Table Of Content.d
e
v
re
se
r sth
g
ir llA
.re
ive
slE
.1
2
0
2
©
th
g
iryp
o
C
Brazier, Andy, et al. Trevor Kletz Compendium : His Process Safety Wisdom Updated for a New Generation, Elsevier, 2021. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/sheffield/detail.action?docID=6461868.
Created from sheffield on 2021-03-22 05:34:39.
TREVOR KLETZ COMPENDIUM
.d
e
v
re
se
r sth
g
ir llA
.re
ive
slE
.1
2
0
2
©
th
g
iryp
o
C
Brazier, Andy, et al. Trevor Kletz Compendium : His Process Safety Wisdom Updated for a New Generation, Elsevier, 2021. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/sheffield/detail.action?docID=6461868.
Created from sheffield on 2021-03-22 05:34:39.
This page intentionally left blank
.d
e
vre
se
r sth
g
ir llA
.re
ive
slE
.1
2
0
2
©
th
g
iryp
o
C
Brazier, Andy, et al. Trevor Kletz Compendium : His Process Safety Wisdom Updated for a New Generation, Elsevier, 2021. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/sheffield/detail.action?docID=6461868.
Created from sheffield on 2021-03-22 05:34:39.
Elsevier
Radarweg29,POBox211,1000AEAmsterdam,Netherlands
TheBoulevard,LangfordLane,Kidlington,OxfordOX51GB,UnitedKingdom
50HampshireStreet,5thFloor,Cambridge,MA02139,UnitedStates
©2021ElsevierInc.Allrightsreserved.
Nopartofthispublicationmaybereproducedortransmittedinanyformorbyanymeans,electronicor
mechanical,includingphotocopying,recording,oranyinformationstorageandretrievalsystem,without
permissioninwritingfromthepublisher.Detailsonhowtoseekpermission,furtherinformationaboutthe
Publisher’spermissionspoliciesandourarrangementswithorganizationssuchastheCopyrightClearance
CenterandtheCopyrightLicensingAgency,canbefoundatourwebsite:www.elsevier.com/permissions.
ThisbookandtheindividualcontributionscontainedinitareprotectedundercopyrightbythePublisher
(otherthanasmaybenotedherein).
Notices
Knowledgeandbestpracticeinthisfieldareconstantlychanging.Asnewresearchandexperiencebroadenour
understanding,changesinresearchmethods,professionalpractices,ormedicaltreatmentmaybecome
necessary.
Practitionersandresearchersmustalwaysrelyontheirownexperienceandknowledgeinevaluatingandusing
anyinformation,methods,compounds,orexperimentsdescribedherein.Inusingsuchinformationormethods
theyshouldbemindfuloftheirownsafetyandthesafetyofothers,includingpartiesforwhomtheyhavea
professionalresponsibility.
Tothefullestextentofthelaw,neitherthePublishernortheauthors,contributors,oreditors,assumeanyliability
foranyinjuryand/ordamagetopersonsorpropertyasamatterofproductsliability,negligenceorotherwise,or
fromanyuseoroperationofanymethods,products,instructions,orideascontainedinthematerialherein.
LibraryofCongressCataloging-in-PublicationData
AcatalogrecordforthisbookisavailablefromtheLibraryofCongress
BritishLibraryCataloguing-in-PublicationData
AcataloguerecordforthisbookisavailablefromtheBritishLibrary
ISBN:978-0-12-819447-8
ForinformationonallElsevierpublications
visitourwebsiteathttps://www.elsevier.com/books-and-journals
.d
e
vre
se
r sth
g
ir llA
.re
ive
slE
.1 Publisher:SusanDennis
20 AcquisitionsEditor:KostasKIMarinakis
2
© EditorialProjectManager:AndreaDulberger
thg ProductionProjectManager:KumarAnbazhagan
iryp CoverDesigner:VictoriaPearson
o
C
TypesetbySPiGlobal,India
Brazier, Andy, et al. Trevor Kletz Compendium : His Process Safety Wisdom Updated for a New Generation, Elsevier, 2021. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/sheffield/detail.action?docID=6461868.
Created from sheffield on 2021-03-22 05:35:42.
TREVOR KLETZ
COMPENDIUM
His Process Safety Wisdom Updated
for a New Generation
A B
NDY RAZIER
RiskConsultant,ABRiskLimited,Llandudno,UnitedKingdom
D E
AVID DWARDS
VisitingProfessorofSafetyandLossPrevention,SchoolofAeronautical,Automotive,
ChemicalandMaterialsEngineering,LoughboroughUniversity,UnitedKingdom
F M
IONA ACLEOD
ManagingDirector,BillionsEuropeLtd.,Stockton-on-Tees,UnitedKingdom
C S
RAIG KINNER
OperationalSafetyDirector,BP,Surrey,UnitedKingdom
I V
VAN INCE
RiskConsultant,ASKConsultants,Beckenham,UnitedKingdom
.d
e
vre
se
r sth
g
ir llA
.re
ive
slE
.1
2
0
2
©
th
g
iryp
o
C
Brazier, Andy, et al. Trevor Kletz Compendium : His Process Safety Wisdom Updated for a New Generation, Elsevier, 2021. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/sheffield/detail.action?docID=6461868.
Created from sheffield on 2021-03-22 05:35:21.
Contents
Introduction 5. Control of modifications
1 TrevorKletz 1 5.1 Introduction 171
2 Usefullinks 5 5.2 Differenttypesofchange 172
3 Aboutthisbook 8 5.3 Modificationsmadeduringmaintenance 174
References 8 5.4 Processmodifications 181
5.5 Modifyingwrittenprocedures 183
1. Hazard and operability (HAZOP) 5.6 Softwaremodifications 185
analysis 5.7 Changesinorganisation 186
5.8 Gradualchanges 190
1.1 Introduction 9
5.9 Modificationstoimprovethe
1.2 HAZOPorganisationandprocess 20
environment 192
1.3 LimitationsofHAZOP 30
5.10 Managingtherisks 193
1.4 Practicalapplication 38
References 200
References 44
2. Hazan (Quantified risk assessment) 6. Human error
2.1 Introduction 47 6.1 Introduction 203
2.2 Riskcriteria 51 6.2 Differenttypesoferror 204
2.3 Frequency/probabilityassessment 56 6.3 Reducinghumanerrorprobability 224
2.4 Consequenceanalysis 66 6.4 Humanfactorsanalysis 240
2.5 PitfallsinHazan 68 References 244
References 71
7. Accident investigations—Missed
3. Inherent safety
opportunities
3.1 Introduction 73
7.0 Introduction 247
3.2 Theconceptofinherentsafety 78
7.1 Accidentinvestigationsoftenfindonly
3.3 Principlesofinherentsafety 85
asinglecause 249
.d 3.4 Applyinginherentsafetythroughasystem’s
e 7.2 Accidentinvestigationsareoften
vreser sthg 3R.e5ferlHiefnoewccyecsfaler1sh91o73uldwego? 106 7.3 sAucpceirdfiecniatlin2v5e2stigationslisthumanerror
ir llA asacause 254
.re 4. Managing maintenance risk 7.4 Accidentreportslookforpeople
ive toblame 256
slE 4.1 Introduction 115 7.5 Accidentreportslistcausesthataredifficult
.1
20 4.2 Identifyingmaintenancerequirements 119 orimpossibletoremove 258
2
© 4.3 Preparingformaintenance 125 7.6 Wechangeproceduresratherthandesigns 261
th
g 4.4 Safetyduringmaintenance 144 7.7 Wemaygotoofar 263
irypo 4.5 Conclusions 167 7.8 Wedonotletotherslearnfromour
C
References 168 experience 264
v
Brazier, Andy, et al. Trevor Kletz Compendium : His Process Safety Wisdom Updated for a New Generation, Elsevier, 2021. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/sheffield/detail.action?docID=6461868.
Created from sheffield on 2021-03-22 05:36:06.
vi
Contents
7.9 Wereadorreceiveonlyoverviews 266 5 May:WanggongchangArmouryExplosion 281
7.10 Weforgetthelessonslearnedandallowthe 6 June:Flixborough 283
accidenttohappenagain 268 7 ChevronPembrokeExplosion 284
7.11 Weexamineeachaccidentinisolation 271 8 July:PiperAlpha 286
References 272 9 August:Banqiao 288
10 September:Longford 290
Appendix 275 11 October:PhillipsPasadena 292
12 November:Sandoz 294
Acalendarofdisasters 275
13 December:Bhopal 295
1 January:Feyzin 276
14 Buncefield 297
2 February:GeorgiaSugar 277
References 298
3 March:TexasCity 278
Index 299
4 April:Chernobyl 279
.d
e
vre
se
r sth
g
ir llA
.re
ive
slE
.1
2
0
2
©
th
g
iryp
o
C
Brazier, Andy, et al. Trevor Kletz Compendium : His Process Safety Wisdom Updated for a New Generation, Elsevier, 2021. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/sheffield/detail.action?docID=6461868.
Created from sheffield on 2021-03-22 05:36:06.
Introduction
1 Trevor Kletz
Oneofthefoundersandleadersofprocesssafetyinthoughtandpractice,ProfessorTrevor
Kletzdiedon31October2013.Heleftbehindamagnificentcanonofpublications,including
16booksandwellovera100reviewedpapersonlosspreventionandprocesssafety,which
communicate useful learning in a readable and understandable way and which will serve
long into the future to guide safety people in their work in our industry and beyond. They
have provided the philosophical and practical basis for many areas of process safety and
encouraged peopleto look atsafetydifferently.
Kletzwrotewithclarityandunderstoodthepowerofstoryasawaytogetimportantmes-
sagesacross.TheaimofthiscompendiumistoupdateandcombineKletz’swritingswithnew
stories and commentary showinghow they remain relevant today andhow the underlying
ideas have been developed further. It is a resource for a new generation of engineers and
others, which is intended to inspire them to make a positive contribution to the way safety
is managed where they work. It should also prompt people who have read his books in
the past to have another look.
Trevor Asher Kletz was born in 1922 in Darlington of Jewish parents, from a Russian
immigrantbackground.Hisfather,ashopkeeper,wasinsistentthatTrevorshouldbetterhim-
selfandheattendedTheKing’sSchool,ChesterandthenLiverpoolUniversity.Whenhewas
11yearsold,anunclehadgivenhimachemistrysetasapresent,whichinfluencedhisdeci-
siontostudychemistry.Hegraduatedin1944andjoinedImperialChemicalIndustries(ICI),
where he spent 8years in research, 16 in production management, and the last 14 as safety
adviser to the Petrochemicals Division. In 1978 he was appointed an industrial professor
.d in the Chemical Engineering Department at Loughborough University. On retiring from
e
vre ICI in 1982 he joined the Department full-time; in 1986 he became a visiting fellow and
ser sthg wUnasivleartstietrylyinatvhiesiUtinngitepdroSfteastseos.r at Loughborough and an adjunct professor at Texas A&M
ir llA David Edwards became aware of Trevor when he joined the Loughborough Chemical
.reive Engineering Department in 1990. He recalls: “I did not know much about how academic careers
slE progressedbutoneofthefewthingstheytoldmewastogetalineofresearch.Safetyseemedthemost
.1
2 prominent of the lines available (mainly due to Frank Lees), so I aligned myself with that. Then I
0
2
© attended one of Trevor’s lectures on inherently safer design, which blew me away - isn’t all plant
th
giryp designed like this (it’s just common sense) - well, actually, no. One thing that particularly struck
o
C
1
TrevorKletzCompendium
2
Introduction
me was Trevor’s graph showing that safety improves with money expended. We spent the next few
yearsworking,withconsiderableguidancefromTrevor,toshowthatinherentlysaferplantsarealso
costeffective.”
Trevor was appointed an OBE in 1997 and he was a Fellow of the Royal Academy of
Engineering, the Institution of Chemical Engineers, the Royal Society of Chemistry, and
the American Institute of Chemical Engineers. He was also an Honorary Fellow of the
Institute of Occupational Safety and Health and the Safety and Reliability Society. He was
one ofthe most famous chemical engineers, who wasnot a chemical engineer!
Trevor retired at the age of 90, as his old school noted: “One of King’s oldest Old
Boys Trevor Kletz has finally retired - what a career! Every engineer/technician in the UK and
far beyond on any chemical plant will have heard of Trevor, who has much improved the
safety of the chemical process industry with his career work. He certainly deserves his place in
the School’s Hall of Fame, and all the accolades he has been awarded in his long career - Happy
retirement Trevor!”
Upuntilthenhewasstillmakingforthrightandinsightfulstatementsaboutsafetyinthe
process industry, saying in 2011 that the industry’s ‘macho culture’ was one of the main
causesof recent accidents.
JillWilday,whoknewhimatICI,commented:“WhenIjoinedICIinthelate70shewasthe
Safety Advisor for Petrochemicals Division and his safety newsletter was circulated throughout ICI
andwasaspopularasNewScientistamongyoungengineers.(Thiswaswellbeforeemailasameans
ofsharinginformation).Thenewsletterpredominantlydescribedincidentsandtheirrecommendations,
butalwayswithanopportunityforyoutoworkoutwhatwentwrongbeforereadingasfarasthecon-
clusionsoftheinternalenquiry.Itwaseasyandentertainingtoreadandconsequentlyitwaspopular,
wellread,andsoitactedtoimproveeveryone’sunderstanding.Healsousedhumourandthosebitsin
particular were much repeated inconversations in the canteen.”
AndyRushtonwasacolleagueofTrevorandDavidEdwardsintheChemicalEngineering
Department at Loughborough University, where they worked together on inherent safety.
Andysays:“Hewasagreatcommunicator(alwaystopofthepollonthe[studentfeedback]‘happy’
sheets)andhisfortewasdistillinghis(andothers’)experience,drawingoutprinciplesandpresenting
theminarelevantway(notjusttoprocessengineers–transport,defenceandothersectorshavebeen
mightilyinfluencedtoo).Hecouldmakewhathewassayingrelevanttoyouandyourproblems,and
could present it with humour, patience and cogency (although not everyone agreed with everything
he said).”
.d Hisentertainingafter-dinnerstoriesfurtherservedtomakepeoplerememberhimandhis
e
vre messages.
ser sth Not only washea masterfulcommunicator, bothwrittenandorally, but he alsohadthe
g insight to reduce seemingly complicated issues to the simple fundamentals and to under-
ir llA stand which were important. He knew that he could save lives by spreading his insights
.re
ive and he had the perseverance, patience, and generosity to repeat his messages until heard
slE and understood.
.1
20 Sowhatwerehismessages?Well,ifyoudon’tknow,youshoulddefinitelyreadthiscom-
2
© th pendium! We also recommend that you read his books, which are listed here.
g
iryp
o
C
Brazier, Andy, et al. Trevor Kletz Compendium : His Process Safety Wisdom Updated for a New Generation, Elsevier, 2021. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/sheffield/detail.action?docID=6461868.
Created from sheffield on 2021-03-08 10:08:04.
3
1 TrevorKletz
Title Firstpublished Latestedition Publisher
Cheaper,saferplants 1984 1984 IChemE
Mythsofthechemicalindustry 1984 1984 IChemE
AnEngineer’sviewofhumanerror 1985 3rd—2001 IChemE
Whatwentwrong? 1985 6th—2019 Elsevier
HazopandHazan—Notesontheidentificationofhazards 1986 1986 IChemE
LearningfromAccidents 1988 3rd—2001 Elsevier
Criticalaspectsofsafetyandlossprevention 1990 1st—1990 Elsevier
Dispellingchemicalengineeringmyths 1990 3rd—1996 CRCPress
Improvingchemicalengineeringpractices 1990 2nd—1990 CRCPress
Plantdesignforsafety 1991 1st—1991 CRCPress
HazopandHazan 1992 4th—1999 IChemE
Lessonsfromdisaster 1993 1st—1993 IChemE
Computercontrolandhumanerror 1995 1st—1995 IChemE
ProcessPlants—ahandbookforinherentlysaferdesign 1998 2nd—2010 CRCPress
Byaccident(autobiography) 2000 1st—2000 PFVPublications
StillgoingWrong 2003 1st—2003 Elsevier
If you only read one of these, choose “Process Plants: A Handbook for Inherently Safer
Design” [1], now in its second edition and co-authored by Professor Paul Amyotte of
Dalhousie University. The inherently safer approach aims to eliminate or reduce hazards
orexposuretothemorthechanceofoccurrencebydesign.Mostpeoplewillsaythatitiscom-
monsense,anditis,butittookTrevortocastthiscommonsenseintoapracticalphilosophy.
Thereareundoubtedlytens,probablyhundreds,possiblythousandsofpeoplewhoeachday
go home to their families and will do for many years to come, but who are only with us
becauseof decisionsinfluenced by this light that Trevorshoneto lead our way.
Craig Skinner, also a chemical engineering graduate of Loughborough University, re-
.d
e
vre marks:“Itwasn’tuntilIwasapracticingchemicalengineerthatKletz’sinherentsafetyreallystarted
ser sthg tmoamnyakkeesyenensegitnoemerei,nagnddetchiseiosinmspolveearntdheprlaasctti3c0alyfreaamrse,wbootrhkwofhiennhearpepnltiesdafteotymparjionrchipalzeasrhdassahnedlpwedheinn
ir llA decidingbetweenengineeringoptions.Overthisperiod,inherentsafetyhasalsogrownfromaphilos-
.reive ophyintoapractical,effectiveprocessandteamactivity,andthisissharedinthisbookalongsideKletz’s
slE originalconceptsand stories,whichwe hope readersfindpragmatic and helpful.”
.12 InherentSafetyisnottheonlyareawherehisclearthinkinghaschangedthewaywethink
0
2
© andact.Hiswritingsonhumanerrorandaccidentinvestigationrefocusedtheemphasisaway
th
g
iryp
o
C
Brazier, Andy, et al. Trevor Kletz Compendium : His Process Safety Wisdom Updated for a New Generation, Elsevier, 2021. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/sheffield/detail.action?docID=6461868.
Created from sheffield on 2021-03-08 10:08:04.
