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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. |
Insufficient Analysis or Research |
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05. |
Insufficient Prior Research |
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06. |
Repeated Drastic Change |
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07. |
Misjudgment |
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08. |
Misperception |
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09. |
Planning and Design |
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10. |
Poor Planning |
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11. |
Inadequate Speciality |
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12. |
Usage |
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13. |
Maintenance/Repair |
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14. |
Failure |
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15. |
Degradation |
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16. |
Secondary Damage |
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17. |
External Damage |
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18. |
Explosion |
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Explosion of hydrogen gas caused due to breakage of an exhaust gas duct at space rocket engine test facilities
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Knowledge Comment: |
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Because cracks were found many times and was grinded at each time, grinding volume became 70% of the material ! If the material was changed at that time, did the accident occur? |
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