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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. |
Planning and Design |
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08. |
Poor Planning |
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09. |
Unripeness Autmatization Planning |
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10. |
Production |
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11. |
Software Production |
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12. |
Non-Regular Action |
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13. |
Change |
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14. |
Change of Operation Procedure |
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15. |
Malfunction |
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16. |
Poor Software |
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17. |
Umbalanced Operation |
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18. |
Secondary Damage |
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19. |
External Damage |
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20. |
Explosion |
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21. |
Bodily Harm |
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22. |
Death |
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23. |
4 person died |
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24. |
Bodily Harm |
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25. |
Injury |
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26. |
15 person injured |
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27. |
Loss to Organization |
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28. |
Economic Loss |
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29. |
Direct Manetary Damage 14 million yen |
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Explosion occurred immediately after automation of a reactor for preparing guanidine nitrate.
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Knowledge Comment: |
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They could not evaluate a risk after change because the automation of the plant was in unripeness. |
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