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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. |
Ignorance |
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05. |
Insufficient Knowledge |
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06. |
Convincement |
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07. |
Malicious Act |
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08. |
Rule Violation |
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09. |
Safety Rule Violation |
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10. |
Usage |
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11. |
Operation/Use |
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12. |
Operation without flow meter |
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13. |
Malfunction |
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14. |
Poor System |
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15. |
No Measurement of Flow Rate |
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16. |
Failure |
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17. |
Abrasion |
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18. |
Corrosion |
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19. |
Secondary Damage |
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20. |
External Damage |
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21. |
Leakage |
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Leakage from a crack of a heat exchanger due to corrosion and abrasion at a manufacturing plant of crude copper phthalocyanine blue
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Knowledge Comment: |
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Because an operation was done without safety instrument, a detection of plugging cannot be recognized and a leakage occurred. |
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