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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. |
Insufficient Analysis or Research |
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05. |
Insufficient Prior Research |
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06. |
Lack of Consideration about Reaction Danger at Condition Change |
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07. |
Additive Reaction |
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08. |
Planning and Design |
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09. |
Poor Planning |
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10. |
Poor Design |
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11. |
Regular Operation |
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12. |
Erroneous Operation |
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13. |
Excess Supply |
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14. |
Bad Event |
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15. |
Chemical Phenomenon |
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16. |
Abnormal Reaction |
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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. |
2 person severely injured |
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Explosion and fire caused due to insufficient agitation of excessive charging quantity at a multi-purpose drug manufacturing reactor
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Knowledge Comment: |
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A pilot plant may not be constructed completely although a pilot plant is required more careful study than a commercial plant. |
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