 |
01. |
Misjudgment |
|
02. |
Misperception |
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03. |
Mis-Convincement |
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04. |
Carelessness |
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05. |
Insufficient Precaution |
|
06. |
Carelessness of Operator |
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07. |
Organizational Problems |
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08. |
Inflexible Management Structure |
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09. |
Insufficient Education/Training |
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10. |
Malicious Act |
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11. |
Rule Violation |
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12. |
Safety Rule Violation |
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13. |
Planning and Design |
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14. |
Poor Planning |
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15. |
Poor Design |
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16. |
Bad Event |
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17. |
Chemical Phenomenon |
|
18. |
Spontaneous Ignition |
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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. |
Injury |
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24. |
2 person injured |
|
|
|
Explosion caused due to air contamination during subdivision work of trimethylindium
|
 |
Knowledge Comment: |
|
Insufficient information transmittion between shifts and insufficient confirmation of following shift generated an accident, but there is insufficient education behind. |
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