Scenario

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
Case Details

Knowledge Comment:
You must teach the properties of chemicals which was used in thd plant to the operators.

Field Chemicals and Plants
Author DOBASHI, Ritsu (School of Engineering, The University of Tokyo)
TAMURA, Masamitsu (Center for Risk Management and Safety Sciences, Yokohama National University)