Scenario

01. Poor Value Perception
02. Poor Safety Awareness
03. Inadequate Safety Measure
04. Carelessness
05. Insufficient Precaution
06. Carelessness of Operator
07. Planning and Design
08. Poor Planning
09. Poor Design
10. Regular Operation
11. Erroneous Operation
12. Mistake
13. Secondary Damage
14. External Damage
15. Leakage
16. Bodily Harm
17. Injury

Leakage of toluene caused due to incorrect disconnection of a coupling during draining of toluene for cleaning
Case Details

Knowledge Comment:
Due to make the structure easy to mistake that which side is upper or down-stream, they opened the hose at up-stream of the valve resulted a leak.

Field Chemicals and Plants
Author WADA, Yuji (National Institute of Advanced Industrial Science and Technology)
TAMURA, Masamitsu (Center for Risk Management and Safety Sciences, Yokohama National University)