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WHAT WENT WRONG?
Case Studies of Process Plant Disasters (Fourth Edition)

PLUS -

STILL GOING WRONG!
CASE HISTORIES OF PROCESS PLANT DISASTERS AND HOW THEY COULD
HAVE BEEN AVOIDED

by Trevor Kletz

Save $5.00! Two Volume Set,

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WHAT WENT WRONG?
Case Studies of Process Plant Disasters
Fourth Edition
by Trevor Kletz
Process Safety Consultant, UK

“The examples were very clear and graphic, with good sketches or pictures.
Without a doubt,
I strongly
recommend this book as required reading for every engineer and supervisor in the
process
industry and
suggested reading for others.” (AFE Facilities Engineering Journal)

“The incidents described could occur in many types of plants, and should therefore
be of
interest to a
wide variety of plant operators. The new fourth edition contains considerable new
material,
with extensive
references.” (Mechanical Engineering)

“This book is recommended for generalists with an interest in industrial safety and
safety/process who
wish to gain some insight into the realities of plant operations.” (IchemE - Institute
Of
Chemical
Engineers)

“This book should be read by every health and safety advisor and all managers and
engineers who work
in the chemical and petrochemical industries. It should also be used by those who
provide
training
courses in these industries.” (The Safety & Health Practitioner, July 2002)

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Expert Trevor Kletz examines the causes and aftermaths of numerous plant
disasters--almost every one
of which could have been prevented. Case histories illustrate what went wrong, why
it went
wrong, and
then guide you in how to circumvent similar tragedies.

Learn from the mistakes of others. This invaluable and respected book examines
the causes
and
aftermaths of numerous plant disasters - almost every one of which could have
been
prevented. Case
histories illustrate what went wrong and why it went wrong, and then guide you in
how to
circumvent
similar tragedies.

Twenty percent of the information in this fourth edition is brand new, with 15 new
figures and
photos to
help you better recognize danger. Extensive references are a hallmark of this
trusted volume.

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“Most of the incidents are very simple. No esoteric knowledge or detailed study
was required
to prevent
them - only a knowledge of what had happened before, which this book provides.” -
Trevor
Kletz.

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CONTENTS

Acknowledgments
Preface
Units and nomenclature
Preparation 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
A final word
Recommended reading
Index

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STILL GOING WRONG!
CASE HISTORIES OF PROCESS PLANT DISASTERS AND HOW THEY COULD
HAVE
BEEN
AVOIDED
by Trevor Kletz

- This volume follows up on the cases and strategies outlined in the original
million-dollar
seller:
“What Went Wrong”
- Contains many new cases and areas for improvement, including the
hazards of rust,
corrosion, and many more new topics
- Written by the world's leading expert on industrial safety

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“Trevor Kletz has helped to educate many people in industry to the hazards that
they are
confronted with
on a regular basis, especially those in the chemical, oil and process industries.
Still Going
Wrong is his
eleventh book, and most people can learn something from it, whether they are
involved in
production,
maintenance or design.

“He has some very good advice for incident investigators, looking for the true cause
of an
accident and
not just who to blame.

“Still Going Wrong? is very aptly titled. All process industries have a tremendous
amount to
learn. The
pressure for improving safety standards is relentless, as it should be. This book
will help
build awareness
of the diverse causes of accidents. It will not prevent them unless the reader is
committed to
thinking
about the lessons and applying them appropriately in their own area of
responsibility. If
lessons in this
book prevent one incident in each reader's plant, the cost of the human suffering
incurred in
the book will
not have been wasted.

“Without a doubt I recommend this book for anyone involved with management,
design,
operation, health
and safety, or maintenance, in the process industries.” - Reviewed by Nick
Spencer (General
Manager
and Director, ConocoPhillips Ltd Humber Refinery, UK)

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“In the preface to this book Trevor Kletz records two invaluable points on ‘safety.’ A
new
Director of
Safety made the first point - ‘safety management is not rocket science.’ The
second point is
that on
reading his own book 'What Went Wrong', I realised that I could use it to ‘wake up’
my people
to the
dangers and horrors others have experienced'. Trevor has been doing the latter all
his
professional life.
Safety management may not be rocket science but it does require detailed
attention and
constant review
and enhancement.

“Trevor has subtitled this book ‘Case studies of Process Disasters and how they
could have
been
avoided.’ Maybe it could have been ‘Here's to the Next One.’

“Trevor has adopted a simple but very effective format of incidents under 16 main
headings.
The choice
was Trevor’s and could have reached two or more times that number. In this he
shows that
there are still
the same fundamental causations of disasters and that the industry has not yet
learnt fully the
messages
of the past! The main heads were: -
1..Maintenance
2 .Entry into Confined Spaces
3. Changes to Process and Plants
4.. Changes in Organisation
5. Changing Procedures Instead of Design
6. Materials of Construction (including Insulation)
7. Operating Methods
8. Explosions
9. Poor Communication
10. I Did Not Know That
11. Control
12. Leaks
13. Reactions-Planned and Unplanned
14. Both Design and Operation Could Have Been Better
15. Accidents in Other Industries
16. Accident Investigation - Missed Opportunities

“As is his style the examples chosen by Trevor are clear and succinctly written
with some
deep feelings. I
(the reviewer) have first- and second-hand knowledge of a number of the events and
I also
feel the
disappointment of realising that not much has changed. The incident that is
described on
pages 51 and
52 could have occurred on a similar plant on the same Works about 15 years
previously
during the initial
commissioning. The symptoms (but not the background) were identical; there was
a fault on
the level
controller and the alarms generated by the 'common cause' of the fluid properties. I
was the
Professional
Engineer during the first incident and, like the second incident, I had been working
12-hour
shifts. In the
first event the plant was put on hold, the incident resolved and the start up
proceeded safely.
Surely this
incident was in the Works memory banks? Why had it been forgotten? One reason
is that the
second
group had adopted a more remote attitude to the operation of the plant and were
less
inclined to be
steeped in the day-to-day detail that was the norm for the previous group. Was this
a culture
change (as
well as a change in organisation where the Shift Manager had become a demigod)
or was it
a form of
arrogance? (At least the flare stack from my plant replaced the damaged flare
stack and is
still in use on
the second plant!)

“It would be wrong to take up other incidents recorded; however many of them have
a
measure of ‘deja
vu.’ Many of the incidents may appear to have been the result of stupid (but not
intentionally
so) mistakes.
Maybe they were but those involved were intelligent persons and the events did
occur and in
some form
or other they are still occurring today. Trevor has reminded us all of this once
again. The
Piper Alpha
Disaster in 1988 (not included) had a very similar background and build-up to an
incident
that occurred in
1966. There was a shift hand-over, a weakness in the permit system, problems
with pump
isolations, an
emergency isolation valve that did not close and finally persons were trapped and
died. The
facts were
the same only the names changed. We should also recognise that we have all
been involved
in 'near
misses' which could have escalated and been one of the examples in Trevor's
book. It is
essential that
we do learn from these incidents and others like them. 'Still Going Wrong' is
another wake up
call, easy to
read and to follow and at times you will be left with the feeling 'Why!?'

“There is the constant thread which runs through the book that the causations are
often
repeated and the
messages are not being learned. There is also another thread that runs through
this book,
that the use of
Audits would go a long way to preventing their recurrence. This is a book which
reminds us
that the
corporate (and industrial) memory is short and requires constant re-enforcement. It
is a book
which
should be read not only by those who design but also by those who operate
process plant of
any form, for
lack of size or complexity does not guarantee immunity. Whatever the area of
endeavour
there are
messages for us all, provided we are willing to see them. Maybe that is the rub.
We have to
be willing!

“Trevor writes the following in ‘Acknowledgements’ to this his latest book, ‘By the
time this
book, is
published, I will be in my 82nd year. It is my final harvest.’ Trevor, I am not
convinced that this
is your final
harvest, you will still be publishing your thoughts and challenging our consciences
for some
time yet.” -
Frank Crawlev, From Industrial Safety Management, Vol 6, No 2, April 2004, p 29.

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“Still Going Wrong is an immensely readable book and one that I would
recommend to all
personnel with
an interest in safety.” - Health and Safety At Work August 2004

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“This book is an excellent compilation of case histories of process plant accidents
and
discussions of
how they could have been avoided. I feel that this book will be of great use to
people who
work in the
chemical process industries and are involved in process design, production, and
maintenance. As with
the author's other books, this one is very easy to read. It imparts much useful and
practical
information,
which could lead to avoidance or minimization of costly accidents, both with
respect to
property and
human life loss. It will make a very useful addition to the technical library of
process
safety/loss prevention
engineers.” - Journal of Loss Prevention in the Process Industries, July 2004

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A million-dollar seller, Kletz’s classic, “What Went Wrong?,” has revolutionized the
way
industry views
safety. This volume, sure to be an instant bestseller, continues the practices and
wisdom of
the original.
Some reviews of the original:

“The incidents described could occur in many types of plants, and should therefore
be of
interest to a
wide variety of plant operators. The new fourth edition contains considerable new
material,
with extensive
references.” (Mechanical Engineering)

“This book is recommended for generalists with an interest in industrial safety and
safety/process who
wish to gain some insight into the realities of plant operations.” (IChemE-Institute
of
Chemical Engineers)

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CONTENTS

Forethoughts
Introduction
A note on nomenclature
1 Maintenance
2 Entry into confined spaces
3 Changes to processes and plants
4 Changes in organization
5 Changing procedures instead of designs
6 Materials of construction (including insulation) and corrosion
7 Operating methods
8 Explosions
9 Poor communication
10 I didn't know that...
11 Control
12 Leaks
13 Reactions - planned and unplanned
14 Both design and operations could have been better
15 Accidents in other industries
16 Accident investigation - Missed opportunities
Afterthoughts

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ABOUT THE AUTHOR

TREVOR KLETZ, D.Sc., F.Eng., a process safety consultant, has published more
than a
hundred papers
and nine books on loss prevention and process safety.

His experience includes 38 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.

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