What Went Wrong? 6th Edition provides a complete analysis of the design, operational, and management causes of process plant accidents and disasters. Co-author Paul Amyotte has built on Trevor Kletz’s legacy by incorporating questions and personal exercises at the end of each major book section. Case histories illustrate what went wrong and why it went wrong, and then guide readers in how to avoid similar tragedies and learn without having to experience the loss incurred by others. Updated throughout and expanded, this sixth edition is the ultimate resource of experienced-based analysis and guidance for safety and loss prevention professionals.
1. Part I: Introduction - p. pgxliv 2. Chapter 1: Case histories and their use in enhancing process safety knowledge - p. pgxliv 3. Chapter 2: Bhopal - p. 17 4. Chapter 3: Opportunities for reflection - p. 29 5. Part II: Maintenance and operations - p. 35 6. Chapter 4: Maintenance: Preparation and performance - p. 35 7. Chapter 5: Operating methods - p. 96 8. Chapter 6: Entry to vessels and other confined spaces - p. 122 9. Chapter 7: Accidents said to be due to human error - p. 151 10. Chapter 8: Labeling - p. 172 11. Chapter 9: Testing of trips and other protective systems - p. 184 12. Chapter 10: Opportunities for reflection - p. 200 13. Part III: Equipment and materials of construction - p. 205 14. Chapter 11: Storage tanks - p. 205 15. Chapter 12: Stacks - p. 235 16. Chapter 13: Pipes and vessels - p. 243 17. Chapter 14: Tank trucks and tank cars - p. 269 18. Chapter 15: Other equipment - p. 283 19. Chapter 16: Materials of construction - p. 307 20. Chapter 17: Opportunities for reflection - p. 332 21. Part IV: Hazards and loss of containment - p. 341 22. Chapter 18: Leaks - p. 341 23. Chapter 19: Liquefied flammable gases - p. 372 24. Chapter 20: Hazards of common materials - p. 390 25. Chapter 21: Static electricity - p. 406 26. Chapter 22: Reactions—Planned and unplanned - p. 415 27. Chapter 23: Explosions - p. 434 28. Chapter 24: Opportunities for reflection - p. 456 29. Part V: Knowledge and communication - p. 473 30. Chapter 25: I did not know… - p. 473 31. Chapter 26: Poor communication - p. 502 32. Chapter 27: Accidents in other industries - p. 513 33. Chapter 28: Accident investigation—Missed opportunities - p. 522 34. Chapter 29: Opportunities for reflection - p. 535 35. Part VI: Design and modifications - p. 562 36. Chapter 30: Inherently safer design - p. 562 37. Chapter 31: Changing procedures instead of designs - p. 581 38. Chapter 32: Both design and operations could have been better - p. 593 39. Chapter 33: Modifications: Changes to equipment and processes - p. 610 40. Chapter 34: Modifications: Changes in organization - p. 649 41. Chapter 35: Reverse flow, other unforeseen deviations, and Hazop - p. 667 42. Chapter 36: Control - p. 683 43. Chapter 37: Opportunities for reflection - p. 712 44. Part VII: Conclusion - p. 718 45. Chapter 38: An accident that may have affected the future of process safety - p. 718 46. Chapter 39: An accident that did not occur - p. 726 47. Chapter 40: Summary of lessons learned - p. 730 48. Chapter 41: Opportunities for reflection - p. 740 49. Appendix A: Relative frequencies of incidents - p. 746 50. Appendix B: Why should we publish accident reports? - p. 749 51. Appendix C: Some tips for accident investigators - p. 755 52. Appendix D: Recommended reading - p. 755 53. Appendix E: Afterthoughts - p. 758 54. Index - p. 761
What Went Wrong? 6th Edition provides a complete analysis of the design, operational, and management causes of process plant accidents and disasters. Co-author Paul Amyotte has built on Trevor Kletz’s legacy by incorporating questions and personal exercises at the end of each major book section. Case histories illustrate what went wrong and why it went wrong, and then guide readers in how to avoid similar tragedies and learn without having to experience the loss incurred by others. Updated throughout and expanded, this sixth edition is the ultimate resource of experienced-based analysis and guidance for safety and loss prevention professionals.
1. Part I: Introduction - p. pgxliv 2. Chapter 1: Case histories and their use in enhancing process safety knowledge - p. pgxliv 3. Chapter 2: Bhopal - p. 17 4. Chapter 3: Opportunities for reflection - p. 29 5. Part II: Maintenance and operations - p. 35 6. Chapter 4: Maintenance: Preparation and performance - p. 35 7. Chapter 5: Operating methods - p. 96 8. Chapter 6: Entry to vessels and other confined spaces - p. 122 9. Chapter 7: Accidents said to be due to human error - p. 151 10. Chapter 8: Labeling - p. 172 11. Chapter 9: Testing of trips and other protective systems - p. 184 12. Chapter 10: Opportunities for reflection - p. 200 13. Part III: Equipment and materials of construction - p. 205 14. Chapter 11: Storage tanks - p. 205 15. Chapter 12: Stacks - p. 235 16. Chapter 13: Pipes and vessels - p. 243 17. Chapter 14: Tank trucks and tank cars - p. 269 18. Chapter 15: Other equipment - p. 283 19. Chapter 16: Materials of construction - p. 307 20. Chapter 17: Opportunities for reflection - p. 332 21. Part IV: Hazards and loss of containment - p. 341 22. Chapter 18: Leaks - p. 341 23. Chapter 19: Liquefied flammable gases - p. 372 24. Chapter 20: Hazards of common materials - p. 390 25. Chapter 21: Static electricity - p. 406 26. Chapter 22: Reactions—Planned and unplanned - p. 415 27. Chapter 23: Explosions - p. 434 28. Chapter 24: Opportunities for reflection - p. 456 29. Part V: Knowledge and communication - p. 473 30. Chapter 25: I did not know… - p. 473 31. Chapter 26: Poor communication - p. 502 32. Chapter 27: Accidents in other industries - p. 513 33. Chapter 28: Accident investigation—Missed opportunities - p. 522 34. Chapter 29: Opportunities for reflection - p. 535 35. Part VI: Design and modifications - p. 562 36. Chapter 30: Inherently safer design - p. 562 37. Chapter 31: Changing procedures instead of designs - p. 581 38. Chapter 32: Both design and operations could have been better - p. 593 39. Chapter 33: Modifications: Changes to equipment and processes - p. 610 40. Chapter 34: Modifications: Changes in organization - p. 649 41. Chapter 35: Reverse flow, other unforeseen deviations, and Hazop - p. 667 42. Chapter 36: Control - p. 683 43. Chapter 37: Opportunities for reflection - p. 712 44. Part VII: Conclusion - p. 718 45. Chapter 38: An accident that may have affected the future of process safety - p. 718 46. Chapter 39: An accident that did not occur - p. 726 47. Chapter 40: Summary of lessons learned - p. 730 48. Chapter 41: Opportunities for reflection - p. 740 49. Appendix A: Relative frequencies of incidents - p. 746 50. Appendix B: Why should we publish accident reports? - p. 749 51. Appendix C: Some tips for accident investigators - p. 755 52. Appendix D: Recommended reading - p. 755 53. Appendix E: Afterthoughts - p. 758 54. Index - p. 761
