What Went Wrong?

Trevor Kletz, OBE, D.Sc., F.Eng. (1922-2013), was a process safety consultant, and 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. He worked thirty-eight years with Imperial Chemical Industries Ltd., where he served as a production manager and safety adviser in the petrochemical division, also holding membership in the Department of Chemical Engineering at Loughborough University, Leicestershire, England. He most recently served as senior visiting research fellow at Loughborough University, and adjunct professor at the Mary Kay O’Connor Process Safety Center, Texas A&M University.

Part 1 ? What Went Wrong? Learning From the Experiences of OthersPreparation for maintenance Modifications Accidents caused by human error Labeling Storage tanks Stacks Leaks Liquefied flammable gases Pipe and vessel failures Other equipment Entry to vessels Hazards of common materials Tank trucks and cars Testing of trips and other protective systems Static electricity Materials of construction Operating methods Reverse flow and other unforeseen deviations I didn't know that Problems with computer control Inherently safer design Reactions-planned and unplanned Part 2 ? How Could Disasters Have Been Avoided?Maintenance Entry into confined spaces Changes to processes and plants Changes in organization Changing procedures instead of designs Materials of construction (including insulation) and corrosion Operating methods Explosions Poor communication Control Leaks Reactions - planned and unplanned Both design and operations could have been better Accidents in other industries Accident investigation - Missed opportunities