedure |
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03. |
No bliud Plate |
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04. |
Organizational Problems |
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05. |
Poor Management |
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06. |
Slackness of Management |
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07. |
Misjudgment |
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08. |
Misperception |
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09. |
Mis-Convincement |
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10. |
Malicious Act |
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11. |
Rule Violation |
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12. |
Safety Rule Violation |
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13. |
Secondary Damage |
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14. |
External Damage |
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15. |
Fire |
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16. |
Bodily Harm |
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17. |
Injury |
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18. |
2 person injured |
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|
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Fire caused due to back flow of dimethylamine during repairing work of piping from a reactor to a scrubber
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Knowledge Comment: |
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Under irresponsible organization, a dangaeous material vessel was opened to atmosphere, a fire occurred by hot work near the vessel. |
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