Scenario

01. Organizational Problems
02. Inflexible Management Structure
03. Insufficient Education/Training
04. Carelessness
05. Insufficient Understanding
06. Insufficient Recognition of Risk
07. Condensation Reaction
08. Planning and Design
09. Poor Planning
10. Poor Design
11. Regular Operation
12. Nonobservance of Procedure
13. Bad Event
14. Chemical Phenomenon
15. Abnormal Reaction
16. Secondary Damage
17. External Damage
18. Explosion
19. Bodily Harm
20. Death
21. Bodily Harm
22. Injury
23. Bodily Harm
24. Sickness
25. 300 near-by inhibitants pained
26. Loss to Organization
27. Economic Loss
28. 1Working House Burnt Completely

Explosion due to condensation from miss-charge of toluidine into a vessel of diketene
Case Details

Knowledge Comment:
You must improve the facility not to be able to occur a mixing of dangerous materils absolutely.

Field Chemicals and Plants
Author ITAGAKI, Haruhiko (Japan National Institute of Occupational Safety and Health)
TAMURA, Masamitsu (Center for Risk Management and Safety Sciences, Yokohama National University)