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01. |
Ignorance of Procedure |
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02. |
Disregard of Procedure |
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03. |
Mis-take of Valve Open/Close |
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04. |
Organizational Problems |
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05. |
Poor Management |
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06. |
Slackness of Management |
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07. |
Malicious Act |
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08. |
Rule Violation |
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09. |
Safety Rule Violation |
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10. |
Secondary Damage |
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11. |
External Damage |
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12. |
Leakage/Fire |
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13. |
Bodily Harm |
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14. |
Injury |
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15. |
4 person injured |
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Fire of residue oil which leaked from carelessly opened valves at an atmospheric distillation unit
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Knowledge Comment: |
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Since the block valve and drain olug on the same piping were opened at the same time, the leakage occurred. It is a matter of course. |
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