Other editions. Enlarge cover. Error rating book. Refresh and try again. Open Preview See a Problem? Details if other :. Thanks for telling us about the problem. Return to Book Page. Preview — What Went Wrong? What Went Wrong? 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 chang "What Went Wrong?
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.
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Get A Copy. Published June 17th by Butterworth-Heinemann first published June 1st More Details Other Editions Friend Reviews. To see what your friends thought of this book, please sign up. To ask other readers questions about What Went Wrong? Lists with This Book. This book is not yet featured on Listopia.
Without a doubt, I strongly recommend this book as required reading for every engineer and supervisor in the process industry and suggested reading for others. The new fourth edition contains considerable new material, with extensive references. It should also be used by those who provide training courses in these industries. This book is a required reading for every engineer and supervisor in the process industry" Chemical Industry Digest, July-August "excellent, if somewhat disturbing book In my opinion, the book should be read by a great many different professions and persons" Ergonomics, Vol 46, Issue 5, show more.
Review quote "Kletz has played a crucial role in advancing process safety. About Trevor A. He worked thirty-eight years with Imperial Chemical Industries Ltd.
WHAT WENT WRONG? Case Histories of Process Plant Disasters by Trevor Kletz - PDF Drive
Rating details. Book ratings by Goodreads. Goodreads is the world's largest site for readers with over 50 million reviews. We're featuring millions of their reader ratings on our book pages to help you find your new favourite book. Close X. I have used units likely to be most familiar to the majority of my readers. Although I welcome the increasing use of SI units, many people still use imperial units—they are more familiar with a 1-in.
Pressures are quoted in pounds force per square inch psi and also in bars. As it is not usual to refer to bar gauge, I have, for example, referred to a gauge pressure of 90 psi 6 bar , rather than a pressure of 90 psig :. Different words are used, in different countries, to describe the same job or piece of equipment. Some of the principal differences between the United States and the United Kingdom are listed here.
Within each country, however, there are differences between companies. More Britons understand U. The different meanings of the terms supervisor and plant manager in the United States and the United Kingdom should be noted. In this book I have used the term foreman as it is understood in both countries, though its use in the United Kingdom is becoming outdated.
Manager is used to describe any professionally qualified person in charge of a unit or group of units. That is, it includes people who, in many U. Certain items of plant equipment have different names in the two countries. Some common examples are as follows:. Trip describes an automatic device that closes or opens a valve when a temperature, pressure, flow, and so on reach a preset value. This chapter focuses on accidents that occurred because equipment was not adequately prepared for maintenance.
Sometimes the equipment was not isolated from hazardous materials, sometimes it was not identified correctly and so the wrong equipment was opened up, and sometimes hazardous materials were not removed. Various incidents have been outlined that reflect the failure in maintenance, human errors, or equipment itself.
Summary of methods for maintenance of isolation is also provided to prevent causes of errors due to isolation failures. When an electrical supply is isolated, it is normal practice to check that the right switches have been locked or fuses removed by trying to start the equipment that has been isolated. On several occasions, maintenance teams have not realized that by isolating a circuit, they have also isolated equipment that was still needed.
Need for tagging is highlighted when the wrong pipeline or piece of equipment has been broken into. Many accidents have occurred because equipment, though isolated correctly, was not completely freed from hazardous materials or because the pressure inside it was not completely blown off and the workers carrying out the repair were not made aware of this.
Therefore it is usual to test for the presence of flammable gas or vapor with a combustible gas detector before maintenance, especially welding or other hot work is allowed to start. This chapter also describes incidents that occurred because of loopholes in the procedure for issuing work permits or because the procedure was not followed, and also points out the formal procedure to be followed. Randall factory inspector said he was surprised at the system of work, as he knew the company's safety documents were very impressive. Unfortunately they were not acted upon.
The following pages describe accidents that occurred because equipment was not adequately prepared for maintenance. Sometimes the equipment was not isolated from hazardous materials; sometimes it was not identified correctly and so the wrong equipment was opened up; sometimes hazardous materials were not removed [ 1, 2]. A pump was being dismantled for repair. When the cover was removed, hot oil, above its auto-ignition temperature, came out and caught fire.
Three men were killed, and the plant was destroyed. Examination of the wreckage after the fire showed that the pump suction valve was open and the drain valve shut [ 3]. The pump had been awaiting repair for several days when a permit-to-work was issued at 8 a.
The foreman who issued the permit should have checked ahead of time that the pump suction and delivery valves were shut and the drain valve open. He claimed that he did so. Either his recollection was incorrect or, after he inspected the valves and before work started, someone closed the drain valve and opened the suction valve. When the valves were closed, there was no indication—on them—of why they were closed. An operator who was not aware that the pump was to be maintained might have opened the suction valve and shut the drain valve so that the pump could be put on line quickly if required.
A complicating factor was that the maintenance team originally intended to work only on the pump bearings.
What Went Wrong?
When team members found that they had to open up the pump, they told the process team, but no further checks of the isolations were carried out. It was not customary in the company concerned to isolate equipment under repair by slip-plates, only by closed valves. But after the fire, the company introduced the following rules:. If hot work is to be carried out or a vessel is to be entered, then slip-plating or physical disconnection must always take place. A notice fixed to the valve is not sufficient. A similar but more serious incident occurred in a polyethylene plant in A take-off branch was dismantled to clear a choke.
The 8-in. Debris was thrown 10 km 6 miles , and the subsequent fire caused two liquefied petroleum gas tanks to burst. Figure The take-off branch was dismantled with the Demco valve open.
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Illustration courtesy of the U. Department of Labor. The valve was operated by compressed air, and the two air hoses, one to open the valve and one to close it, were connected up the wrong way around. The two connectors should have been different in size or design so that this could not occur. In addition, they were not disconnected, and a lockout device on the valve—a mechanical stop—had been removed.
It is also bad practice to carry out work on equipment isolated from hot flammable gas under pressure by a single isolation valve. The take-off branch should have been slip-plated, and double block and bleed valves should have been provided so the slip-plate could be inserted safely Figure [16, 17].
disadetha.tk There was another similarity to the first incident. In this case, the equipment also had been prepared for repair and then had to wait for a couple of days until the maintenance team was able to work on it. During this period, the air lines were reconnected, the lockout removed, and the isolation valve opened.
In both incidents, the procedures were poor and were not followed. It is unlikely that the accidents occurred the first time this happened. If the managers had kept their eyes open, they might have seen that the procedures were not being followed. The explosion and fire on the Piper Alpha oil platform in the North Sea, which killed people, was also caused by poor isolation.
A pump relief valve was removed for overhaul and the open end blanked. Another shift, not knowing that the relief valve was missing, started up the pump.