Category: refinery

Madonna has just released another greatest hits CD.  Trevor Kletz has done similar in releasing the fifth edition of “What Went Wrong?” He admits that almost all of the content has appeared elsewhere.  It’s been almost 20 years since I had to read Kletz’s books and articles as part of working in a Major Hazards Branch of an OHS regulator in Australia.  Not being an engineer, the books informed me but were a chore.  This is not the case with the last edition.

Kletz has two parts to the book.  The first is a collection of short case notes recording as he says

“…the immediate technical causes of the accidents and the changes in design and methods of working needed to prevent them from happening again”.

The second discusses the weaknesses of management systems.  In short, the book reflects the expanding nature of safety management over the last forty years.  Kletz may be from the Olde School of safety engineers (he is 87 years old) but often one needs a fresh perspective on a profession and coming from a person with such extensive experience, Kletz is worth listening to.  Thankfully, he does not sound like a grumpy old man.

Kletz notes that process industry lessons seem to fade after a few years.  In my opinion this may be an effect of the transience of modern careers where corporate memory is often fragmented.  It may also be due to the shipping of manufacturing and process industries off-shore and the establishment of large complexes in countries with different (lax) safety requirements.  It may also be due to a corporate performance regime where maintenance is not valued or understood as that supports long term thinking rather than quite returns on investment.

Regardless of the cause, the short-term memory makes the need for such books as this as more important than never.

In anticipation of his look at management systems he notes in his preface, that management systems need maintaining and, more importantly, reading.  In some circumstances, too much faith is placed in the system (I would refer to the Esso Longford explosion as an example).  Kletz says all systems have limitations.

“All they can do is make the most of people’s knowledge and experience by applying them in a systematic way.  If people lack knowledge and experience, the systems are empty shells.”

What Kletz does not write about is human error because, as he says, “all accidents are due to human error”.  He avoids making the weak logic jump that the behaviouralists make where, “if all accidents are due to human error then fix the human and you fix the hazard”.  Kletz devotes a whole chapter to his classification of human errors as

• Mistakes;
• Violations or noncompliance;
• Mismatches;
• Slips and lapses of attention.

This edition of “What Went Wrong?” provides a baseline for the safety concepts we have come to accept but also a critical eye on safety and manufacturing management shortcomings.  The style is very easy to read although occasionally repetitive.  Thankfully the process technicalities are avoided unless they relate to the technical point Kletz is making.  I found part B hugely useful but it is recommended for all safety professionals.

Kevin Jones