Scenario

01. Organizational Problems
02. Inflexible Management Structure
03. Insufficient Education/Training
04. Poor Value Perception
05. Poor Safety Awareness
06. Inadequate Risk Recognition
07. Misjudgment
08. Misperception
09. Convincement
10. Regular Movement
11. Careless Movement
12. Work without Confirmation
13. Malicious Act
14. Rule Violation
15. Safety Rule Violation
16. Bad Event
17. Chemical Phenomenon
18. Abnormal Reaction
19. Secondary Damage
20. External Damage
21. Rapture/Explosion
22. Bodily Harm
23. Death
24. Bodily Harm
25. Injury
26. 3 person injured
27. Loss to Organization
28. Economic Loss
29. Manetary Damage 55 million yen

Rupture and fire of a measuring tank caused due to an incompatible reaction from transport of a different chemical to a tank containing a chemical
Case Details

Knowledge Comment:
Although you may do the work of others by good will, an action without recognition may result a trouble.

Field Chemicals and Plants
Author ITAGAKI, Haruhiko (Japan National Institute of Occupational Safety and Health)
TAMURA, Masamitsu (Center for Risk Management and Safety Sciences, Yokohama National University)