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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. |
Organizational Problems |
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05. |
Inflexible Management Structure |
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06. |
Insufficient Education/Training |
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07. |
Ignorance |
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08. |
Insufficient Knowledge |
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09. |
Insufficient Study |
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10. |
Planning and Design |
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11. |
Poor Planning |
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12. |
Poor Design |
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13. |
Bad Event |
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14. |
Thermo-Fluid Event |
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15. |
Stagnation |
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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. |
Death |
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|
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Explosion of a machine for melting and volume reduction of polystyrene foam
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Knowledge Comment: |
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The result of the work that was done without understanding of genuine danger from design through operation ! |
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