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01. |
Poor Value Perception |
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02. |
Poor Safety Awareness |
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03. |
Ignorance of Secure Detrioration of Cooling Ability |
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04. |
Insufficient Analysis or Research |
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05. |
Insufficient Prior Research |
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06. |
Insufficient Study of Reaction Danger |
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07. |
Planning and Design |
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08. |
Poor Planning |
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09. |
No Emwegency Blowdown |
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10. |
Usage |
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11. |
Maintenance/Repair |
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12. |
Oversight of Corrosion |
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13. |
Non-Regular Action |
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14. |
Inaction |
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15. |
No Action against Temperature Rising |
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16. |
Malfunction |
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17. |
Poor Hardware |
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18. |
Decline of Heat Transfer Capacity |
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19. |
Bad Event |
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20. |
Chemical Phenomenon |
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21. |
Abnormal Reaction |
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22. |
Failure |
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23. |
Large-Scale Damage |
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24. |
Rapture |
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25. |
Bodily Harm |
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26. |
Injury |
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Rupture of a reactor caused by an abnormal reaction due to lowered cooling ability of the reactor on manufacturing a pharmaceutical intermediate
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Knowledge Comment: |
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By not finding the corrosion, temperature rising resulted an abnormal reaction. |
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