 |
01. |
Organizational Problems |
|
02. |
Poor Management |
|
03. |
Poor Operation Management |
|
04. |
Poor Value Perception |
|
05. |
Poor Safety Awareness |
|
06. |
Inadequate Risk Recognition |
|
07. |
Ignorance |
|
08. |
Insufficient Knowledge |
|
09. |
Insuficient Study and Experience |
|
10. |
Malicious Act |
|
11. |
Rule Violation |
|
12. |
Safety Rule Violation |
|
13. |
Bad Event |
|
14. |
Chemical Phenomenon |
|
15. |
Coking |
|
16. |
Failure |
|
17. |
Large-Scale Damage |
|
18. |
Leakage |
|
19. |
Secondary Damage |
|
20. |
External Damage |
|
21. |
Explosion |
|
22. |
Loss to Organization |
|
23. |
Economic Loss |
|
24. |
Direct Monetary Damage 190 million yen |
|
|
|
Leakage and fire caused due to a rupture of a heating furnace tube from unbalanced heating at a heating furnace of a fuel oil direct desulfurization unit
|
 |
Knowledge Comment: |
|
Firing only inlet side burner of the furnace resulted the coking ! Nobody did such a obvious design. |
|
|
|
|
