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01. |
Organizational Problems |
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02. |
Poor Management |
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03. |
Poor Operation Management |
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04. |
Poor Value Perception |
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05. |
Poor Safety Awareness |
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06. |
Inadequate Risk Recognition |
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07. |
Ignorance |
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08. |
Insufficient Knowledge |
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09. |
Insuficient Study and Experience |
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10. |
Malicious Act |
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11. |
Rule Violation |
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12. |
Safety Rule Violation |
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13. |
Bad Event |
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14. |
Chemical Phenomenon |
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15. |
Coking |
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16. |
Failure |
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17. |
Large-Scale Damage |
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18. |
Leakage |
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19. |
Secondary Damage |
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20. |
External Damage |
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21. |
Explosion |
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22. |
Loss to Organization |
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23. |
Economic Loss |
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24. |
Direct Monetary Damage 190 million yen |
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![](../dfen/DC1200027.jpg)
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
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Knowledge Comment: |
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Firing only inlet side burner of the furnace resulted the coking ! Nobody did such a obvious design. |
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