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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. |
Misjudgment |
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08. |
Misperception |
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09. |
Mis-Convincement |
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10. |
Planning and Design |
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11. |
Poor Planning |
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12. |
Poor Start-up Planning |
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13. |
Regular Operation |
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14. |
Erroneous Operation |
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15. |
Selfish Judgment |
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16. |
Secondary Damage |
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17. |
External Damage |
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18. |
Explosion |
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19. |
Bodily Harm |
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20. |
Injury |
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21. |
3 person injured |
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22. |
Loss to Organization |
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23. |
Economic Loss |
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24. |
Direct Manetary Loss 210 million yen |
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Explosion and fire of a boiler for power generation on restarting operation
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Knowledge Comment: |
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Reckless Operation ! They separated the fuel gas in pipings from atmosphere only by one valve at many pipings, moreover the valves opened slightly. |
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