Not Again ! Will We Ever Learn ?
My recent post on Andrew Hopkins "Failure to Learn" prompted so much enthusiastic interest that I dug deeper into the cupboard and found Trevor Kletz's classic (and genuinely timeless) book "What Went Wrong" which covers the following (all too familiar) topics:
Part A - WHAT WENT WRONG?
- Preparation for maintenance
- Modifications
- Accidents said to be due to human error
- Labeling
- Storage tanks
- Stacks
- Leaks
- Liquefied flammable gases
- Pipe and vessel failures
- Other equipment
- Entry to vessels
- Hazards of common materials
- Tank trucks and cars
- Testing of trips and other protective systems
- Static electricity
- Materials of construction
- Operating methods
- Reverse flow and other unforeseen deviations and HAZOP
- I didn't know that ..
- Problems with computer control
- Inherently safer design
- Reactions - planned and unplanned
Part B - STILL GOING WRONG
- Maintenance
- Entry into confined spaces
- Changes to processes and plants
- Changes in organization
- Changing procedures instead of designs
- Materials of construction (including insulation) and corrosion
- Operating methods
- Explosions
- Poor communication
- I did not know...
- Control
- Leaks
- Reactions - planned and unplanned
- Both design and operations could have been better
- Accidents in other industries
- Accident investigation - Missed opportunities
- An accident that may have affected the future of Process Safety
This was originally published in 1985 and was followed up by "Still Going Wrong!" (if you haven't read it, I'm sure you can guess the ending and also 'whodunnit') and the key subtitle in both these books is...
...and How They Could Have Been Avoided
So if we "know" what can go wrong and we have the wisdom to prevent them happening (again) - why are major incidents still a somewhat regular occurrence ?
Trevor notes in "Still Going Wrong" the following...
"A high price was paid for the information in this book: people were killed or injured and billions of dollars worth of equipment was damaged. Someone has paid the "tuition fees". There is no need for you to pay them again"
Remember ignorance is no excuse and surely we cannot claim that we have not and are not duly informed.
Those of you with a keen eye will spot the typo in the image of the book. This isn't in online versions and maybe dear old Trevor put it there to either catch us out or it proves that, despite his apparent omniscience, he was just as fallible as the rest of us mere mortals.
Gone - but not forgotten !
Retired
8 年Hi David, a great article! I will ring in the week ref Trevor Kletz.
Principal Human Performance in Safety Specialist
8 年I recall reading Trevor Kletz books and his analysis of incidents, thanks for reminding -- and these are timeless. Thanks for pointing out the error in the cover page!! I did not notice it! and sure many...
Processing Major Hazards│ Centre of Excellence │Rio Tinto│Perth Hub
8 年Great post David. There are many "fresh" leaders who have never had to lead through adverse times. The majority of industry is reducing overheads and looking to streamline operations for a competitive edge, that lessons learned publications should be dusted off, reviewed and shared. I also revere the lessons learned publications of John F Murphy.
Retired
8 年I periodically have a read from a section or two of his various books I have in my office at home. Why? Because as he reminded us often "organizations have no memory" and as a safety professional I feel duty bound to just remind myself of what has and can go wrong and the subsequent lessons learned from serious incidents, then look for the "tell-tale" precursor signs in my own business. He also had a real knack of getting to the hub of what to look at, talk about and make the complex a bit simpler to understand.
Freelance Consultant on Process Safety
8 年Prof.Kletz not only introduced the Hazop concept to Hydrocarbon industry but has left a wealth of his knowledge through these two books.Everyone involved in Safety Management should go on reading these two books again and again and again.