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01. |
Insufficient Analysis or Research |
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02. |
Insufficient Practice |
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03. |
Lack of Imagination |
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04. |
Poor Value Perception |
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05. |
Poor Safety Awareness |
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06. |
Insufficient Safety Measure |
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07. |
Misjudgment |
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08. |
Misperception |
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09. |
Mis-Convincement |
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10. |
Neutralization Reaction |
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11. |
Planning and Design |
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12. |
Poor Planning |
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13. |
Poor Design |
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14. |
Regular Operation |
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15. |
Nonobservance of Procedure |
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16. |
Procedure Ignorance |
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17. |
Bad Event |
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18. |
Chemical Phenomenon |
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19. |
Abnormal Reaction |
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20. |
Secondary Damage |
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21. |
External Damage |
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22. |
Explosion |
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23. |
Bodily Harm |
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24. |
Death |
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25. |
Bodily Harm |
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26. |
Injury |
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27. |
Loss to Organization |
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28. |
Economic Loss |
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29. |
Direct Monetary Damage 48 million yen |
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Explosion of hydrogen peroxide due to the change of a feeding line to a vessel at a surfactant manufacturing plant
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Knowledge Comment: |
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It is irreponsible not to remodel the plant as it was, if the plant was unsuitable for operation. |
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