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What Went Wrong? - 6th Edition - ISBN: 9780128105399, 9780128105405

What Went Wrong?

6th Edition

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

Authors: Trevor Kletz Paul Amyotte
eBook ISBN: 9780128105405
Hardcover ISBN: 9780128105399
Imprint: Butterworth-Heinemann
Published Date: 27th June 2019
Page Count: 840
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What Went Wrong? 6th Edition provides a complete analysis of the design, operational, and management causes of process plant accidents and disasters. Co-author Paul Amyotte has built on Trevor Kletz’s legacy by incorporating questions and personal exercises at the end of each major book section. Case histories illustrate what went wrong and why it went wrong, and then guide readers in how to avoid similar tragedies and learn without having to experience the loss incurred by others. Updated throughout and expanded, this sixth edition is the ultimate resource of experienced-based analysis and guidance for safety and loss prevention professionals.

Key Features

  • 20% new material and updating of existing content with parts A and B now combined
  • Exposition of topical concepts including Natech events, process security, warning signs, and domino effects
  • New case histories and lessons learned drawn from other industries and applications such as laboratories, pilot plants, bioprocess plants, and electronics manufacturing facilities


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

Table of Contents

1. Case Histories and Their Use in Enhancing Process Safety Knowledge
2. Bhopal
3. Opportunities for Reflection

4. Maintenance: Preparation and Performance
5. Operating Methods
6. Entry to Vessels and Other Confined Spaces
7. Accidents Said to Be Due to Human Error
8. Labeling
9. Testing of Trips and Other Protective Systems
10. Opportunities for Reflection

11. Storage Tanks
12. Stacks
13. Pipes and Vessels
14. Tank Trucks and Tank Cars
15. Other Equipment
16. Materials of Construction
17. Opportunities for Reflection

18. Leaks
19. Liquefied Flammable Gases
20. Hazards of Common Materials
21. Static Electricity
22. Reactions – Planned and Unplanned
23. Explosions
24. Opportunities for Reflection

26. Poor Communication
27. Accidents in Other Industries
28. Accident Investigation – Missed Opportunities
29. Opportunities for Reflection

30. Inherently Safer Design
31. Changing Procedures Instead of Designs
32. Both Design and Operations Could Have Been Better
33. Modifications: Changes to Equipment and Processes
34. Modifications: Changes in Organization
35. Reverse Flow, Other Unforeseen Deviations, and Hazop
36. Control
37. Opportunities for Reflection

38. An Accident That May Have Affected the Future of Process Safety
39. An Accident That Did Not Occur
40. Summary of Lessons Learned

1. Relative Frequencies of Incidents
2. Why Should We Publish Accident Reports?
3. Some Tips for Accident Investigators
4. Recommended Reading
5. Afterthoughts


No. of pages:
© Butterworth-Heinemann 2019
27th June 2019
eBook ISBN:
Hardcover ISBN:

About the Authors

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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