Learning from Accidents

Trevor Kletz, OBE, D.Sc., F.Eng., a process safety consultant, has published more than a hundred papers and nine books on loss prevention and process safety, including most recently Lessons From Disaster: How Organizations Have No Memory and Accidents Recur and Computer Control and Human Error. His experience includes thirty-eight years with Imperial Chemical Industries Ltd., where he served as a production manager and safety adviser in the petrochemical division, and membership in the department of chemical engineering at Loughborough University, Leicestershire, England. He is currently senior visiting research fellow at Loughborough University and an officer of the Order of the British Empire.

Introduction; Two simple incidents; Protective system failure; Poor procedures and poor management; A gas leak and explosion - The hazards of insularity; A liquid leak and fire - The hazards of amateurism; Another tank explosion - The hazards of optional extras; Flixborough; Seveso; Bhopal; Three Mile Island; Chernobyl; Aberfan; Missing recommendations; Three weeks in a works; Some pipe failures; Piper Alpha; The King's Cross underground railway station fire; Clapham Junction - Every sort of human error; Herald of Free Enterprise; Some aviation accidents; Invisable hazards; Signals passed at danger; Longford: The hazards of following fashions; The Gresford colliery explosion; Green intention, red result; Looking beyond violations; Keeping an open mind; Secondhand software: The Therac story. Conclusions; Epilogue: Myths on incident investigations - widely held beliefs that are not wholly true.