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01. |
Poor Value Perception |
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02. |
Poor Safety Awareness |
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03. |
Inadequate Risk Recognition |
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04. |
Organizational Problems |
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05. |
Poor Management |
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06. |
Poor Operation Management |
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07. |
Insufficient Analysis or Research |
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08. |
Insufficient Practice |
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09. |
Lack of Imagination |
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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. |
Planning and Design |
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14. |
Poor Planning |
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15. |
Poor Process Design |
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16. |
Bad Event |
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17. |
Thermo-Fluid Event |
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18. |
Static Electricity |
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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. |
Bodily Harm |
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23. |
Injury |
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24. |
2 person injured |
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25. |
Loss to Organization |
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26. |
Economic Loss |
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27. |
Manetary Damage 47 million yen |
|
|
|
Explosion on sampling of kerosene fractions from a tank roof
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Knowledge Comment: |
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They overlooked the dissolved hydrogen at the process, moreover insufficient conutermeasure against ststic electricity. |
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