Lessons from Disaster: How Organizations Have No Memory and Accidents RecurIt is by avoiding accidents that the process industries will improve their public image. Lessons from Disaster focuses upon the apparent inability of organizations to learn, and retain in long-term, the lessons drawn from accidents. Incidents of a similar type continue to occur within companies repeatedly. Trevor Kletz illustrates this with detailed cases, which form a gold mine of experience and advice for every engineer. He offers, with his customary vision and imagination, his own advice on how to improve the corporate memory. |
Contents
2 | 15 |
5 | 21 |
3 | 27 |
6 | 33 |
4 | 39 |
2 | 45 |
4 | 53 |
2 | 63 |
7 | 88 |
2 | 94 |
6 | 102 |
8 | 109 |
1 A FUTURE ACCIDENT REPORT | 120 |
2 | 127 |
CHANGES IN SAFETYA PERSONAL VIEW | 143 |
IMPROVING THE CORPORATE MEMORY | 166 |
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Common terms and phrases
2nd edition Gulf Aberfan accident reports Accidents in Industry audits bar gauge Bhopal BLEVE cause Chapter Chemical Engineers chemical industry Clapham Junction corporate memory damage described discussed ethylene ethylene oxide example failed failure Feyzin Figure fire flammable Flixborough foreman happened hazardous materials Hazop Health and Safety Histories of Process HMSO hose human error hydrocarbons incident Industry Butterworths inherently safer designs installed Institution of Chemical isolation valves killed Kletz leak Learning from Accidents lessons liquefied liquid London look Loss Prevention no-one operators organisation pipe Piper Alpha pressure problems procedures Process Plant Disasters protective equipment pump reactor realise recommendations relief valve Rugby safety adviser Safety Executive Section 2.1 senior managers serious accident slip-plates sodium chlorate someone source of ignition staff steam studbolts tanker technical temperature testing trips and alarms vapour vent vessel water hammer wrong