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