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Disaster Prevention & Avoidance

Still Going Wrong! by Trevor Kletz

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Still Going Wrong! Case Histories of Process
Plant Disasters and How They Could Have
Been Avoided, by Trevor Kletz. 2003, 250
by Trevor Kletz

Trevor Kletz's earlier book, What Went Wrong?, revolutionized the way industry
views safety.
This completely new volume, Still Going Wrong!, continues and extends the
practices and
wisdom of the original, while focusing on innovations and strategies that Kletz and
have pioneered over the last decade.

Kletz reinforces the messages in his previous book of famous case histories, but
Still Going
Wrong! hits on many new points, such as how many accidents occur through
miscommunications within the organization and how changing procedures, rather
design, can make a plant safer.

Like What Went Wrong?, this new volume discusses the technical causes of
accidents, but
Still Going Wrong! pays closer attention to the underlying weaknesses in the
and design systems that made it possible for the technical errors to occur in the
first place.
All new material treating the hazards of corrosion, and numerous new topics,
maintenance; entry into confined spaces; materials of construction (including
explosions; leaks; reactions - planned and unplanned; accident investigation; and,

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- This volume follows up on the cases and strategies outlined in the original
seller: “What Went Wrong”
- Contains many new cases and areas for improvement, including the
hazards of rust,
corrosion, and many more new topics
- Written by the world's leading expert on industrial safety

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“Trevor Kletz has helped to educate many people in industry to the hazards that
they are
confronted with on a regular basis, especially those in the chemical, oil and
industries. Still Going Wrong is his eleventh book, and most people can learn
from it, whether they are involved in production, maintenance or design.

“He has some very good advice for incident investigators, looking for the true cause
of an
accident and not just who to blame.

“Still Going Wrong? is very aptly titled. All process industries have a tremendous
amount to
learn. The pressure for improving safety standards is relentless, as it should be.
This book
will help build awareness of the diverse causes of accidents. It will not prevent
them unless
the reader is committed to thinking about the lessons and applying them
appropriately in
their own area of responsibility. If lessons in this book prevent one incident in each
plant, the cost of the human suffering incurred in the book will not have been

“Without a doubt I recommend this book for anyone involved with management,
operation, health and safety, or maintenance, in the process industries.” -
Reviewed by Nick
Spencer (General Manager and Director, ConocoPhillips Ltd Humber Refinery, UK)

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“In the preface to this book Trevor Kletz records two invaluable points on ‘safety.’ A
Director of Safety made the first point - ‘safety management is not rocket science.’
second point is that on reading his own book 'What Went Wrong', I realised that I
could use it
to ‘wake up’ my people to the dangers and horrors others have experienced'. Trevor
been doing the latter all his professional life. Safety management may not be
rocket science
but it does require detailed attention and constant review and enhancement.

“Trevor has subtitled this book ‘Case studies of Process Disasters and how they
could have
been avoided.’ Maybe it could have been ‘Here's to the Next One.’

“Trevor has adopted a simple but very effective format of incidents under 16 main
The choice was Trevor’s and could have reached two or more times that number. In
this he
shows that there are still the same fundamental causations of disasters and that
the industry
has not yet learnt fully the messages of the past! The main heads were: -
2 .Entry into Confined Spaces
3. Changes to Process and Plants
4.. Changes in Organisation
5. Changing Procedures Instead of Design
6. Materials of Construction (including Insulation)
7. Operating Methods
8. Explosions
9. Poor Communication
10. I Did Not Know That
11. Control
12. Leaks
13. Reactions-Planned and Unplanned
14. Both Design and Operation Could Have Been Better
15. Accidents in Other Industries
16. Accident Investigation - Missed Opportunities

“As is his style the examples chosen by Trevor are clear and succinctly written
with some
deep feelings. I (the reviewer) have first- and second-hand knowledge of a number
of the
events and I also feel the disappointment of realising that not much has changed.
incident that is described on pages 51 and 52 could have occurred on a similar
plant on the
same Works about 15 years previously during the initial commissioning. The
symptoms (but
not the background) were identical; there was a fault on the level controller and the
generated by the 'common cause' of the fluid properties. I was the Professional
during the first incident and, like the second incident, I had been working 12-hour
shifts. In the
first event the plant was put on hold, the incident resolved and the start up
proceeded safely.
Surely this incident was in the Works memory banks? Why had it been forgotten?
reason is that the second group had adopted a more remote attitude to the
operation of the
plant and were less inclined to be steeped in the day-to-day detail that was the
norm for the
previous group. Was this a culture change (as well as a change in organisation
where the
Shift Manager had become a demigod) or was it a form of arrogance? (At least the
stack from my plant replaced the damaged flare stack and is still in use on the
second plant!)

“It would be wrong to take up other incidents recorded; however many of them have
measure of ‘deja vu.’ Many of the incidents may appear to have been the result of
stupid (but
not intentionally so) mistakes. Maybe they were but those involved were intelligent
and the events did occur and in some form or other they are still occurring today.
Trevor has
reminded us all of this once again. The Piper Alpha Disaster in 1988 (not included)
had a
very similar background and build-up to an incident that occurred in 1966. There
was a shift
hand-over, a weakness in the permit system, problems with pump isolations, an
isolation valve that did not close and finally persons were trapped and died. The
facts were
the same only the names changed. We should also recognise that we have all
been involved
in 'near misses' which could have escalated and been one of the examples in
Trevor's book.
It is essential that we do learn from these incidents and others like them. 'Still
Going Wrong'
is another wake up call, easy to read and to follow and at times you will be left with
the feeling

“There is the constant thread which runs through the book that the causations are
repeated and the messages are not being learned. There is also another thread
that runs
through this book, that the use of Audits would go a long way to preventing their
This is a book which reminds us that the corporate (and industrial) memory is
short and
requires constant re-enforcement. It is a book which should be read not only by
those who
design but also by those who operate process plant of any form, for lack of size or
does not guarantee immunity. Whatever the area of endeavour there are messages
for us all,
provided we are willing to see them. Maybe that is the rub. We have to be willing!

“Trevor writes the following in ‘Acknowledgements’ to this his latest book, ‘By the
time this
book, is published, I will be in my 82nd year. It is my final harvest.’ Trevor, I am not
that this is your final harvest, you will still be publishing your thoughts and
challenging our
consciences for some time yet.” - Frank Crawlev, From Industrial Safety
Management, Vol 6,
No 2, April 2004, p 29.

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“Still Going Wrong is an immensely readable book and one that I would
recommend to all
personnel with an interest in safety.” - Health and Safety At Work August 2004

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“This book is an excellent compilation of case histories of process plant accidents
discussions of how they could have been avoided. I feel that this book will be of
great use to
people who work in the chemical process industries and are involved in process
production, and maintenance. As with the author's other books, this one is very
easy to read.
It imparts much useful and practical information, which could lead to avoidance or
minimization of costly accidents, both with respect to property and human life
loss. It will
make a very useful addition to the technical library of process safety/loss
engineers.” - Journal of Loss Prevention in the Process Industries, July 2004

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A million-dollar seller, Kletz’s classic, “What Went Wrong?,” has revolutionized the
industry views safety. This volume, sure to be an instant bestseller, continues the
and wisdom of the original. Some reviews of the original:

“The incidents described could occur in many types of plants, and should therefore
be of
interest to a wide variety of plant operators. The new fourth edition contains
new material, with extensive references.” (Mechanical Engineering)

“This book is recommended for generalists with an interest in industrial safety and
safety/process who wish to gain some insight into the realities of plant operations.”
(IChemE-Institute of Chemical Engineers)

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A note on nomenclature
1 Maintenance
2 Entry into confined spaces
3 Changes to processes and plants
4 Changes in organization
5 Changing procedures instead of designs
6 Materials of construction (including insulation) and corrosion
7 Operating methods
8 Explosions
9 Poor communication
10 I didn't know that...
11 Control
12 Leaks
13 Reactions - planned and unplanned
14 Both design and operations could have been better
15 Accidents in other industries
16 Accident investigation - Missed opportunities

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TREVOR KLETZ, D.Sc., F.Eng., a process safety consultant, has published more
than a
hundred papers and nine books on loss prevention and process safety.

His experience includes 38 years with Imperial Chemical Industries Ltd., where he
served as
a production manager and safety adviser in the petrochemical division, and
membership in
the department of chemical engineering at Loughborough University,
England. He is currently senior visiting research fellow at Loughborough University.

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2003, 250 pages. Order #DR763.
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