Kletz What Went Wrong

Case Studies of Process Plant Disasters and How They Could Have Been Avoided
5. Auflage 2009
ISBN: 978-0-08-094969-7
Verlag: Elsevier Science & Technology
Format: EPUB
Kopierschutz: 6 - ePub Watermark

E-Book, Englisch, 640 Seiten, Format (B × H): 286 mm x 221 mm

"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.



* 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

Zielgruppe

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

Autoren/Hrsg.

Kletz, Trevor

Fachgebiete

• Wirtschaftswissenschaften Wirtschaftssektoren & Branchen Fertigungsindustrie Chemische Industrie

Inhaltsverzeichnis

Part 1 ? What Went Wrong? Learning From the Experiences of Others
Preparation for maintenance
Modifications
Accidents caused by human error
Labeling
Storage tanks
Stacks
Leaks
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?
Maintenance
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
Explosions
Poor communication
Control
Leaks
Reactions - planned and unplanned
Both design and operations could have been better
Accidents in other industries
Accident investigation - Missed opportunities

Leseproben

Preface
In 1968, after many years' experience in plant operations, I was appointed safety adviser to the heavy organic chemicals division (later the petrochemicals division) of Imperial Chemical Industries. My appointment followed a number of serious fires in the 1960s, and therefore I was mainly concerned with process hazards rather than those of a mechanical nature. Today I would be called a process safety adviser. One of my tasks was to pass on to design and operating staff details of accidents that had occurred and the lessons that should be learned. This book contains a selection of the reports I collected from many different companies, as well as many later reports. Although most have been published before, they were scattered among many different publications, some with small circulations. The purpose here is to show what has gone wrong in the past and to suggest how similar incidents might be prevented in the future. Unfortunately, the history of the process industries shows that many incidents are repeated after a lapse of a few years. People move on, and the lessons are forgotten. This book will help keep the memories alive. The advice is given in good faith but without warranty. Readers should satisfy themselves that it applies to their circumstances. In fact, you may feel that some of my recommendations are not appropriate for your company. Fair enough, but if the incidents could occur in your company, and you do not wish to adopt my advice, then please do something else instead. But do not ignore the incidents. To quote the advice of John Bunyan, written more than 300 years ago, What of my dross thou findest there, be boldTo throw away, but yet preserve the gold.What if my gold be wrapped up in ore?None throws away the apple for the core:But if thou shalt cast all away as vain … You have been warned what will happen. You may believe that the accidents could not happen at your plant because you have systems to prevent them. Are you are sure that they are always followed, everywhere, all the time? Perhaps they are followed most of the time but someone turns a blind eye when a job is urgent. Also remember that systems have limitations. All they can do is make the most of people's knowledge and experience by applying them in a systematic way. If people lack knowledge and experience, the systems are empty shells. Many of the accidents I describe occurred in plants that had such systems, but the systems were not always followed. The accidents happened because of various management failures: failure to convince people that they should follow the systems, failure to detect previous violations (by audits, spot checks, or just keeping an open eye), or deliberately turning a blind eye to avoid conflict or to get a job done quickly. The first step down the road to many a serious accident occurred when someone turned a blind eye to a missing blind (see Chapter 1). The incidents described could occur in many different types of plants and are therefore of widespread interest. Some of them illustrate the hazards involved in activities such as preparing equipment for maintenance and modifying plants. Others illustrate the hazards associated with widely used equipment, such as storage tanks and hoses, and with that universal component of all plants and processes: people. Other incidents illustrate the need for techniques, such as hazard and operability studies, and protective devices, such as emergency isolation valves. You will notice that most of the incidents are very simple. No esoteric knowledge or detailed study was required to prevent them—only a knowledge of what had happened before, which this book provides. Only a few incidents started with the sudden failure of a major component. Most started with a flaw in a minor component, an instrument that was out of order or not believed, a poor procedure, or a failure to follow procedures or good engineering practice. For want of a nail, a kingdom was lost. Many of the incidents described could be discussed under more than one heading. Therefore, cross-references have been included. If an incident that happened in your plant is described, you may notice that one or two details have been changed. Sometimes this has been done to make it harder for people to tell where the incident occurred. Sometimes this has been done to make a complicated story simpler but without affecting the essential message. Sometimes—and this is the most likely reason—the incident did not happen in your plant at all. Another plant had a similar incident. Many of the incidents did not actually result in death, serious injury, or serious damage—they were so-called near misses, although they were really near accidents. But they could have had much more serious consequences. We should learn from these near misses, as well as from incidents that had serious results. Most of the incidents described occurred at so-called major hazard plants or storage installations—that is, those containing large quantities of flammable, explosive, or toxic chemicals. The lessons learned apply particularly to such plants. However, most of the incidents could have occurred at plants handling smaller quantities of materials or less hazardous materials, and the consequences, though less serious, would be serious enough. At a major-hazard plant, opening up a pump that is not isolated could cause (and has caused) a major fire or explosion. At other plants, this would cause a smaller fire or a release of corrosive chemicals—still enough to kill or injure the employee on the job. Even if the contents of the plant are harmless, there is still a waste of materials. The lessons to be learned therefore apply throughout the process industries. For the second edition of this book, I added more incidents, extended the sections on Bhopal and Mexico City, and added chapters on some little-known but quite common hazards and on accidents in computer-controlled plants. For the third edition, I added sections or chapters on heat exchangers, furnaces, inherently safer design, and runaway reactions, and extended many other chapters. Although I have read many accident reports since the first edition appeared, most have merely reinforced the messages of the book, and I added only those incidents that tell us something new. For the fourth edition, I added further incidents to every chapter. For the fifth edition, Part A of this book, changes have been minor. A supplement to What Went Wrong? called Still Going Wrong was published in 2003. It is reprinted as Part B, and many reports on incidents that have occurred since then or become available since then have been added. There is, however, one difference between Parts A and B. In Part A I emphasized the immediate technical causes of the accidents and the changes in design and methods of working needed to prevent them from happening again. In Part B I have, whenever possible, discussed also the underlying weaknesses in the management systems. It is not possible to do this in every case, as the information is not always available. Too many reports still describe only the immediate technical causes. I do not blame their authors for this. Most of them are close to the ‘coal-face.’ They want to solve the immediate technical problems and get the plant back on line in a safe manner as soon as they can, so they concentrate on the immediate technical causes. More senior people, before approving the reports, should look for the underlying weaknesses that result in poor designs, poor methods of working, failures to learn from the past, tendencies to blame people who make occasional but inevitable errors, and so on. They should also see that changes that cannot be made on the existing plants are fed back to the design organizations, both in-house and contractors, for use in the future. Because of this difference in approach, I have not merged the contents of the two original books but left them as they were. There are therefore chapters in Parts A and B with the same or similar titles. In Part A, some of the chapters covered different types of equipment, whereas others covered procedures such as maintenance or modifications. In Part B, most of the chapters cover procedures, but a number of reports on explosions and leaks are collected under these headings. This part also emphasizes the multiple causes of accidents. As a result, the accidents described in the chapter on the management of change, for example, also have other causes, whereas some incidents in other chapters also involve the management of change. Similarly, several scattered reports show that some accidents cannot be prevented by more detailed...

Über Autor(innen)

Kletz, Trevor
Trevor Kletz, OBE, D.Sc., F.Eng., a process safety consultant, has 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. His experience includes thirty-eight years with Imperial Chemical Industries Ltd., where he served as a production manager and safety adviser in the petrochemical division, and membership in the department of chemical engineering at Loughborough University, Leicestershire, England. He is currently senior visiting research fellow at Loughborough University and an officer of the Order of the British Empire.