Scenario > Explosion of an intermediate concentration tank at an insecticide manufacturing plant

01.

Organizational Problems

02.

Poor Management

03.

All Member Fatigue

04.

Poor Value Perception

05.

Poor Safety Awareness

06.

Insuficient Education/Training for Safety

07.

Carelessness

08.

Insufficient Precaution

09.

Concentrated to One Person

10.

Non-Regular Operation

11.

Change in Operation

12.

Operation Procedure Change

13.

Bad Event

14.

Chemical Phenomenon

15.

Abnormal Reaction

16.

Failure

17.

Large-Scale Damage

18.

Rapture

19.

Secondary Damage

20.

External Damage

21.

Explosion/Fire

22.

Bodily Harm

23.

Injury

24.

Loss to Organization

25.

Economic Loss

26.

Manetary Damage 70 million yen

Explosion of an intermediate concentration tank at an insecticide manufacturing plant

	Knowledge Comment:
	One person judged all the matter when many operations concentrated and there was no time to think. Every human beings has his limit.

Field	Chemicals and Plants
Author	DOBASHI, Ritsu (School of Engineering, The University of Tokyo) YOSHINAGA, Jun (Graduate School of New Frontier Sciences, The University of Tokyo) TAMURA, Masamitsu (Center for Risk Management and Safety Sciences, Yokohama National University)