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01. |
Ignorance |
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02. |
Insufficient Knowledge |
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03. |
Insufficient Study of Reation |
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04. |
Poor Value Perception |
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05. |
Poor Safety Awareness |
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06. |
Insufficient Education/Training |
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07. |
Hydrolysis |
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08. |
Planning and Design |
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09. |
Poor Planning |
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10. |
Unclear Operating Indication |
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11. |
Regular Movement |
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12. |
Careless Movement |
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13. |
Interruption at Halfway |
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14. |
Bad Event |
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15. |
Chemical Phenomenon |
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16. |
Heat Generation/Ignition |
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17. |
Secondary Damage |
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18. |
External Damage |
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19. |
Explosion |
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20. |
Bodily Harm |
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21. |
Injury |
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22. |
Loss to Organization |
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23. |
Economic Loss |
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Explosion at a reactor caused due to a temperature rise of a recovery process of hydroxylamine sulfate at a pharmaceutical production plant
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Knowledge Comment: |
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Interruption of an operation may cause an undesired trouble |
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