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01. |
Insufficient Analysis or Research |
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02. |
Insufficient Prior Research |
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03. |
Erosion of Heat Exchanger Tube |
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04. |
Poor Value Perception |
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05. |
Poor Safety Awareness |
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06. |
Inadequate Risk Recognition |
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07. |
Planning and Design |
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08. |
Poor Planning |
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09. |
Poor Design |
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10. |
Usage |
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11. |
Maintenance/Repair |
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12. |
Insufficient Inspection |
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13. |
Bad Event |
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14. |
Thermo-Fluid Event |
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15. |
Erosion |
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16. |
Secondary Damage |
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17. |
External Damage |
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18. |
Leakage |
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|
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Fire occurred due to dispersion of molten nitrate caused by high-pressure steam entering into a molten nitrate vessel of a phthalic anhydride reactor after opening a steam generation tube
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Knowledge Comment: |
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An erosion was generated by insufficient analysisis at U bend of heat exchanger tube |
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