Still Going Wrong!: Case Histories Of Process Plant Disasters And How They Could Have Been Avoided F
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How to Avoid Process Plant Disasters: Lessons from Still Going Wrong!
Process plants are complex systems that involve many hazards and risks. When things go wrong, the consequences can be catastrophic, resulting in loss of life, property, and reputation. How can we prevent such disasters from happening
One way is to learn from the past mistakes of others. That's what Trevor Kletz, a renowned expert on process safety, does in his book Still Going Wrong!: Case Histories of Process Plant Disasters and How They Could Have Been Avoided. This book is a sequel to his previous bestseller What Went Wrong: Case Histories of Process Plant Disasters, which has been widely used as a reference and training material for engineers and managers in the chemical and petrochemical industries.
In Still Going Wrong!, Kletz presents 24 new case studies of real incidents that occurred in process plants around the world. He analyzes the causes and consequences of each incident, and identifies the lessons learned and the recommendations for improvement. He covers topics such as management of change, process hazards analysis, human factors, design errors, maintenance failures, corrosion, leaks, explosions, fires, and toxic releases.
The book is written in a clear and engaging style, with illustrations and diagrams to help explain the technical aspects. It is not only informative but also entertaining, as Kletz uses humor and anecdotes to make his points. The book is suitable for anyone who works in or with process plants, such as engineers, managers, operators, technicians, regulators, consultants, students, and teachers.
By reading Still Going Wrong!, you will gain valuable insights into how to avoid process plant disasters and how to improve your safety culture and performance. You will also discover how to apply the principles of process safety management to your own operations and projects. As Kletz says in his introduction: \"The aim of this book is not to criticize but to help you do a better job.\"
In this article, we will review some of the case studies from Still Going Wrong! and highlight the main takeaways for process plant safety. We will focus on three chapters that cover different types of incidents: Chapter 2: Changes; Chapter 3: Leaks; and Chapter 4: Explosions.
Chapter 2: Changes
Changes are inevitable in any process plant, as new technologies, products, markets, regulations, and customer demands emerge. However, changes can also introduce new hazards or worsen existing ones, if they are not properly managed and controlled. Kletz shows several examples of how changes led to disasters, such as:
A change in feedstock composition caused a runaway reaction and a fire in a polyethylene plant.
A change in operating conditions resulted in a loss of containment and a toxic release in a chlorine plant.
A change in maintenance procedures led to a valve failure and a gas explosion in a refinery.
The common theme in these cases is that the changes were not adequately assessed for their potential impact on safety, and that the relevant information was not communicated to all the parties involved. Kletz recommends that any change should be subjected to a formal management of change (MOC) process, which involves:
Identifying and documenting the change and its justification.
Evaluating the hazards and risks associated with the change.
Obtaining approval from the appropriate authority before implementing the change.
Informing and training all the affected personnel about the change.
Updating all the relevant documents and records to reflect the change.
Reviewing and auditing the change after implementation to verify its effectiveness and safety.
Kletz also emphasizes that MOC should apply not only to physical changes (such as equipment, materials, or processes), but also to organizational changes (such as personnel, roles, responsibilities, or procedures). He warns that organizational changes can have unintended consequences on safety culture and performance, especially if they result in loss of expertise, experience, or communication.
Chapter 3: Leaks
Leaks are one of the most common causes of process plant incidents. They can occur due to various reasons, such as corrosion, erosion, fatigue, stress, vibration, thermal expansion, mechanical damage, human error, or sabotage. Leaks can lead to fires, explosions, or toxic releases, depending on the nature and quantity of the leaked material and the surrounding conditions. Kletz presents several cases of leaks that had disastrous outcomes, such as:
A leak of liquefied petroleum gas (LPG) from a corroded pipe caused a massive vapor cloud explosion in Mexico City.
A leak of methyl isocyanate (MIC) from a storage tank caused a deadly gas release in Bhopal.
A leak of hydrofluoric acid (HF) from a ruptured hose caused a toxic cloud in Texas City.
The common theme in these cases is that the leaks were not detected or controlled in time, and that the emergency response was inadequate or ineffective. Kletz suggests that leaks can be prevented or minimized by:
Designing and installing pipes, valves, fittings, flanges, gaskets, seals, hoses, etc. according to appropriate standards and specifications.
Inspecting and testing pipes and equipment regularly for signs of deterioration or damage.
Using corrosion inhibitors, coatings, cathodic protection, etc. to protect pipes and equipment from corrosion.
Using leak detection systems (such as pressure sensors, flow meters, acoustic devices, infrared cameras, etc.) to monitor pipes and equipment for leaks.
Using isolation valves, excess flow valves, rupture disks ec8f644aee