 |
01. |
Ignorance |
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02. |
Insufficient Knowledge |
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03. |
Insufficient Experience/Study |
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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. |
Planning and Design |
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08. |
Poor Planning |
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09. |
Poor Design |
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10. |
Production |
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11. |
Hardware Production |
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12. |
Wrong Piping Construction |
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13. |
Failure |
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14. |
Fracture/Damage |
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15. |
Cast Iron Valve Damage |
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16. |
Secondary Damage |
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17. |
External Damage |
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18. |
Leakage |
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|
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Leakage of fuel oil caused due to damage to a valve made of cast iron at a refinery
|
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Knowledge Comment: |
|
Insufficient design standeard and/or lack of study induces an accident. We do not recover the wrong design by operation. |
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