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

What Went Wrong?: Case histories of process plant disasters and how they could have been avoided

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

About the Author :
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. 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.