 |
01. |
Organizational Problems |
|
02. |
Poor Management |
|
03. |
Slackness of Management |
|
04. |
Poor Value Perception |
|
05. |
Poor Safety Awareness |
|
06. |
Inadequate Risk Recognition |
|
07. |
Misjudgment |
|
08. |
Misjudgment of Situation |
|
09. |
Continueing Thoughtless Liquid Draw-off |
|
10. |
Malicious Act |
|
11. |
Rule Violation |
|
12. |
Safety Rule Violation |
|
13. |
Planning and Design |
|
14. |
Poor Planning |
|
15. |
Poor Shutdown Planning |
|
16. |
Secondary Damage |
|
17. |
External Damage |
|
18. |
Explosion |
|
19. |
Loss to Organization |
|
20. |
Economic Loss |
|
21. |
Manetary Damage8 million nyen |
|
|
|
Explosion of hydrogen gas due to a backflow during a turnaround shutdown at a hydrogen producing unit.
|
 |
Knowledge Comment: |
|
Remaining of hydrogen in the column at shutdown and neglect the operation indication resulted an accident. |
|
|
|
|
