Scenario

01. Poor Value Perception
02. Poor Safety Awareness
03. Inadequate Risk Recognition
04. Organizational Problems
05. Poor Management
06. Slackness of Management/Habit
07. Carelessness
08. Insufficient Precaution
09. Mannerism
10. Planning and Design
11. Poor Planning
12. Poor Inspection Planning
13. Bad Event
14. Mechanical Event
15. Fault
16. Regular Operation
17. Erroneous Operation
18. Not Closing Valve
19. Failure
20. Fracture/Damage
21. Secondary Damage
22. External Damage
23. Leakage/Fire
24. Bodily Harm
25. Injury
26. 4 person injured
27. Loss to Organization
28. Economic Loss
29. Direct Monetary Damage 63 million yen

Fire of hydraulic oil caused due to damage to a drain hose during a performance test of a hydraulic motor
Case Details

Knowledge Comment:
Even the inspection is executed regularly, preparation for the test must be completely.

Field Chemicals and Plants
Author DOBASHI, Ritsu (School of Engineering, The University of Tokyo)
TAMURA, Masamitsu (Center for Risk Management and Safety Sciences, Yokohama National University)