Fiona Macleod illustrates Trevor Kletz’ thoughts on accident investigation
IN LATE 2013, I attended the funeral of Trevor Kletz at the Linthorpe Road Cemetery in Middlesbrough, UK. I didn’t know him well – we had only met a couple of times in person – but his influence on my career was so important, I wanted to pay my respects.
The burial was a small family affair. His children were enormously welcoming and friendly, and delighted – if a little bemused - to hear how influential their father had been, and how many lives he had certainly saved.
I tried to explain to them that, for me, there were two things that set their father apart from other engineers, writers, thinkers and academics.
The first was his deep respect for practical experience; the way he spent time in the field, listening to people at the sharp end of operations and maintenance and then synthesising what he learned to improve design.
The second was his clear, pithy communication.
Kletz understood the power of a story as a way to get important messages across. His writing had an enormous influence on my generation of process engineers.
I was delighted to be invited to contribute to a new process safety book, The Trevor Kletz Compendium1 of his work as a way to keep that process safety wisdom alive and relevant to future generations.
There are many steps to getting process safety right. My colleague David Edwards set out a hierarchy of safety controls in a previous article (TCE 969 March 2022) and the Compendium contains a comprehensive chapter on each of these topics: inherent safety; HAZOP; HAZAN; managing maintenance risk; control of modifications; human error; and accident investigation.
In the chapter on accident investigation, I tried to illustrate pitfalls with a story from my own experience, because as Kletz wrote in 2009: “Case histories grab our attention much more effectively than advice”.2
The Compendium ends with a calendar of disasters, at least one for every month of the year, including: Feyzin; Georgia Sugar; Texas City; Chernobyl; Wanggongchan Armoury; Flixborough; Piper Alpha; Banqiao; Longford; Phillips Passadena; Sandoz; and Bhopal – with a bite-sized summary suitable for toolbox talks and safety moments.
“Failures should be seen as educational experiences. Having paid the tuition fee, we should learn the lessons.”2
Case histories grab our attention much more effectively than advice
As a co-author of the Compendium, there are three things that would make me very happy.
The first is if you would take a look at the book. There’s a wealth of updated and accessible information here.
The second is if it inspires you to go back to some of Kletz’ original writing.
And the third, and most important, would be if it motivated you to leave your office and engage in a process safety conversation with at least three people, each in their normal working environment: someone new to the organisation or at the start of their career; someone who works abnormal hours - nightshifts and weekends; and someone who knows your site or company or industry history through long experience.
Any process safety walkabout - to find out how a key process safety system works in practice in your organisation – starts as a talkabout. Why not pull the threads and see where they lead you?
Failures should be seen as educational experiences. Having paid the tuition fee, we should learn the lessons
1. Trevor Kletz Compendium: His Process Safety Wisdom Updated for a New Generation, Brazier, A, Edwards, D, Macleod, F, Skinner, C, Vince, I; Elsevier, 2021.
2. Kletz, TA, What Went Wrong? Case Histories of Process Plant Disasters and How They Could Have Been Avoided, Butterworth-Heinemann, 5th Edition, 2009.
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