Scenario

01. Organizational Problems
02. Poor Management
03. Poor Operation Management
04. Poor Value Perception
05. Poor Safety Awareness
06. Inadequate Risk Recognition
07. Carelessness
08. Insufficient Precaution
09. Mannerism
10. Planning and Design
11. Poor Planning
12. Poor Planning of Repair
13. Usage
14. Maintenance/Repair
15. Hot Bolting
16. Malfunction
17. Poor Hardware
18. Insufficient Tightening Force
19. Secondary Damage
20. External Damage
21. Leakage/Fire

Leakage and fire from a reactor flange during shutdown operation at a hydrogenation plant of pyrolysis gasoline
Case Details

Knowledge Comment:
Insufficient tightening force at the start-up operation leads the result of temperature decreasing work at shutdown operation. It is important to execute the quantative control of the tightening force.

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