 |
01. |
Organizational Problems |
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02. |
Inflexible Management Structure |
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03. |
Insufficient Education/Training |
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04. |
Carelessness |
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05. |
Insufficient Understanding |
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06. |
Insufficient Recognition of Risk |
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07. |
Poor Value Perception |
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08. |
Poor Safety Awareness |
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09. |
Insufficient Safety Measure |
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10. |
Malicious Act |
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11. |
Rule Violation |
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12. |
Neglect of Indication |
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13. |
Bad Event |
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14. |
Chemical Phenomenon |
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15. |
Melting |
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16. |
Secondary Damage |
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17. |
External Damage |
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18. |
Fire |
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|
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Fire of a fuel oil fraction during sampling at a vacuum distillation unit
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Knowledge Comment: |
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The fire occurred by neglect of the work standard which inhibited the valve full open. |
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