A disastrous explosion accident with the force of 40 tons of TNT occurred on February 9, 1991. The explosion origin was defined by witness tes- timony, material evidence and field investigation. Two primary causes of the explosion were identified through "event tree analysis" by elimi- nating non-relevant factors and conducting a detailed study on relevant factors. It has been concluded that this was a "human element accident" which occurred due to poor safety in production. Lessons learned from this accident are summarized. © 1993.
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