 |
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. |
Insufficient Safety Measure |
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07. |
Insufficient Analysis or Research |
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08. |
Insufficient Prior Research |
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09. |
Insuficient Reaction Study |
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10. |
Planning and Design |
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11. |
Poor Planning |
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12. |
Mal Position of Rapture Disk Outlet |
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13. |
Regular Operation |
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14. |
Nonobservance of Procedure |
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15. |
Stopped as Temperature High |
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16. |
Bad Event |
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17. |
Chemical Phenomenon |
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18. |
Runaway Reaction |
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19. |
Secondary Damage |
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20. |
Damage to Environment |
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21. |
Environmental Pollution |
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22. |
Bodily Harm |
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23. |
Sickness |
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24. |
220 thousand person sickness |
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25. |
Damage to Society |
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26. |
Social Systems Failure |
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27. |
Social Function Loss |
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28. |
Foeced Refuge |
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29. |
Loss to Organization |
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30. |
Social Loss |
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31. |
Loss to Organization |
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32. |
Social Loss |
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33. |
Loss to Organization |
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34. |
Economic Loss |
|
|
|
Leakage of toxic substances at a chemical plant
|
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Knowledge Comment: |
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The damage was enlarged by the communication delay of the bad information until a reconfirmation was performed. |
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