Critical Aspects of Safety and Loss Prevention reflects the author's managerial experience and safety operations experience. This book is a collection of almost 400 thoughts and observations on safety and loss prevention, illustrated by accounts of accidents. The items, mostly short, are arranged alphabetically and cross-references are provided. The accident reports in this volume highlight the ignorance, incompetence and folly but also originality and inventiveness in the cause of accident prevention. This book also argues on the importance of loss prevention over the traditional safety approach. This book will be of interest to persons who work in design, operations and maintenance and to safety professionals.
Front Cover 1
Critical Aspects of Safety and Loss Prevention 4
Copyright Page 5
Introduction 8
Chapter 1. A 12
Abbeystead 12
Abdication, management by 12
Aberfan 12
Absolute requirements 13
Abstractions 13
Acceptable risk 14
Access 14
Accident 15
Accident chains 16
Accident investigation 16
Accident-prone 18
Accident reports 19
Accident statistics 20
Accuracy 21
Acids 21
Action 21
Action replays 22
Acts of God 23
Add-ons 24
Addresses 24
Adequacy 24
Advice 25
Aerosol cans 26
Air 27
Air coolers 27
Airlines 27
ALARA 28
Alarms 28
ALARP 29
Alcohol 29
Alertness 30
Alternatives 31
Amalgamation 31
Amateurism 32
Ammonia 33
Anaesthetics 35
Analysis 35
Anomalies 37
Area classification 37
Arsenic 37
Arson 38
Asbestos 38
Assessment 39
Assumptions 39
Astonishment 40
Asymptote 41
Attenuation 41
Attitude 42
Audits 42
Australia 45
Auto-ignition temperature 45
Automation 45
Aversion to risk 46
Avoidance of risk 47
Chapter 2. B 48
Back flow 48
Batch processes 48
Benzene 48
Bhopal 49
Bible 51
Big plants 52
(Are things as) Black as they seem? 52
Black books 53
Blame 53
BLEVE 54
Blind 56
Blind-eyes 57
Boilers 58
Boil-over 59
Bolts 59
Books on process safety and loss prevention 60
(safety) Books 60
Boredom 61
Breaking the rules 61
Bretherick 62
Bridges 62
Brunner Mond 63
Buckets 63
Buck-passing 63
Buildings 64
Burns 64
Chapter 3. C 65
Cancer 65
Canvey Island 65
Care 66
Carelessness 66
Caring 66
Cause 67
Cause and effect 67
Caution 69
Centrifuges 69
Chains 70
Challenger 72
(absence of) Change 73
Change – new problems 73
Change – old problems 73
Check lists 74
Chemstar 74
Chernobyl 74
Chlorine 76
Choice of problems 77
Chokes 77
CIMAH Regulations 78
Cleanliness 79
Codes of practice 79
Cognitive dissonance 80
Coincidences 80
Cold readings 81
Combustible gas detectors 82
Combustion 82
Common mode failures 82
Communication 82
Comparisons 83
Complacency 84
Compressed air 84
Compromise 84
Compressor houses 85
Computers 85
Confidence limits 86
Confidentiality 86
Construction 86
Containers 88
Contamination 88
Context 89
Contractors 89
Contradictory instructions 90
Control 91
'Controversial chemicals' 91
Corner cutting 92
Corrosion 92
Corrosive chemicals 93
COSHH Regulations 93
Cost estimates 94
Cost of saving a life 94
Costs 95
Cranes 97
Creativity 97
Creep 97
Criminals 98
Criteria 98
Culture 98
Custom and practice 99
Cyanates 100
Cyanides 100
Cyclohexane 100
Cylinders 101
Chapter 4. D 102
Damage control 102
Danger 102
Dangerous occurrence 102
Data 103
Dead-ends 103
Debts 104
Decisions 104
Defence in depth 105
Definitions 106
Demolition 106
Design 107
Deterministic accidents 108
Detail 108
Diesel engines 108
Difference of opinion 109
Dioxin 109
Disbelief 110
Discretion 110
Dismantling 111
Dispersion 111
Distillation 111
Distraction 113
Diversity 113
Dolls 113
Domino effects 113
Drains 114
Drugs 115
Drums 115
Du Pont 116
Dusts and powders 116
Chapter 5. E 118
Early involvement in design 118
Effects 118
Electrical area classification 118
Electricity 120
Emergencies 120
Emergency equipment 121
Emergency isolation valves 122
Employer's responsibilities 123
Empty vessels 124
Enforcement 124
Entry 124
Equipment 127
. shift jobs 127
Evangelicalism, evangelism 128
Exchanging one problem for another 128
(loss of) Expectation of life 129
Expenditure proposals 130
Experience 130
(learning from others') Experience 130
(limitatioiis of) Experience 131
Experts 132
Expert systems 132
Explosions 133
Explosion venting 133
Extrapolation 134
Extravagance 135
Eyebolts 136
Eye protection 136
Chapter 6. F 138
Factories Acts, Factory Inspectors 138
Fail-safe 139
Failures 139
Failure rates 140
False alarms 140
Falsification 141
Familiarity 141
Fatal accident rate 142
Fate 143
Feedback to design 144
Fencing 144
Fermi estimates 145
Feyzin 146
Fin-fans 146
Fire 146
Flame traps 148
Flammable atmospheres 149
Flare stacks 150
Flashing liquids 150
Flexes 151
Flixborough 151
Foam-over, froth-over 152
Follow-up 153
Folly 154
Food 155
Force 155
Forecasts 156
Foresight 157
Forgetfulness 157
Forgotten knowledge 157
Fractional dead time 158
Friendly plants 158
Froth-over 159
Fugitive emissions 159
Full-scale deflection 159
Furnaces 160
Chapter 7. G 162
Gas detection 162
Gas dispersion 162
Giving up 162
Glass 162
Good practice 162
Grimaldi 163
Guarding 163
Guidance notes 163
'Gut feel' 164
Chapter 8. H 165
Hazard analysis (Hazan) 165
Hazard and operability study (Hazop) 166
Hazard and risk 168
Hazardous substances 169
Health and Safety at Work Act 169
Heavy oils 171
Higee 172
Hired equipment 172
History of safety 172
Honesty 173
Hoses 174
Hubris 175
Human failing 176
Humour 178
Hydrogen 182
Hydrogenation 182
Chapter 9. I 183
latrogenesis 183
ICI 183
Ideas 183
Identification of equipment 184
Identification of hazards 186
Ignition 186
Ignorance 188
Impatience 188
Improvement notice 188
Incentive schemes 188
Inconsistency 189
India 189
Indices of woe 189
Industrial hygiene 190
Inert gas 190
Influences 190
Information 191
Inherently safer design 191
Innovation 191
Inhibitors 192
Inspection 192
Instructions 194
Instruments 195
Insularity 196
Insulation 197
Insurance 199
Intangibles 200
Intensification 200
Interference 200
Isle of Man 200
Ionizing radiations 200
Isolation 201
Investigation 202
Chapter 10. J 203
Joints 203
Joint ventures 203
Judgement 203
Chapter 11. K 204
King's Cross 204
Knock-on effects 205
Knowledge 205
Knowledge of what we don't know 205
Chapter 12. L 207
Labels 207
Language 207
Large plants 208
(better) Late than never 208
Law 209
Layered accident investigations 210
Layout and location 210
Lead 210
Leaks 211
Leak tests 217
Learning 217
Level glasses 217
Life 218
Limitations 218
Liquefied petroleum gass 218
Location 218
Loss 219
Loss control 219
Loss prevention 219
Lost knowledge 220
Lost-time accident rate 222
LPG 222
Lying 222
Chapter 13. M 223
Machinery 223
Magic charm to prevent accidents 223
Maintenance 223
Major hazard 224
Management 224
Manliness 226
Materials of construction 226
Measurement of safety 227
Meccano or dolls? 227
Mechanical accidents 228
Memory 229
Methods of working 229
Methyl isocyanate 230
Mexico city 230
Minimum standards 230
Misquotations 230
Modern standards 230
Modifications 231
Modifications after an accident 234
Money 234
Morality 234
Motivation 235
Myths 236
Chapter 14. N 237
Near-miss 237
'Need to know' 237
Never 237
New hazards 237
New processes 237
Nitrogen 238
Non-events 239
Non-return valves 240
Non-sparking tools 240
'Normal Accidents' 240
Nothing 241
Novelty 241
Nuclear power 243
Nuts and bolts 244
Chapter 15. O 245
Occupational disease 245
Old days 245
Old equipment 245
Old plants and modern standards 246
Old-timer 246
Operations research 247
Optional extras 248
Other industries 248
Overreaction 249
Over-reporting 250
Oxidation 250
Oxygen 251
Chapter 16. P 252
Packaged deals 252
Panic 252
Patience 253
Penny-pinching 254
Perception of risk 254
Permits-to-work 255
Persistence 255
Perspective 256
Persuation 257
Philosophers' stone 258
Photography 258
Pipe failures 258
Piper Alpha 259
Plastics 259
Platitudes 260
Plugs 261
Poisons 261
Policy 261
Polymerization 262
Poor equipment 262
Posters 262
Powders 263
Practicable 263
Practice 263
Pressure 263
Pressure tests 264
Pressure vessels 265
Priorities 265
Probabilities 265
Probit 265
Problems 266
Procedures 266
Process safety 266
Production or safety? 266
Prohibition Notice 267
(self-fulfilling) Prophecies 267
Prosecution 268
Protective clothing 269
Protective equipment 269
Publication 270
Pumps 272
(accidental) Purification 272
Chapter 17. Q 273
Qualitative 273
Quantitative 273
Chapter 18. R 274
Radioactivity 274
Railways 274
Random accidents 274
Reactions 274
Reactors 276
'Reasonable care' 277
'Reasonably practicable' 277
Recognition 278
Redundancy 278
Recognition 279
Regulations 279
Reliability 279
Reliability data 280
Relief devices 280
Remedies 283
Removing equipment or procedures 284
Reorganization 285
Repeated accidents 285
Research 286
Responsibility 287
(legal) Responsibility 287
(managerial) Responsibility 288
(personal) Responsibility 289
Retribution 290
Reverse flow 290
Risk 291
Risk compensation 291
Risk criteria 291
Risk management 292
Risk perception 292
Rotameters 292
Rules and regulations 292
Runaway reactions 293
Chapter 19. S 294
Sabotage 294
Safety 294
'Safety first' 295
Safety professionals 295
Sampling 296
Scale-up 298
Scrap 298
Secrecy 299
Security 299
Selling safety 300
Serendipity 301
Service lines 302
Seveso 303
Shipping 304
Short cuts 305
Sight glasses 305
Simple causes 305
Simplicity 306
Single-Stream plants 307
(visit accident) Sites 307
Sleeping beauties 308
Slop-over 308
Sloppy thinking 308
Small companies 309
Smoke 310
Smoke screens 311
Smoking 311
Software 311
Solvents 311
Spark-resistant tools 312
Stacks 313
Standards 313
(five) Star Grading System 313
Statistics 313
Static electricity 313
Steam 314
Storage 315
Strength of equipment 315
Stress 315
Substitution 316
Success 317
Summerland 317
Surprise 318
Surveys 318
(treating) Symptoms instead of diseases 319
System accidents 320
Systems of work 320
Chapter 20. T 321
Take-over 321
Talebearing 321
Tankers 321
Tanks 323
Tay Bridge 325
Team working 326
Temporary jobs 326
Tests 327
'They' 328
Thinking 329
Threads 329
Three Mile Island 330
Threshold limit values 331
Tidiness 331
Time and money 332
Timebombs 333
Time of response 333
Time span of forgetfulness 336
Tolerable risk 337
Tolerance 337
Tools 337
Top event 337
Total loss control 337
Toxicity 338
Trade-off 338
Tradition 338
Training 338
Transport 339
Trapped pressure 339
Traps 340
Triangles 341
Trips 342
Chapter 21. U 343
Underestimated hazards 343
Under-reporting 343
Unexpected hazards 344
Uniformity 345
United Kingdom 345
United States 346
Unlikely hazards 346
Useless equipment and operations 347
Utilities 348
Chapter 22. V 349
Vacuum 349
Valves 349
Variety 349
Vents 350
Ventilation 350
Vessels 352
Viruses 352
Chapter 23. W 353
Water 353
Water hammer 354
Welding 354
Whistle blowing 355
Will and might 355
Windows 357
Wolves in sheep's clothing 357
Working practice 358
Chapter 24. Z 359
Zeebrugge 359
Introduction
Trevor Kletz
This book is a collection of nearly 400 thoughts and observations on safety and loss prevention, illustrated by accounts of accidents. The items, mostly short, are arranged alphabetically and cross-references are provided.
In 1968, after many years’ experience in plant operation, I was appointed the first technical safety adviser to the Heavy Organic Chemicals (later Petrochemicals) Division of ICI. My appointment followed a number of serious fires and I was mainly concerned with process safety. However, my views reflect my managerial experience – when safety was one of my line responsibilities – as well as my full-time safety experience and the book will therefore, I hope, be found useful by all who work in design, operations and maintenance as well as by safety professionals.
Because I have spent my career in the chemical industry there is a bias towards process safety but nevertheless most of the book will, I hope, interest people in other industries and those concerned with safety generally.
The items are arranged in alphabetical order and the book is self-indexing, that is, cross-references are provided in the body of the text. The titles of other items are printed in italic the first time they appear in each item, if the cross-reference is relevant. (I have not printed words such as ‘accident’ and ‘fire’ in italic every time they occur.) Some of the titles are the names of items of equipment such as valves and tanks; some are the names of places, such as Flixborough and Seveso, where accidents have occurred; some are the names of hazardous substances such as asbestos and benzene; others are the names of abstractions such as management and inspection and a few are the names of people or organizations, such as Du Pont or ICI.
To describe further the scope of the book it is easier to say what it is not than what it is:
• It is not a comprehensive treatment of the subject. For that see Loss Prevention in the Process Industries by F P Lees1. F P Lees, Loss Prevention in the Process Industries, Butterworths, 1980 referred to herein as Lees. In fact, this book can be considered a series of footnotes to Lees, with the emphasis on practice rather than theory and illustrated by accounts of accidents that have occurred.
• It is neither an encyclopedia nor a dictionary. It is intended to be read, or dipped into, and not just used as a work of reference. Many important topics, such as fire and explosions, adequately covered elsewhere, are considered briefly or not at all (the brief comments made try to bring out points not usually covered) and instead I have discussed topics, such as contamination and (accidental) purification, that are neglected elsewhere. I have tried to illuminate neglected corners rather than the whole structure.
Industrial hygiene is considered only briefly. See asbestos, cancer and fugitive emissions.
• The book is not a guide to the law, and references to it are concerned with principles rather than details. See, for example, ‘reasonably practicable’.
Several common themes run through the book which tries to express a consistent philosophy. These themes are:
• A commitment to the loss prevention rather than the traditional safety approach.
• An irreverent attitude towards some of the established views and customs of many safety professionals. See, for example lost-time accident rate and human failing. In safety, as everywhere else, it is no bad thing to question the accepted wisdom from time to time. Most of what we have learned is good, sound stuff but there is some chaff amongst the wheat.
• A belief that we know the answers to most of our problems but lack the will to apply the knowledge we have. See, for example, philosophers’ stone and production or safety?
• A belief that many of our problems are older than we think and that solutions have been known for a long time.
• A preference for specific rather than general advice. See attitude and policy. The historian Barbara Tuchman writes2. Barbara Tuchman, Practicing History, Ballantine Books, New York, 1982, p. 36, ‘When I come across a generalisation unsupported by illustration I am instantly on my guard; my reaction is show me.’ I agree, and when I can do so, without making the accounts too long, I have described accidents to support my recommendations.
• A belief that we cannot do everything at once and therefore need a rational system for setting priorities, something better than giving the most to those who shout the loudest.
I have tried to avoid being solemn but that does not mean that I am not serious. When others have put things better than I can I have not hesitated to quote them and I have used quotations from writers on other subjects when they throw light on our own. See, for example, management and persistence.
American readers should note that I have used the term manager, as it is used in the UK, to include those professionally qualified (or equivalent) people who would be called supervisors or superintendents in most US companies.
Thanks are due to the many colleagues, past and present, who have suggested ideas for inclusion or commented on my contributions. In particular I would like to thank:
• The hundreds of colleagues in ICI with whom I discussed almost every topic in the book during my 14 years (1968–1982) as a safety adviser, and especially the staff of Petrochemicals Division Safety and Loss Prevention Group.
• The staff of the Department of Chemical Engineering at Loughborough University of Technology, and especially Professor F P Lees, for giving me the opportunity of continuing my work after my retirement from ICI.
• The many people in other companies and organizations who have given freely of their knowledge and experience and especially those who have allowed me to describe their companies’ mistakes.
• The editors of Health and Safety at Work and The Chemical Engineer for allowing me to quote from my articles in those journals.
• Mr S Coulson for drawing most of the Figures.
• The Leverhulme Trust for financial support.
• All who have encouraged me, by their support, to write and lecture on safety, as without the opportunity to communicate one’s knowledge, it remains vague and ill-defined. The man who said, ‘I don’t know what I think until I’ve heard what I’ve said or read what I’ve written’ was not as foolish as he might at first seem.
I have been unable to trace the owners of the copyright of a few of the Figures and I hope that, in the interests of safety, they will not object to the inclusion of their work.
The advice in the book is given in good faith but without warranty and readers should satisfy themselves that it is applicable to their circumstances.
The following abbreviations are used for those reference works most frequently mentioned:
EVHE: T A Kletz, An Engineer’s View of Human Error, Institution of Chemical Engineers, Rugby, 1985
LFA: T A Kletz, Learning from Accidents in Industry, Butterworths, 1988
Lees: F P Lees, Loss Prevention in the Process Industries, Butterworths, 1980
Myths: T A Kletz, Myths of the Chemical Industry or 44 Things a Chemical Engineer ought NOT to Know, Institution of Chemical Engineers, 1984. 2nd edition, entitled Improving Chemical Engineering Practices: A New Look at Old Myths of the Chemical Industry, Hemisphere Publishing, New York, 1990
WWW: T A Kletz, What Went Wrong? – Case Histories of Process Plant Disasters, Gulf Publishing Company, Houston, Texas, 2nd edition, 1988
References to the above are given to Chapters or Sections (§) rather than pages as these differ less between editions.
To avoid the clumsy phrases ‘he or she’ and ‘him or her’ I have used ‘he’ and ‘him’. Though there has been a welcome increase in the number of women employed in the process industries the designer, manager or accident victim is usually a man.
The pages that follow, especially the accident reports, record much ignorance, incompetence and folly but also originality and inventiveness in the cause of accident prevention.
1. F P Lees, Loss...
| Erscheint lt. Verlag | 28.6.2014 |
|---|---|
| Sprache | englisch |
| Themenwelt | Technik ► Bauwesen |
| Technik ► Elektrotechnik / Energietechnik | |
| ISBN-10 | 1-4831-9235-0 / 1483192350 |
| ISBN-13 | 978-1-4831-9235-2 / 9781483192352 |
| Haben Sie eine Frage zum Produkt? |
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