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01. |
Organizational Problems |
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02. |
Poor Management |
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03. |
Slackness of Management |
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04. |
Carelessness |
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05. |
Insufficient Precaution |
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06. |
Wrong Taking-over |
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07. |
Misjudgment |
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08. |
Misperception |
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09. |
Mis-Convincement |
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10. |
Regular Operation |
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11. |
Erroneous Operation |
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12. |
Reverse Operation |
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13. |
Bad Event |
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14. |
Chemical Phenomenon |
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15. |
Abnormal Reaction |
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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. |
Injury |
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21. |
3 person injured |
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22. |
Loss to Organization |
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23. |
Economic Loss |
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24. |
Manetary Damage 44 million yen |
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|
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Explosion due to a runaway reaction from operation by misunderstanding of the reaction progress during preparation of organic peroxide
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Knowledge Comment: |
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Mis-convincement results an accident. Taking-over between the shifts must execute correctly and in detail. |
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