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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. |
Inflexible Management Structure |
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06. |
Insufficient Education/Training |
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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. |
Regular Operation |
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11. |
Erroneous Operation |
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12. |
Wrong Change of Utility |
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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. |
Chemical Phenomenon |
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18. |
Abnormal Reaction |
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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. |
Death |
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24. |
Bodily Harm |
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25. |
Injury |
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26. |
4 person injured |
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27. |
Loss to Organization |
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28. |
Economic Loss |
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29. |
Manetary Damage 160 million yen |
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Explosion caused due to a change of a draw-off method of coolant in a jacket of a reactor from air pressure to steam pressure at a medical intermediate manufacturing plant
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Knowledge Comment: |
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They only thought the merit of the change, but they would not think about the demerit of the change. |
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