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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. |
Organizational Problems |
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05. |
Inflexible Management Structure |
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06. |
Insufficient Education/Training |
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07. |
Carelessness |
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08. |
Insufficient Understanding |
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09. |
Insufficient Recognition of Risk |
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10. |
Planning and Design |
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11. |
Poor Planning |
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12. |
Poor Overhaul Planning |
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13. |
Malicious Act |
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14. |
Rule Violation |
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15. |
Neglect of Order Book |
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16. |
Secondary Damage |
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17. |
External Damage |
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18. |
Explosion |
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19. |
Bodily Harm |
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20. |
Death |
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21. |
1 person died |
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22. |
Loss to Organization |
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23. |
Economic Loss |
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24. |
Tankm etc. Damage |
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Explosion in an intermediate tank during turnaround shutdown maintenance at a dimethylformamide manufacturing plant
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Knowledge Comment: |
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They mis-took the condition in a tank by opening a manway. Multi inspections should be required when danger was foreseen. |
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