What Went Wrong?: Case Histories of Process Plant Disasters and How They Could Have Been Avoided

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Butterworth-Heinemann, Jun 17, 2009 - Technology & Engineering - 640 pages
"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
 

Contents

B Still Going Wrong
359
Appendix 1 Relative Frequencies of Incidents
583
Appendix 2 Why Should We Publish Accident Reports?
587
Appendix 3 Some Tips for Accident Investigators
589
Appendix 4 Recommended Reading
591
Appendix 5 Afterthoughts
593
Index
595
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About the author (2009)

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.

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