 |
01. |
Poor Value Perception |
|
02. |
Poor Safety Awareness |
|
03. |
Inadequate Risk Recognition |
|
04. |
Ignorance |
|
05. |
Insufficient Knowledge |
|
06. |
Insufficient Experience |
|
07. |
Planning and Design |
|
08. |
Poor Planning |
|
09. |
Poor Purge Planning |
|
10. |
Usage |
|
11. |
Maintenance/Repair |
|
12. |
Preoaration Work |
|
13. |
Regular Movement |
|
14. |
Careless Movement |
|
15. |
Insufficient Recognition |
|
16. |
Bad Event |
|
17. |
Chemical Phenomenon |
|
18. |
Burning |
|
19. |
Bodily Harm |
|
20. |
Injury |
|
21. |
4 person injured |
|
22. |
Loss to Organization |
|
23. |
Economic Loss |
|
24. |
Manetary Damage 10 million yen |
|
|
|
Fire of special material gas come into contact with air in exhaust piping at a semiconductor factory
|
 |
Knowledge Comment: |
|
They did not know that pressurized displacement of the gas needs many hours. They opened piping to atmosphere after short period resulted a fire. |
|
|
|
|
