 |
01. |
Poor Value Perception |
 |
02. |
Poor Safety Awareness |
 |
03. |
Inadequate Risk Recognition |
 |
04. |
Organizational Problems |
 |
05. |
Inflexible Management Structure |
 |
06. |
Insufficient Education/Training |
 |
07. |
Carelessness |
 |
08. |
Insufficient Precaution |
 |
09. |
Carelessness of operators |
 |
10. |
Planning and Design |
 |
11. |
Poor Planning |
 |
12. |
Poor Design |
 |
13. |
Regular Operation |
 |
14. |
Nonobservance of Procedure |
 |
15. |
Insufficient Recognition |
 |
16. |
Bad Event |
 |
17. |
Mechanical Event |
 |
18. |
Meander |
 |
19. |
Bad Event |
 |
20. |
Chemical Phenomenon |
 |
21. |
Evaporation/Combustible Gas-air Mixture |
 |
22. |
Secondary Damage |
 |
23. |
External Damage |
 |
24. |
Explosion/Fire |
 |
25. |
Loss to Organization |
 |
26. |
Economic Loss |
 |
27. |
Direct Monetary Damage 200 million yen |
|
|
 |

Explosion and fire of toluene excessively contained in paper in the paper-coating process
|
 |
Knowledge Comment: |
 |
You must teach the properties of chemicals which was used in thd plant to the operators. |
|
|
|
|