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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. |
Insufficient Analysis or Research |
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08. |
Insufficient Prior Research |
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09. |
No Care of Flange with a Spacer |
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10. |
Planning and Design |
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11. |
Poor Planning |
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12. |
Poor Design |
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13. |
Usage |
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14. |
Maintenance/Repair |
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15. |
Distortion of the Flange |
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16. |
Malfunction |
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17. |
Poor Hardware |
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18. |
Uneven Stretch |
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19. |
Secondary Damage |
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20. |
External Damage |
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21. |
Leakage/Fire |
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22. |
Loss to Organization |
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23. |
Economic Loss |
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24. |
Direct Manetary Damage 86 million yen |
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Leakage and fire from a flange with a special shape at the reactor outlet at a gas oil medium-pressure hydrocracker
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Knowledge Comment: |
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Take attention caredully for the special parts of special structure. |
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