What Went Wrong?

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.