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01. |
Ignorance |
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02. |
Insufficient Knowledge |
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03. |
Insufficient Study |
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04. |
Insufficient Analysis or Research |
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05. |
Insufficient Practice |
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06. |
Lack of Imagination |
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07. |
Organizational Problems |
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08. |
Inflexible Management Structure |
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09. |
Insufficient Information/Communication |
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10. |
Non-Regular Action |
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11. |
Change |
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12. |
Change Procedure |
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13. |
Planning and Design |
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14. |
Poor Planning |
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15. |
Poor Design |
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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. |
Bad Event |
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20. |
Thermo-Fluid Event |
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21. |
Reverse Flow |
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22. |
Secondary Damage |
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23. |
External Damage |
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24. |
Explosion |
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25. |
Bodily Harm |
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26. |
Injury |
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27. |
2 person injured |
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Explosion of hydrogen during cleaning a water scrubber at a semiconductor plant
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Knowledge Comment: |
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Let the person who did not know the reaction danger make a plan the chemical cleaning, then the accident occurred. Never think so easy ! |
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