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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. |
Poor Management |
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06. |
Slackness of Management |
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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 Design |
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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. |
Mechanical Event |
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18. |
Vibration |
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19. |
Secondary Damage |
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20. |
External Damage |
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21. |
Leakage/Fire |
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22. |
Loss to Organization |
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23. |
Economic Loss |
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24. |
Manetary Damage 150 million yen |
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Fire caused due to a flange loosened from vibrations at a synthetic rubber plant
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Knowledge Comment: |
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The flange bolts were loosened by leaving atsevere vibration. No one noticed it and the operation was continued, and then a leakage occurred. |
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