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01. |
Ignorance of Procedure |
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02. |
Disregard of Procedure |
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03. |
Disregard of Work Procedure |
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04. |
Organizational Problems |
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05. |
Poor Management |
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06. |
Slackness of Management |
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07. |
Malicious Act |
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08. |
Rule Violation |
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09. |
Safety Rule Violation |
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10. |
Secondary Damage |
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11. |
External Damage |
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12. |
Leakage/Fire |
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13. |
Loss to Organization |
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14. |
Economic Loss |
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15. |
Manetary Damage 35 million yen |
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Leakage and fire caused due to start-up with a hose connected to an opened vent valve at inlet piping of a furnace at a fuel oil desulfurization unit
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Knowledge Comment: |
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Open the valve, connect the hose, then the plant start ! It is just like the action with devils on the back. |
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