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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. |
Insufficient Analysis or Research |
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05. |
Insufficient Practice |
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06. |
Lack of Imagination |
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07. |
Ignorance |
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08. |
Insufficient Knowledge |
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09. |
Insuficient Study and Experience |
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10. |
Planning and Design |
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11. |
Poor Planning |
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12. |
Regular Operation |
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13. |
Erroneous Operation |
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14. |
Closing Valves by Mistake |
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15. |
Bad Event |
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16. |
Chemical Phenomenon |
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17. |
Pressure Rise |
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18. |
Failure |
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19. |
Large-Scale Damage |
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20. |
Rapture |
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21. |
Secondary Damage |
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22. |
External Damage |
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23. |
Explosion |
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24. |
Bodily Harm |
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25. |
Injury |
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26. |
2 person injured |
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27. |
Loss to Organization |
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28. |
Economic Loss |
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29. |
Manetary Damage 14 million yen |
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Rupture, explosion and fire caused due to pressure rise during cleaning operation for a distillation kettle
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Knowledge Comment: |
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Inner pressure rose and the vessel ruptured by all the valve closing in errouneous operation and by too hot heating medium. |
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