What Went Wrong?

What Went Wrong?

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

6th Edition - June 6, 2019

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  • Authors: Trevor Kletz, Paul Amyotte
  • Hardcover ISBN: 9780128105399
  • eBook ISBN: 9780128105405

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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

Product details

  • No. of pages: 840
  • Language: English
  • Copyright: © Butterworth-Heinemann 2019
  • Published: June 6, 2019
  • Imprint: Butterworth-Heinemann
  • Hardcover ISBN: 9780128105399
  • eBook ISBN: 9780128105405

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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