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01. |
Ignorance |
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02. |
Insufficient Knowledge |
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03. |
Insuficient Study and Experience |
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04. |
Poor Value Perception |
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05. |
Poor Safety Awareness |
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06. |
Wrong Risk Recognition |
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07. |
Insufficient Analysis or Research |
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08. |
Insufficient Prior Research |
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09. |
Insufficient Knowledge Characteristics |
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10. |
Planning and Design |
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11. |
Poor Planning |
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12. |
Poor Design |
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13. |
Non-Regular Action |
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14. |
Inaction |
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15. |
No Idea in Next Step |
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16. |
Bad Event |
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17. |
Chemical Phenomenon |
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18. |
Abnormal Reaction |
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19. |
Secondary Damage |
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20. |
External Damage |
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21. |
Explosion |
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22. |
Bodily Harm |
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23. |
Death |
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24. |
Loss to Organization |
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25. |
Economic Loss |
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26. |
Monetary Damage 37 million yen |
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Run-away reaction occurred during vacuum distillation of epichlorohydrin waste liquid including dimethylsulfoxide
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Knowledge Comment: |
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For the first treating of dangerous material, there were insufficient pre-study and inadequate knowledge of heat exchange resulted an accident. |
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