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.
- 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
INTRODUCTION 1. Case Histories and Their Use in Enhancing Process Safety Knowledge 2. Bhopal 3. Opportunities for Reflection
MAINTENANCE AND OPERATIONS 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
EQUIPMENT AND MATERIALS OF CONSTRUCTION 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
HAZARDS AND LOSS OF CONTAINMENT 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
KNOWLEDGE AND COMMUNICATION 26. Poor Communication 27. Accidents in Other Industries 28. Accident Investigation
Missed Opportunities 29. Opportunities for Reflection
DESIGN AND MODIFICATIONS 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
CONCLUSION 38. An Accident That May Have Affected the Future of Process Safety 39. An Accident That Did Not Occur 40. Summary of Lessons Learned
APPENDICES 1. Relative Frequencies of Incidents 2. Why Should We Publish Accident Reports? 3. Some Tips for Accident Investigators 4. Recommended Reading 5. Afterthoughts
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.
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.