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What Went Wrong?

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

  • 6th Edition - June 6, 2019
  • Latest edition
  • Authors: Trevor Kletz, Paul Amyotte, Paul R. Amyotte
  • Language: English

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 h… Read more

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Description

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

Readership

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

Table of contents

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

Product details

  • Edition: 6
  • Latest edition
  • Published: June 27, 2019
  • Language: English

About the authors

TK

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

PA

Paul Amyotte

Paul Amyotte is a Distinguished Research Professor and Professor of Chemical Engineering at Dalhousie University (Halifax, Canada). He is a chemical engineering graduate of the Royal Military College of Canada (Bachelor’s), Queen’s University (Master’s), the Technical University of Nova Scotia (PhD) and a registered professional engineer in Nova Scotia. Dr. Amyotte is a member and past president of Canadian Society of Chemical Engineering, a member of American Institute of Chemical Engineers, a Fellow of Chemical Institute of Canada, the Engineering Institute of Canada, Canadian Academy of Engineering, Engineers Canada, and the Canadian Academy of Engineering. Dr. Amyotte has an extensive record of authorship, with six books, several book chapters, and over 350 papers published in peer-reviewed journals or presented at national and international conferences. He has presented invited plenary lectures at symposia in Canada, France, Italy, Malaysia, Netherlands, Norway, Poland, Qatar, Taiwan, and the United States. He is the current editor of the Journal of Loss Prevention in the Process Industries, and a past president of the Canadian Society for Chemical Engineering, Engineers Nova Scotia, and Engineers Canada. He has also served as chair of the Canadian Engineering Qualifications Board, member of the Canadian Engineering Accreditation Board, and co-chair of the Materials and Chemical Engineering Evaluation Group of the Natural Sciences and Engineering Research Council of Canada. Dr. Amyotte has consulted on numerous industrial projects involving hazard analysis, incident investigation, and material explosibility. Dr. Amyotte is a recipient of distinct awards including Cybulski Medal from the Polish Academy of Sciences, the Trevor Kletz Merit Award from the Mary Kay O’Connor Process Safety Center, and the Process Safety Management Award from the Canadian Society for Chemical Engineering.
Affiliations and expertise
Dalhousie University Halifax B3H 4R2 Canada

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