0957–5820/04/$30.00+0.00# 2004 Institution of Chemical Engineers

www.ingentaselect.com=titles=09575820.htm Trans IChemE, Part B, May 2004Process Safety and Environmental Protection, 82(B3): 256

BOOK REVIEW

Still Going Wrong?Case Histories of Process Plant Disasters and HowThey Could Have Been AvoidedTrevor KletzGulf Professional Publishing, 2003230 pp, £29.95, ISBN 0 7506 7709 0

Reviewed by Nick Spencer(General Manager and Director, ConocoPhillips Ltd HumberRefinery, UK)

Trevor Kletz has helped to educate many people in industryto the hazards that they are confronted with on a regularbasis, especially those in the chemical, oil and processindustries. Still Going Wrong is his eleventh book, andmost people can learn something from it, whether they areinvolved in production, maintenance or design.

This latest book complements his earlier book What WentWrong? It contains many very recent events as well asidentifying new causes of incidents, and sadly some of thenow well-known causes.

The book describes incidents that could occur in manytypes of plant. Virtually every incident could be avoided.The book contains much advice for those who operateprocess plants, but also for those who design them. Ahigh price has been paid for this valuable information, andit should be used. The learnings can be used as safety topics,part of an engineer’s training programme, and as a way tokeep the personnel in a plant talking about process safety.

As Kletz comments on many occasions, Safety Manage-ment Systems are important, but equally as important orperhaps more so, is what actually happens in the field. Thetendency to overly complicate design, or not design outtraps, clearly is a significant source of incidents. The need tokeep systems as simple as possible comes through as atheme. He has some very good advice for incident investi-gators, looking for the true cause of an accident and not justwho to blame.

The book is arranged into chapters covering differenttypes of equipment as well as procedures and maintenance.

It emphasizes the multiple causes of accidents, and whereverpossible the underlying weaknesses in the managementsystems are discussed. However, in many cases there isnot enough information to delve into the latent causes andthe reports describe only the immediate technical causes.Although human error is not discussed as a particular topic,it is clearly included throughout the book. Most incidentshave an element of human error. Someone has to decidewhat to do, how to do it or who has to do it. All may makeerrors. The book distinguishes errors into four groups—Mistakes, Violation or Non-Compliance, Mismatches, andfinally Slips and Lapses of Attention. For those who want toexplore this area in more detail, Kletz’s book An Engineer’sView of Human Error (IChemE, 2001) is very useful.

Another theme that comes through clearly in the book isthe failure of industry to learn from past accidents. Everychapter shows that organizations have limited memory.There must be something seriously wrong with safetyeducation when so many accidents repeat themselves sooften. Kletz has some practical advice about how to improvethis situation.

Still Going Wrong? is very aptly titled. All processindustries have a tremendous amount to learn. The pressurefor improving safety standards is relentless, as it should be.This book will help build awareness of the diverse causes ofaccidents. It will not prevent them unless the reader iscommitted to thinking about the lessons and applyingthem appropriately in their own area of responsibility. Iflessons in this book prevent one incident in each reader’splant, the cost of the human suffering incurred in the bookwill not have been wasted.

Without a doubt I recommend this book for anyoneinvolved with management, design, operation, health andsafety, or maintenance, in the process industries.

This book is available via IChemE’s Virtual Bookshop:www.icheme.org/shop (IChemE members receive 10%discount)

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