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01. |
Organizational Problems |
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02. |
Poor Management |
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03. |
Poor Repair Management |
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04. |
Carelessness |
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05. |
Insufficient Understanding |
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06. |
Insufficient Recognition of Risk |
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07. |
Planning and Design |
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08. |
Poor Planning |
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09. |
Poor Repair Management Planning |
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10. |
Usage |
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11. |
Maintenance/Repair |
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12. |
Poor Attention at Repair |
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13. |
Failure |
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14. |
Deformation |
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15. |
Gasket Failure |
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16. |
Secondary Damage |
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17. |
External Damage |
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18. |
Leakage |
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Leakage of hydrogen caused due to misuse of a gasket at a hydrogenation desulfurizing unit of an oil refinery
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Knowledge Comment: |
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A accident that is the same kind of the previous accident will have to occur again in the future, if a management system for the temporary use of a gasket would not be established. |
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