 |
01. |
Poor Value Perception |
|
02. |
Poor Safety Awareness |
|
03. |
Insufficient Recognition of Risk |
|
04. |
Misjudgment |
|
05. |
Misjudgment of Situation |
|
06. |
Misjudgment of Using Environment |
|
07. |
Carelessness |
|
08. |
Insufficient Precaution |
|
09. |
Carelessness of Operator |
|
10. |
Planning and Design |
|
11. |
Poor Planning |
|
12. |
Wrong Material Selection |
|
13. |
Usage |
|
14. |
Maintenance/Repair |
|
15. |
Insufficient Inspection |
|
16. |
Failure |
|
17. |
Abrasion |
|
18. |
Corrosion |
|
19. |
Secondary Damage |
|
20. |
External Damage |
|
21. |
Leakage/Fire |
|
22. |
Loss to Organization |
|
23. |
Economic Loss |
|
24. |
Manetary Damage 45 million yen |
|
|
|
Fire of a vacuum residue leaked from an opening of pipe caused due to corrosion in the bottom recycling line at a vacuum distillation unit.
|
 |
Knowledge Comment: |
|
The trigger is the material selection which was done by overlooking the environment with high temperature and high sulfur. |
|
|
|
|
