What Went Wrong? - 6th Edition - ISBN: 9780128105399

What Went Wrong?

6th Edition

Case Histories of Process Plant Disasters and How They Could Have Been Avoided

Authors: Trevor Kletz Paul Amyotte
Hardcover ISBN: 9780128105399
Imprint: Butterworth-Heinemann
Published Date: 28th June 2019
Page Count: 840
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What Went Wrong: Case Histories of Process Plant Disasters and How They Could Have Been Avoided, Sixth Edition, the latest release of Trevor Kletz’s well-known book, presents a complete analysis of the design, operational and managerial causes of process plant accidents and disasters, including their aftermaths. It builds on Kletz’s legacy by including questions and personal exercises, adding new case studies that focus on safer design, safety culture and recognition of warning signs, and including safety management system elements, such as management of change. The book now covers Buncefield, Macondo and Texas City, as well as Bhopal under inherent safety.

Case histories illustrate what went wrong, then guiding readers in how to avoid similar tragedies and learn from the mistakes of others. Updated throughout and expanded, this new edition is the ultimate resource of experienced based analysis and guidance for safety and loss prevention professionals.

Key Features

  • Contains 20% new material and an update of existing content, with parts A and B now combined
  • Includes case studies that incorporate Safety Instrumented Systems terminology and information
  • Presents biological hazard case histories and examples of recent incidents


Safety and loss prevention engineers and managers and process and plant designers in all chemical, petroleum and process industry sectors

Table of Contents

Preparation for maintenance
Accidents caused by human error
Storage tanks
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?
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
Poor communication
Reactions - planned and unplanned
Both design and operations could have been better
Accidents in other industries
Accident investigation - Missed opportunities


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© Butterworth-Heinemann 2019
Hardcover ISBN:

About the Author

Trevor Kletz

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.

Affiliations and Expertise

Process Safety Consultant, UK

Paul Amyotte

Paul Amyotte

Since 2011 Dr. Paul Amyotte, P.Eng. has held the C.D. Howe Chair in Process Safety at Dalhousie University, where he is also a Professor of Chemical Engineering. Dr. Amyotte’s research and practice interests are in industrial safety and loss management, particularly in the areas of process safety and inherently safer design (ISD). He is an expert in the prevention and mitigation of dust explosions. He has written a book with us entitled An Introduction to Dust Explosions, and wrote the second edition of Process Plants: A Handbook for Inherently Safer Design in conjunction with Trevor Kletz. He has published or presented approximately 300 research papers, and is the editor of the Journal of Loss Prevention in the Process Industries. He is also a Past-President of the Canadian Society for Chemical Engineering, Engineers Nova Scotia, and Engineers Canada. Dr. Amyotte leads a comprehensive research team of undergraduate and graduate students as well as postdoctoral fellows working to advance process safety practice worldwide.

Affiliations and Expertise

Professor of Chemical Engineering and C.D. Howe Chair in Engineering, Department of Chemical Engineering, Process Engineering and Applied Science, Dalhousie University, Canada

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