SPO操作员误开带压 PVC 反应器底阀（旁路安全联锁）→氯乙烯液体/蒸气释放并被引燃，5 死 3 重伤
未充分规划人因后果；安全联锁可被轻易旁路且无锁具；反应器分组相似无状态指示；培训与演练不足
The recorded code SPO is an ISO 14224:2016 functional failure code (describes what the equipment failed to do). The damage mechanism (how it failed) is shown in the Mapping block above. The two are distinct dimensions in ISO 14224.
fatigue_fractureBending bendingKeyway Wear keyway_wearCorrosion/Erosion corrosion_erosionBlade Crack blade_crackBlade Detachment blade_detachmentGlass-lining Damage glass_lining_damageGear Wear/Pitting gear_wear_pittingBearing Failure bearing_failureOil Seal Leak oil_seal_leakInternal Corrosion Thinning internal_corrosion_thinningStress Corrosion Cracking (SCC) sccWeld Crack weld_crackGlass-lining Failure glass_lining_failureCorrosion corrosionAnchor Bolt Loosening anchor_bolt_looseningFace Wear face_wearO-ring Aging o_ring_agingSpring Failure spring_failureSecondary Seal Leak secondary_seal_leakDry-running Burn dry_running_burnFlush Loss flush_lossFilter Clogging filter_cloggingGasket Aging gasket_agingFlange Face Corrosion flange_face_corrosionJacket Corrosion jacket_corrosionJacket Fouling jacket_foulingHalf-pipe Weld Leak half_pipe_weld_leakCoil Perforation coil_perforationVibration Fatigue vibration_fatigueSupport Loosening support_looseningSet Point Drift set_point_driftValve Seat Leakage seat_leakagePremature Fatigue Rupture premature_ruptureBackside Corrosion backside_corrosionRelief Line Blockage vent_line_blockageQuench System Failure quench_system_failureSensor Drift sensor_driftThermowell Corrosion thermowell_corrosionDiaphragm Failure diaphragm_failureImpulse Line Blockage impulse_line_blockageImpulse Line Blockage impulse_line_blockage_2Coating→False Reading coating_false_readingElectrode Fouling electrode_foulingCalibration Drift calibration_driftValve Body Corrosion / Erosion fmValve-seat Surface Damage -> Internal Leak fm_2Valve-plug Erosion fm_3Valve Stem Sticking / Bending fm_4Packing Wear -> External Leak fm_5Diaphragm Rupture fm_6Spring Fatigue / Fracture fm_7I/P Converter Failure i_pFeedback Link Loosening fm_8Coil Burnout fm_9Valve Plug Sticking -> Failure to Actuate fm_10Contact Corrosion / Poor Contact fm_11Filter-element Blockage -> Insufficient Supply fm_12Pressure-Relief Valve Set-point Drift fm_13