What Went Wrong?
Case Histories of Process Plant Disasters and How They Could Have Been AvoidedBy
- Trevor Kletz, Process Safety Consultant, UK
"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.
Safety and loss prevention engineers and managers, process and plant designers, in all chemical, petroleum and process industry sectors
Hardbound, 640 Pages
Published: June 2009
Imprint: Butterworth Heinemann
- 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