What Went Wrong?

What Went Wrong?

by Trevor Kletz
Released June 2009
Publisher(s): Elsevier Science
ISBN: 9781856175319

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Book description

"What Went Wrong?" has revolutionized the way industry views safety.

The new edition continues and extends the wisdom, innovations and strategies of previous editions, by introducing new material on recent incidents, and adding an extensive new section that shows how many accidents occur through simple miscommunications within the organization, and how strightforward changes in design can often remove or reduce opportunities for human errors.

Kletz' approach to learning as deeply as possible from previous experiences is made yet more valuable in this new edtion, which for the first time brings together the approaches and cases of "What Went Wrong" with the managerially focussed material previously published in "Still Going Wrong". Updated and supplemented with new cases and analysis, this fifth edition is the ultimate resource of experienced based anaylsis and guidance for the safety and loss prevention professionals.





* A million dollar bestseller, this trusted book is updated with new material, including the Texas City and Buncefield incidents, and supplemented by material from Trevor Kletz's 'Still Going Wrong'
* Now presents a complete analysis of the design, operational and for the first time, managerial causes of process plant accidents and disasters, plus their aftermaths
* Case histories illustrate what went wrong, why it went wrong, and then guide readers in how to avoid similar tragedies: learn from the mistakes of others

Table of contents

  1. Brief Table of Contents
  2. Table of Contents
  3. Copyright
  4. Dedication
  5. Acknowledgments
  6. Preface
  7. Units and Nomenclature
  8. Still Going Wrong
  9. Part A. What Went Wrong?
    1. Chapter 1. Preparation for Maintenance
      1. 1.1. Isolation
      2. 1.2. Identification
      3. 1.3. Removal of Hazards
      4. 1.4. Procedures not Followed
      5. 1.5. Quality of Maintenance
      6. 1.6. A Personal Note
    2. Chapter 2. Modifications
      1. 2.1. Startup Modifications
      2. 2.2. Minor Modifications
      3. 2.3. Modifications Made During Maintenance
      4. 2.4. Temporary Modifications
      5. 2.5. Sanctioned Modifications
      6. 2.6. Process Modifications
      7. 2.7. New Tools
      8. 2.8. Organizational Changes
      9. 2.9. Gradual Changes
      10. 2.10. Modification Chains
      11. 2.11. Modifications Made to Improve the Environment
      12. 2.12. Control of Modifications
    3. Chapter 3. Accidents Said to Be Due to Human Error
      1. 3.1. Introduction
      2. 3.2. Accidents that Could be Prevented by Changing the Plant Design or Method of Working
      3. 3.3. Accidents that Could be Prevented by Better Training
    4. Chapter 4. Labeling
      1. 4.1. Labeling of Equipment
      2. 4.2. Labeling of Instruments
      3. 4.3. Labeling of Chemicals
      4. 4.4. Labels not Understood
    5. Chapter 5. Storage Tanks
      1. 5.1. Overfilling
      2. 5.2. Overpressuring
      3. 5.3. Sucking In
      4. 5.4. Explosions
      5. 5.5. Floating-Roof Tanks
      6. 5.6. Miscellaneous Incidents
      7. 5.7. Fiberglass-Reinforced (FRP) Tanks
    6. Chapter 6. Stacks
      1. 6.1. Stack Explosions
      2. 6.2. Blocked Stacks
      3. 6.3. Heat Radiation
    7. Chapter 7. Leaks
      1. 7.1. Some Common Sources of Leaks
      2. 7.2. Control of Leaks
      3. 7.3. Leaks onto Water, Wet Ground, or Insulation
      4. 7.4. Detection of Leaks
      5. 7.5. Fugitive Emissions
    8. Chapter 8. Liquefied Flammable Gases
      1. 8.1. Major Leaks
      2. 8.2. Minor Leaks
      3. 8.3. Other Leaks
      4. 8.4. Safety in the Design of Plants Handling Liquefied Light Hydrocarbons
    9. Chapter 9. Pipe and Vessel Failures
      1. 9.1. Pipe Failures
      2. 9.1.1. Dead-Ends
      3. 9.1.2. Poor Support
      4. 9.1.3. Water Injection
      5. 9.1.4. Bellows
      6. 9.2. Pressure Vessel Failures
    10. Chapter 10. Other Equipment
      1. 10.1. Centrifuges
      2. 10.2. Pumps
      3. 10.3. Air Coolers
      4. 10.4. Relief Valves
      5. 10.5. Heat Exchangers
      6. 10.6. Cooling Towers
      7. 10.7. Furnaces
    11. Chapter 11. Entry to Vessels
      1. 11.1. Vessels not Freed from Hazardous Material
      2. 11.2. Hazardous Materials Introduced
      3. 11.3. Vessels not Isolated from Sources of Danger
      4. 11.4. Unauthorized Entry
      5. 11.5. Entry into Vessels with Irrespirable Atmospheres
      6. 11.6. Rescue
      7. 11.7. Analysis Of Vessel Atmosphere
      8. 11.8. What is a Confined Space?
      9. 11.9. Every Possible Error
    12. Chapter 12. Hazards of Common Materials
      1. 12.1. Compressed Air
      2. 12.2. Water
      3. 12.3. Nitrogen [4,29]
      4. 12.4. Heavy Oils (Including Heat Transfer Oils)
    13. Chapter 13. Tank Trucks and Cars
      1. 13.1. Overfilling
      2. 13.2. Burst Hoses
      3. 13.3. Fires and Explosions
      4. 13.4. Liquefied Flammable Gases
      5. 13.5. Compressed Air
      6. 13.6. Tipping Up
      7. 13.7. Emptying into or Filling from the Wrong Place
      8. 13.8. Contact with Live Power Lines
    14. Chapter 14. Testing of Trips and Other Protective Systems
      1. 14.1. Testing Should be Thorough
      2. 14.2. All Protective Equipment should be Tested
      3. 14.3. Testing Can be Overdone
      4. 14.4. Protective Systems Should not Reset Themselves
      5. 14.5. Trips Should not be Disarmed Without Authorization
      6. 14.6. Instruments should Measure Directly What we Need to Know
      7. 14.7. Trips are for Emergencies, not for Routine Use
      8. 14.8. Tests may Find Faults
      9. 14.9. Some Miscellaneous Incidents
      10. 14.10. Some Accidents at Sea
    15. Chapter 15. Static Electricity
      1. 15.1. Static Electricity from Flowing Liquids
      2. 15.2. Static Electricity from Gas and Water Jets
      3. 15.3. Static Electricity from Powders and Plastics
      4. 15.4. Static Electricity from Clothing
    16. Chapter 16. Materials of Construction
      1. 16.1. Wrong Material Used
      2. 16.2. Hydrogen Produced by Corrosion
      3. 16.3. Other Effects of Corrosion
      4. 16.4. Loss of Protective Coatings
      5. 16.5. Some other Incidents Caused by Corrosion
      6. 16.6. Fires
      7. 16.7. Choosing Materials
    17. Chapter 17. Operating Methods
      1. 17.1. Trapped Pressure
      2. 17.2. Clearing Choked Lines
      3. 17.3. Faulty Valve Positioning
      4. 17.4. Responsibilities not Defined
      5. 17.5. Communication Failures
      6. 17.6. Work at Open Manholes
      7. 17.7. One Line, Two Duties
      8. 17.8. Inadvertent Isolation
      9. 17.9. Incompatible Storage
      10. 17.10. Maintenance: Is it Really Necessary?
      11. 17.11. An Interlock Failure
      12. 17.12. Emulsion Breaking
      13. 17.13. Chimney Effects
    18. Chapter 18. Reverse Flow, Other Unforeseen Deviations, and Hazop
      1. 18.1. Reverse Flow from a Product Receiver or Blowdown Line Back into the Plant
      2. 18.2. Reverse Flow into Service Mains
      3. 18.3. Reverse Flow Through Pumps
      4. 18.4. Reverse Flow from Reactors
      5. 18.5. Reverse Flow from Drains
      6. 18.6. Other Deviations
      7. 18.7. A Method for Foreseeing Deviations
      8. 18.8. Some Pitfalls in Hazop
      9. 18.9. Hazop of Batch Plants
      10. 18.10. Hazop of Tank Trucks
      11. 18.11. Hazop: Conclusions
    19. Chapter 19. I Didn't Know That ♦ ♦ ♦
      1. 19.1. Ammonia can Explode
      2. 19.2. Hydraulic Pressure Tests can be Hazardous
      3. 19.3. Diesel Engines can Ignite Leaks
      4. 19.4. Carbon Dioxide can Ignite a Flammable Mixture
      5. 19.5. Mists can Explode
      6. 19.6. The Source of the Problem Lay Elsewhere
    20. Chapter 20. Problems with Computer Control
      1. 20.1. Hardware and Software Faults
      2. 20.2. Treating the Computer as a Black Box
      3. 20.3. Misjudging the way Operators will Respond
      4. 20.4. Other Problems
      5. 20.5. Unauthorized Interference
      6. 20.6. New Applications
      7. 20.7. Conclusions
      8. Additional Reading
    21. Chapter 21. Inherently Safer Design
      1. 21.1. Bhopal
      2. 21.2. Other Examples of Inherently Safer Design
      3. 21.3. User-Friendly Design
      4. Additional Reading on Bhopal
    22. Chapter 22. Reactions—Planned and Unplanned
      1. 22.1. Lack of Knowledge
      2. 22.2. Poor Mixing
      3. 22.3. Contamination
      4. 22.4. Reactions with Auxiliary Materials
      5. 22.5. Poor Training or Procedures
      6. 22.6. Use-by Dates
      7. Additional Reading on Runaway Reactions
  10. Part B. Still Going Wrong
    1. Chapter 23. Maintenance
      1. 23.1. Inadequate Preparation on a Distant Plant
      2. 23.2. Precautions Relaxed too Soon
      3. 23.3. Failure to Isolate Results in a Fire
      4. 23.4. Unintentional Isolation
      5. 23.5. Bad Practice and Poor Detailed Design
      6. 23.6. Dismantling
      7. 23.7. Commissioning
      8. 23.8. Other Hidden Hazards
      9. 23.9. Changes in Procedure
      10. 23.10. Dead-Ends
    2. Chapter 24. Entry into Confined Spaces
      1. 24.1. Incomplete Isolation
      2. 24.2. Hazardous Materials Introduced
      3. 24.3. Weaknesses in Protective Equipment
      4. 24.4. Poor Analysis of Atmosphere
      5. 24.5. When Does a Space Become Confined?
      6. 24.6. My First Entry and a Gasholder Explosion
      7. 24.7. Failure of a Complex Procedure
      8. 24.8. Epidemics of Unsafe Entries
    3. Chapter 25. Changes to Processes and Plants
      1. 25.1. Changes to Processes
      2. 25.2. Changes to Plant Equipment
      3. 25.3. Gradual Changes
      4. 25.4. Changes made Because the Reasons for Equipment or Procedures has Been Forgotten
    4. Chapter 26. Changes in Organization   This chapter is based in part on a paper presented at the Hazards XVII Conference held in Manchester, United Kingdom, in March 2003, and is included with the permission of the Institute of Chemical Engineers.
      1. 26.1. An Incident at an Ethylene Plant
      2. 26.2. The Longford Explosion
      3. 26.3. The Texas City Explosion
      4. 26.4. Outsourcing
      5. 26.5. Multiskilling and Downsizing
      6. 26.6. How to Lose your Reputation
      7. 26.7. Administrative Convenience Versus Good Science
      8. 26.8. The Control of Managerial Modifications
      9. 26.9. Some Points a Guide Sheet Should Cover
      10. 26.10. Afterthoughts
    5. Chapter 27. Changing Procedures Instead of Designs
      1. 27.1. Misleading Valve Layouts
      2. 27.2. Simple Redesign Overlooked
      3. 27.3. Unimaginative Thinking
      4. 27.4. Just Telling People to Follow the Rules
      5. 27.5. Don't Assemble it Incorrectly
      6. 27.6. Tighten Correctly or Remove the Need
      7. 27.7. Should Improvements to Procedures Ever be the First Choice?
    6. Chapter 28. Materials of Construction (Including Insulation)
      1. 28.1. Rust
      2. 28.2. Insulation
      3. 28.3. Brittle Failure
      4. 28.4. Wrong Materials of Construction
      5. 28.5. Corrosion Sends a Column into Orbit
      6. 28.6. Unexpected Corrosion
      7. 28.7. Another Failure to Inspect Pipework
      8. 28.8. How not to Write an Accident Report
    7. Chapter 29. Operating Methods
      1. 29.1. The Alarm Must be False
      2. 29.2. A Familiar Accident—But not as Simple as it Seemed
      3. 29.3. More Reluctance to Believe the Alarm
      4. 29.4. The Limitations of Instructions
      5. 29.5. The Limitations of Instructions Again
      6. 29.6. Empty Plant That is Out of Use
      7. 29.7. A Minor Job Forgotten—Until there was a Leak
      8. 29.8. Design Error + Construction Error + Operating Error = Spillage
    8. Chapter 30. Explosions
      1. 30.1. An Explosion in a Gas-Oil Tank
      2. 30.2. Another Sort of Explosion
      3. 30.3. One + One = More than Two
      4. 30.4. “Near Enough is Good Enough”
      5. 30.5. Another Explosion Ignited by a Carbon Bed
      6. 30.6. An Explosion in an Alternative to a Carbon Bed
      7. 30.7. Only a Minor Change
      8. 30.8. An Explosion in a Pipe
      9. 30.9. A Dust Explosion in a Duct
      10. 30.10. Obvious Precautions Neglected
      11. 30.11. A Drum Explosion
      12. 30.12. Foam-Over—The Cinderella of the Oil and Chemical Industries
      13. 30.13. Explosions of Cold Gasoline in the Open Air
      14. 30.14. The Inevitability of Ignition
    9. Chapter 31. Poor Communication
      1. 31.1. What is Meant By Similar?
      2. 31.3. Wrong Material Delivered
      3. 31.4. Packaged Deals
      4. 31.5. “Draftsmen's Delusions”
      5. 31.6. Same Plant and Product, but no Communication
      6. 31.7. A Failure at the Design/Construction Interface
      7. 31.8. Failure of Communication Between Marketing and Technology
      8. 31.9. Too Much Communication
      9. 31.10. No One Told the Designers
      10. 31.11. Conclusions
    10. Chapter 32. I Did Not Know ♦♦♦
      1. 32.1. … That Metals Can Burn
      2. 32.2. … That Aluminum is Dangerous When Wet
      3. 32.3. … That Rubber and Plastics are Permeable
      4. 32.4. …That Some Plastics can Absorb Process Materials and Swell
      5. 32.5. … What Lay Underneath
      6. 32.6. … The Method of Construction
      7. 32.7. … Much about Static Electricity
      8. 32.8. … That a Little Contamination can have a Big Effect
      9. 32.9. … That we cannot get a Tight Seal between Thin Bolted Sheets
      10. 32.10. … That Unforeseen Sources of Ignition are Often Present
      11. 32.11. … That Keeping the Letter of the Law is not Enough
      12. 32.12. … The Power of Compres Sed Air
    11. Chapter 33. Control
      1. 33.1. Instruments that cannot do what we want them to do
      2. 33.2. Too Little Instrumentation
      3. 33.3. Diagrams were not up to Date
      4. 33.4. An Automatic Restart Fails to Restart
      5. 33.5. Procedures: An Essential Feature of Control Systems
    12. Chapter 34. Leaks
      1. 34.1. Leaks from Tanks
      2. 34.2. Leaks from Lined Pipes
      3. 34.3. A Leak through Closed Valves
      4. 34.4. A Leak caused by Surge Pressure
      5. 34.5. Leaks from Screwed Fittings
      6. 34.6. Other weak Spots in Pipework
    13. Chapter 35. Reactions—Planned and Unplanned
      1. 35.1. Delayed Mixing
      2. 35.2. Waiting Until after the Fourth Accident
      3. 35.3. Lower Temperature may not mean less Risk
      4. 35.4. Forgetting to add a Reactant
      5. 35.5. Inadequate Tests
      6. 35.6. A Heating Medium was too Hot
      7. 35.7. An Unstable Substance Left Standing for too Long
    14. Chapter 36. Both Design and Operations Could Have Been Better
      1. 36.1. Water in Relief Valve Tailpipes
      2. 36.2. A Journey in a Time Machine
      3. 36.3. Chokes in Flarestacks
      4. 36.4. Other Explosions in Flarestacks
      5. 36.5. Design Poor, Protection Neglected
      6. 36.6. Several Poor Systems do not make a Good System
      7. 36.7. “Failures in Management, Equipment, and Control Systems”
      8. 36.8. Changes to Design and Operations
      9. 36.9. The Irrelevance of Blame
    15. Chapter 37. Accidents in Other Industries
      1. 37.1. An Explosion in a Coal Mine
      2. 37.2. Marine Accidents
      3. 37.3. Human Error
      4. 37.4. Tests should be like Real Life
      5. 37.5. Load and Strength too Close
      6. 37.6. The Nineteenth Century
    16. Chapter 38. Accident Investigation—Missed Opportunities
      1. 38.1. Accident Investigations often find only a Single Cause
      2. 38.2. Accident Investigations are often Superficial
      3. 38.3. Accident Investigations List Human Error as a Cause
      4. 38.4. Accident Reports Look for People to Blame
      5. 38.5. Accident Reports List Causes that are Difficult or Impossible to Remove
      6. 38.6. We Change Procedures Rather than Designs
      7. 38.7. We May go too Far
      8. 38.8. We do not Let others Learn from our Experience
      9. 38.9. We Read or Receive only Overviews
      10. 38.10. We Forget the Les Sons Learned and Allow the Accident to Happen Again
    17. Chapter 39. An Accident That May Have Affected the Future of Process Safety
      1. 39.1. Why did ICI, more so than other Companies, make these Changes?
      2. 39.2. What Would Have Happened if ICI had not Existed?
      3. 39.3. Why did ICI come to an End?
      4. 39.4. What will we Miss in the Years to Come?
  11. Appendix 1. Relative Frequencies of Incidents
    1. Primary Causes
    2. Responsibility
  12. BibliographyReferences
  13. Appendix 2. Why Should We Publish Accident Reports?
    1. “It's Not Like That Today”
  14. Appendix 3. Some Tips for Accident Investigators
  15. Appendix 4. Recommended Reading   Reports about safety originally published by Her Majesty's Stationery Office are now supplied by HSE Books, Sudbury, United Kingdom.
    1.  
  16. Appendix 5. Afterthoughts
  17. Index
    1. A
    2. B
    3. C
    4. D
    5. E
    6. F
    7. G
    8. H
    9. I
    10. J
    11. K
    12. L
    13. M
    14. N
    15. O
    16. P
    17. Q
    18. R
    19. S
    20. T
    21. U
    22. V
    23. W
    24. X
    25. Y

Product information

  • Title: What Went Wrong?
  • Author(s): Trevor Kletz
  • Release date: June 2009
  • Publisher(s): Elsevier Science
  • ISBN: 9781856175319