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Not Again ! Will We Ever Learn ?

August 25, 2016

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:


  • 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


  • 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 !

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