Scenario

01. Misjudgment
02. Misunderstanding
03. Not Foreseen the Progress of Defect
04. Poor Value Perception
05. Poor Safety Awareness
06. Inadequate Risk Recognition
07. Organizational Problems
08. Poor Management
09. Poor Collection of New Information
10. Planning and Design
11. Poor Planning
12. Poor Design
13. Usage
14. Maintenance/Repair
15. No Inspction
16. Failure
17. Large-Scale Damage
18. Rapture
19. Loss to Organization
20. Economic Loss
21. Damage to Society
22. Social Systems Failure
23. 95 houses of near-by inhibitant damaged

Rupture of a reactor during an air-tight test of reactor used for 21 years at a catalytic hydro-desulfurization unit
Case Details

Knowledge Comment:
For a metal material, it is very important to recheck successively the using condition and repair method with following new information.

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)