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What Went Wrong? - 5th Edition - ISBN: 9781856175319, 9780080949697

What Went Wrong?

5th Edition

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

Author: Trevor Kletz
Hardcover ISBN: 9781856175319
Paperback ISBN: 9781493303908
eBook ISBN: 9780080949697
Imprint: Butterworth-Heinemann
Published Date: 17th June 2009
Page Count: 640
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"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.

Key Features

  • A million dollar bestseller, this trusted book is updated with new material, including the Texas City and Buncefield incidents, and supplemented by material from Trevor Kletz's 'Still Going Wrong'
    * Now presents a complete analysis of the design, operational and for the first time, managerial causes of process plant accidents and disasters, plus their aftermaths
    * Case histories illustrate what went wrong, why it went wrong, and then guide readers in how to avoid similar tragedies: learn from the mistakes of others


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

Table of Contents

Part 1 ? What Went Wrong? Learning From the Experiences of Others
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


No. of pages:
© Butterworth-Heinemann 2009
17th June 2009
Hardcover ISBN:
Paperback ISBN:
eBook 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


"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

"very readable, precise and well documented... This book is a required reading for every engineer and supervisor in the process industry"
(Chemical Industry Digest, July-August 2002)

"excellent, if somewhat disturbing book... In my opinion, the book should be read by a great many different professions and persons"
Ergonomics, Vol 46, Issue 5, 2003

Ratings and Reviews