Scenario

01. Poor Value Perception
02. Poor Safety Awareness
03. Insuficient Education/Training for Safety
04. Carelessness
05. Insufficient Understanding
06. Insufficient Recognition of Risk
07. Organizational Problems
08. Poor Management
09. Slackness of Management
10. Malicious Act
11. Rule Violation
12. Safety Rule Violation
13. Bad Event
14. Chemical Phenomenon
15. Abnormal Reaction
16. Secondary Damage
17. External Damage
18. Leakage/Explosion
19. Bodily Harm
20. Death
21. 3 person died
22. Bodily Harm
23. Injury
24. 33 person injured
25. Loss to Organization
26. Economic Loss
27. Direct Monetary Damage 160 million yen
28. Damage to Society
29. Social Systems Failure

Explosion and fire caused due to a runaway reaction on start-up of the preparation of an adhesive manufacturing plant
Case Details

Knowledge Comment:
A runaway reaction occurred by heating strongly because the reaction did not proceed at initial stage of batch reaction. Large disaster generated involving the neibourhood area.

Field Chemicals and Plants
Author KOSEKI, Hirosi (National Research Institute of Fire and Disaster)
TAMURA, Masamitsu (Center for Risk Management and Safety Sciences, Yokohama National University)