Learning from Accidents

357 Pages·2003·1.56 MB·English

Learning from Accidents
This book has been written
to remember the dead and injured
and to warn the living
Learning from Accidents
Third edition
Trevor Kletz
OBE, DSc, FEng, FRSC, FIChemE
OXFORD AUCKLAND BOSTON JOHANNESBURG MELBOURNE NEWDELHI
Butterworth-Heinemann
An imprint of Gulf Professional Publishing
Linacre House, Jordan Hill, Oxford OX2 8DP
225 Wildwood Avenue, Woburn, MA 01801-2041
A division of Reed Educational and Professional Publishing Ltd
A member of the Reed Elsevier plc group
First published as Learning from Accidents in Industry1988
Reprinted 1990
Second edition 1994
Third edition 2001
© Trevor Kletz 2001
All rights reserved. No part of this publication
may be reproduced in any material form (including
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Applications for the copyright holder’s written permission
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British Library Cataloguing in Publication Data
Kletz, Trevor A.
Learning from accidents. – 3rd ed.
1. Industrial accidents 2. Industrial accidents –
Investigations 3. Chemical industry – Accidents
I. Title
363.1'165
Library of Congress Cataloguing in Publication Data
Kletz, Trevor A.
Learning from accidents/Trevor Kletz. – 3rd ed.
p. cm.
Includes bibliographical references and index.
ISBN 0 7506 4883 X
1. Chemical industry – Accidents. 2. Industrial accidents.
3. Industrial accidents – Investigation.
HD7269.C45 K43 2001
363.11'65–dc21 2001035380
ISBN 0 7506 4883 X
For information on all Butterworth-Heinemann publications
visit our website at www.bh.com
Composition by Scribe Design, Gillingham, Kent
Printed and bound in Great Britain by Biddles of Guildford and Kings Lynn
Contents
Forethoughts vii
Preface ix
Acknowledgements xii
Introduction 1
1 Two simple incidents 13
2 Protective system failure 22
3 Poor procedures and poor management 32
4 A gas leak and explosion – The hazards of insularity 40
5 A liquid leak and fire and the hazards of amateurism 52
6 A tank explosion – The hazards of optional extras 63
7 Another tank explosion – The hazards of modification
and ignorance 73
8 Flixborough 83
9 Seveso 103
10 Bhopal 110
11 Three Mile Island 122
12 Chernobyl 135
13 Aberfan 146
14 Missing recommendations 155
15 Three weeks in a works 162
16 Pipe failures 179
17 Piper Alpha 196
18 The King’s Cross underground railway station fire 207
19 Clapham Junction – Every sort of human error 216
20 Herald of Free Enterprise 226
21 Some aviation accidents 234
22 Invisible hazards 253
23 Signals passed at danger 259
24 Longford: the hazards of following fashions 267
25 The Gresford Colliery explosion 275
26 Green intention, red result 281
27 Looking beyond violations 291
vi Contents
28 Keeping an open mind 297
29 Secondhand software: the Therac story 303
30 Conclusions 308
Appendix 1 325
Appendix 2 328
Appendix 3 335
Afterthought 336
Index 337
Forethoughts
It is the success of engineering which holds back the growth of engineering
knowledge, and its failures which provide the seeds for its future development.
D. I. Blockley and J. R. Henderson, Proc. Inst. Civ. Eng. Part 1, Vol.
68, Nov. 1980, p. 719.
What has happened before will happen again. What has been done before
will be done again. There is nothing new in the whole world.
Ecclesiastes, 1, 9 (Good News Bible).
What worries me is that I may not have seen the past here – perhaps I
have seen the future.
Elie Wiesel
Below, distant, the roaring courtiers
rise to their feet – less shocked than irate.
Salome has dropped the seventh veil
and they’ve discovered there are eight.
Danny Abse, Way out in the Centre.
...But if so great desire
Moves you to hear the tale of our disasters
Briefly recalled...
However I may shudder at the memory
And shrink again in grief, let me begin.
Virgil, The Aeneid.
I realised that there is no rocket science in this. Improving safety can be
quite simplistic if we go back to basics and not overcomplicate the
processes we use.
Comment made by a supervisor after I had described some accidents.

Preface
I would like to thank the companies where the accidents I have described
occurred for letting me publicise their failures, so that others can learn
from them, and the many colleagues with whom I have discussed these
accidents and who made various comments, some emphasising the
immediate causes and others the underlying ones. All were valuable. My
colleagues – particularly those who attended the discussions described in
Part 4 of the Introduction – are the real authors of this book. I am merely
the amanuensis.
Rabbi Judah the Prince (c. 135–217 AD) said, ‘Much have I learnt from
my teachers, more from my colleagues and most of all from my students’.
I do not always name the products made on the plants where the
incidents occurred, partly to preserve their anonymity but also for another
reason: If I said that an explosion occurred on a plant manufacturing
acetone, readers who do not use acetone might be tempted to ignore that
report. In fact, most of the recommendations apply to most plants, regard-
less of the materials they handle. To misquote the well-known words of
the poet John Donne,
No plant is an Island, entire of itself; every plant is a piece of the Continent,
a part of the main. Any plant’s loss diminishes us, because we are involved
in the Industry; and therefore never send to know for whom the inquiry
sitteth; it sitteth for thee.
Descriptions of most of the accidents described in this book have
appeared before but scattered throughout various publications, often in
a different form. References are given at the end of each chapter and
thanks are due to the original publishers for permission to quote from
them.
For the second and third editions I added chapters on some of the major
incidents that had occurred since the first edition was written and I made
some changes and additions to the original text. I retained the original
chapter numbers, except that the last chapter is now number 30. I am
x Preface
grateful to Brian Appleton, one of the assessors at the Piper Alpha
inquiry, for writing a chapter on that disaster.
Since the first edition was published I have written a book with a rather
similar title, Lessons from Disaster – How Organisations have No Memory
and Accidents Recur (Institution of Chemical Engineers, 1993) but its
theme is different. This book deals mainly with accident investigation and
the need to look beyond the immediate technical causes for ways of avoid-
ing the hazards and for weaknesses in the management system. The other
book, as the sub-title indicates, shows how accidents are forgotten and
then repeated, and suggests ways of improving the corporate memory.
To avoid the clumsy phrases ‘he or she’ and ‘his or hers’ I have usually
used ‘he’ or ‘his’. There has been a welcome increase in the number of
women working in industry but the manager, designer or accident victim
is still usually male.
A note for American readers
The term ‘plant manager’ is used in the UK sense to describe the first
level of professional management, someone who would be known as a
supervisor in most US companies. The person in charge of a site is called
a works manager.
A note on units
I have used the units likely to be most familiar to the majority of my
readers.
Short lengths, such as pipeline sizes, are in inches and millimetres;
longer lengths are usually in metres only (1 metre = 3.28 feet).
Pressures are in pounds force per square inch (psi) and bars (1bar = 100
kilopascals and is also almost exactly 1 atmosphere and 1 kilogram per
square centimetre).
Masses are in kilograms or metric tonnes (1 metric tonne = 1.10 short
[US] tons or 0.98 long [UK] tons).
Volumes are in cubic metres (1m3 = 264 US gallons or 220 imperial
gallons or 35.3 cubic feet).
Temperatures are in degrees Celsius (°C).
A note on the organisation of maintenance in the process industries
A note on this subject may be helpful to readers from other industries. In
most process industry factories, including oil refineries and chemical
works, there is a dual organisation. One stream of managers, foremen and
operators are responsible for running the process while another stream of