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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. |
Carelessness |
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05. |
Insufficient Precaution |
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06. |
Inadequate Handling |
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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. |
Non-Regular Operation |
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11. |
Emergency Operation |
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12. |
Emergency Shutdown |
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13. |
Malfunction |
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14. |
Poor Hardware |
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15. |
Check Valve Leakage |
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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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19. |
Loss to Organization |
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20. |
Economic Loss |
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21. |
Manetary Damage 90 million yen |
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Fire of a raw material feed pump caused due to incorrect operation during emergency shutdown procedure at a fuel oil direct desulfurization unit
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Knowledge Comment: |
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At an emergency shutdown case, the high-pressure pump is stopped at first resulted back flow of the process fluid. |
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