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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 Practice |
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06. |
Lack of Imagination |
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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. |
Non-Regular Operation |
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11. |
Emergency Operation |
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12. |
Emergency Shutdown |
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13. |
Secondary Damage |
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14. |
External Damage |
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15. |
Explosion |
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16. |
Bodily Harm |
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17. |
Death |
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18. |
3 person died |
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19. |
Bodily Harm |
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20. |
Injury |
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21. |
7 person injured |
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22. |
Loss to Organization |
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23. |
Economic Loss |
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24. |
Direct Monetary Damage 300 million yen |
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25. |
Damage to Society |
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26. |
Social Systems Failure |
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27. |
Damaged 6 km radius |
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Explosion caused due to valve operation trouble during an emergency shutdown of a compressor at a vinyl chloride plant
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Knowledge Comment: |
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Human beings do not do many actions and judgments at the same time. Emergency procedure must be simple. |
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