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01. |
Poor Value Perception |
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02. |
Poor Safety Awareness |
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03. |
Inadequate Risk Recognition |
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04. |
Organizational Problems |
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05. |
Inflexible Management Structure |
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06. |
Insufficient Education/Training |
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07. |
Ignorance |
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08. |
Insufficient Knowledge |
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09. |
Poor Study |
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10. |
Usage |
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11. |
Maintenance/Repair |
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12. |
Not repaired |
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13. |
Malicious Act |
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14. |
Rule Violation |
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15. |
Safety Rule Violation |
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16. |
Bad Event |
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17. |
Electrical Failure |
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18. |
Static Electricity Electrification |
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19. |
Secondary Damage |
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20. |
External Damage |
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21. |
Fire |
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22. |
Bodily Harm |
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23. |
Sickness |
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24. |
3 person sickness |
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25. |
Loss to Organization |
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26. |
Economic Loss |
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27. |
Direct Monetary Damage 13 million yen |
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Fire caused due to static electricity near an ink tank of a gravure printing machine
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Knowledge Comment: |
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Both of manager and operators did not understand that ink can fire easily and static electricity may cause ignition. |
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