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01. |
Poor Value Perception |
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02. |
Poor Safety Awareness |
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03. |
Inadequate Risk Recognition |
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04. |
Insufficient Analysis or Research |
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05. |
Insufficient Prior Research |
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06. |
Corrosion/Flow |
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07. |
Ignorance |
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08. |
Insufficient Knowledge |
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09. |
Insufficient Study |
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10. |
Oxidation Reaction |
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11. |
Planning and Design |
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12. |
Poor Planning |
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13. |
Poor Operation Planning |
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14. |
Non-Regular Action |
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15. |
Change |
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16. |
Flow Rate Change |
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17. |
Bad Event |
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18. |
Thermo-Fluid Event |
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19. |
Temperature Rising |
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20. |
Failure |
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21. |
Abrasion |
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22. |
Corrosion |
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23. |
Secondary Damage |
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24. |
External Damage |
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25. |
Fire |
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26. |
Loss to Organization |
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27. |
Economic Loss |
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28. |
Manetary Damage 160 million yen |
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Leakage and fire caused due to an abnormal reaction from contamination of a heat medium to raw materials in a heat exchanger type reactor having a corroded part at an acrolein manufacturing plant
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Knowledge Comment: |
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High temperature and corrosive, moreover absolutely inhibited contamination with opposite side material in the heat exchanger ! Careful judgment and sufficient study are required. Please more carefully ! |
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