Scenario

01. Poor Value Perception
02. Poor Organizational Culture
03. No Consideration on Sagety Engineering
04. Organizational Problems
05. Poor Management
06. Poor Operation Management
07. Carelessness
08. Insufficient Precaution
09. Carelessness of Operator
10. Planning and Design
11. Poor Planning
12. Poor Design
13. Regular Operation
14. Erroneous Operation
15. Operation with Insufficient Confirmation
16. Bad Event
17. Chemical Phenomenon
18. Abnormal Reaction
19. Secondary Damage
20. External Damage
21. Rapture/Leakage
22. Bodily Harm
23. Injury
24. 6 person injured

Rupture of a waste liquid container caused due to an incompatible reaction in chemical analysis at a LSI factory
Case Details

Knowledge Comment:
Although the causes looks like human errors itself, insufficient considerations on planning and design may often exist in a base. Its typical example !

Field Chemicals and Plants
Author KOBAYASHI, Mitsuo (Office K)
TAMURA, Masamitsu (Center for Risk Management and Safety Sciences, Yokohama National University)