What Went Wrong?

What Went Wrong?

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

5th Edition - June 17, 2009

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  • Author: Trevor Kletz
  • eBook ISBN: 9780080949697

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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

Product details

  • No. of pages: 640
  • Language: English
  • Copyright: © Butterworth-Heinemann 2009
  • Published: June 17, 2009
  • Imprint: Butterworth-Heinemann
  • eBook ISBN: 9780080949697

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

Ratings and Reviews

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  • R. J. Sat Jul 13 2019

    R Jayapal

    Excellent but expensive book. You can also try this book "What was wrong? Route to root cause.".This 5 dollar book can be bought from notionpress. com. Describes a few industrial accidents and finds root cause.

  • Yann G. Mon Mar 12 2018

    What went worng Trevor Kletz

    A bible which should be read by every manager and engineer in the process industry having the responsibility to ensure process safety of their operations.