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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. |
Organizational Problems |
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05. |
Poor Management |
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06. |
Poor Operation Management |
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07. |
Usage |
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08. |
Maintenance/Repair |
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09. |
Insufficient Inspection |
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10. |
Bad Event |
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11. |
Mechanical Event |
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12. |
Looseness of Bolt |
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13. |
Failure |
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14. |
Deformation |
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15. |
Creep |
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16. |
Secondary Damage |
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17. |
External Damage |
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18. |
Leakage/Fire |
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Leakage and fire of naphtha and hydrogen caused due to a tightening problem of a flange at a naphtha catalytic reforming unit
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Knowledge Comment: |
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Tightening force of the flange bolts was imbalance. The looseness was gradualy progressed. |
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