 |
01. |
Organizational Problems |
|
02. |
Poor Management |
|
03. |
Slackness of Management |
|
04. |
Poor Value Perception |
|
05. |
Poor Safety Awareness |
|
06. |
Inadequate Risk Recognition |
|
07. |
Ignorance |
|
08. |
Insufficient Knowledge |
|
09. |
Insufficient Experience |
|
10. |
Planning and Design |
|
11. |
Poor Planning |
|
12. |
Poor Design |
|
13. |
Non-Regular Action |
|
14. |
Inaction |
|
15. |
No Measure against Abnormal Vibration |
|
16. |
Bad Event |
|
17. |
Mechanical Event |
|
18. |
Vibration |
|
19. |
Secondary Damage |
|
20. |
External Damage |
|
21. |
Fire |
|
22. |
Loss to Organization |
|
23. |
Economic Loss |
|
24. |
Direct Monetary Damage 7 million yen |
|
|
|
Fire caused due to leakage of heavy oil from vibration in the distillation section at a fuel oil direct desulfurization unit
|
 |
Knowledge Comment: |
|
It is a matter of course that a valve was opened or a screw was loosened if the abnormal vibration is left. |
|
|
|
|
