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01. |
Organizational Problems |
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02. |
Poor Management |
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03. |
Looseness of Discipline |
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04. |
Ignorance of Procedure |
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05. |
Disregard of Procedure |
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06. |
Omission of Confirmation |
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07. |
Poor Value Perception |
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08. |
Poor Safety Awareness |
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09. |
Inadequate Risk Recognition |
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10. |
Planning and Design |
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11. |
Poor Planning |
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12. |
No Consideration on Safety Engineering |
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13. |
Malicious Act |
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14. |
Rule Violation |
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15. |
Safety Rule Violation |
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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. |
Failure |
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20. |
Large-Scale Damage |
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21. |
Rapture |
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22. |
Loss to Organization |
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23. |
Economic Loss |
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24. |
Manetary Damage 100 million yen |
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Rupture of a triethanolamine tank caused due to an erroneous injection of nitric acid
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Knowledge Comment: |
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For the nozzle connction at the lorry station, there are triple mistake; bad arrangement of location of nozzles, mis-connection by the driver who was the first time there and no confirmation of the valve operation. |
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