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01. |
Poor Value Perception |
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02. |
Poor Safety Awareness |
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03. |
Insufficient Safety Measure |
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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. |
Planning and Design |
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08. |
Poor Planning |
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09. |
Poor Piping Design |
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10. |
Usage |
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11. |
Maintenance/Repair |
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12. |
Wrong Gasket Monuting |
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13. |
Malfunction |
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14. |
Poor Hardware |
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15. |
Gasket Leak |
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16. |
Secondary Damage |
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17. |
External Damage |
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18. |
Fire |
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19. |
Loss to Organization |
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20. |
Economic Loss |
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21. |
Manetary Damage 25 million yen |
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Fire of gas oil caused due to leakage from a bonnet flange of a valve usually not used at an atmospheric distillation unit
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Knowledge Comment: |
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A flange was mounted just above the hot temperature pump ! The fire did not occur if the position had been slightly different. |
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