Accident investigation: Keep asking "why?"

Journal of Hazardous Materials

Volumn 130, Issue 1-2 SPEC. ISS., 2006, Pages 69-75

  Kletz, Trevor A ^a  

^a Department of Electrical and Computer Engineering   (United States)

Author keywords

Accident reports; Accidents, investigation of; Bhopal; Discussions; Flixborough; Inherently safer design; Training

Indexed keywords

ACCIDENTS; PERSONNEL TRAINING; SAFETY FACTOR;

ACCIDENT REPORTS; ACCIDENTS, INVESTIGATION OF; BHOPAL; DISCUSSIONS; FLIXBOROUGH; INHERENTLY SAFER DESIGN;

ACCIDENT PREVENTION;

CARBARIL; METHYL ISOCYANATE;

ACCIDENT PREVENTION; ACCIDENTS; PERSONNEL TRAINING; SAFETY FACTOR;

HAZARDOUS WASTE;

ACCIDENT; CHEMICAL INDUSTRY; CONFERENCE PAPER; DISASTER; EXPLOSION; HAZARD; WATER CONTAMINATION;

ACCIDENT PREVENTION; CHEMICAL INDUSTRY; EXPLOSIONS; GREAT BRITAIN; HUMANS; INDIA; ORGANIZATIONAL INNOVATION; SAFETY MANAGEMENT;

EID: 33644648096     PISSN: 03043894     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.jhazmat.2005.07.047     Document Type: Conference Paper

References (20)

1. T.A. Kletz third ed. Learning from Accidents 2001 Butterworth-Heinemann London (Chapter 8)
2. R.J. Parker (Chairman), The Flixborough disaster, Report of the Court of Inquiry, Her Majesty's Stationery Office, London, 1975.
3. J.-R. Chen An inherently safer process of cyclohexane oxidation using pure oxygen - an example of how better process safety leads to better productivity Process Saf. Prog. 23 1 2004 72 81
4. T.A. Kletz third ed. Learning from Accidents 2001 Butterworth-Heinemann London (Chapter 10)
5. W.D. Cullen, The Public Inquiry into the Pipe Alpha Disaster, Her Majesty's Stationery Office, London, 1990.
6. AEA Technology, Improving Inherent Safety - A Pilot Study, HSE Books, Sudbury, UK, 1997.
7. D. Mansfield, L. Poulter, and T.A. Kletz Improving Inherent Safety 1997 HSE Books Sudbury, UK (HSE Offshore Technology Paper No. OTH 96 321)
8. M. Swidzinski, Process ontensification: an offshore oil and gas industry perspective, Minutes of the 10th Meeting of the Process Intensification Network, 3 June, www.pinetwork.org, 2004.
9. T.A. Kletz, Still Going Wrong - Case Histories of Process Plant Disasters and How They Could Have Been Avoided, Gulf Professional, Boston, MA, Sections 3-1, 8-7 and 13-7, 2003.
10. Anon., The Fires and Explosion at BP Oil (Grangemouth) Refinery Ltd., Her Majesty's Stationery Office, London, 1989.
11. T.J. Laney Lessons from the Aramco tank fire third ed. C.H. Vervalin Fire Protection Manual for Hydrocarbon Processing Plants vol. 1 1963 Gulf Publishing Houston, TX 101 105 (presented at the American Gas Association Production-Chemical Conference, and reprinted with some revisions)
12. T.A. Kletz What are the causes of change and innovation in safety Second International Symposium on Loss Prevention and Safety Promotion in the Process Industries Heidelburg, Dechema, Frankfurt, Germany, September 1977 1993 1 13. (reprinted in lessons from disaster, Institution of Chemical Engineers, Rugby, UK, 5)
13. Anon., undated (about 1978), Hazard Workshop Module, Preparation for Maintenance, Institution of Chemical Engineers, Rugby UK) (the later editions are called Training Packages).
14. T.A. Kletz first ed. What Went Wrong? Case Histories of Process Plant Disasters 1985 Gulf Publishing Houston, TX (fourth ed., 1988, Section 10.4.3)
15. Anon., Chemical Age, 12 December, p. 40 and 9 January 1970, p. 11, 1969 (similar reports appeared in many other journals).
16. T.A. Kletz, Learning from Accidents in Industry, Butterworths, London, 1988 (Chapter 5) (the third ed., 2001 called 'Learning from Accidents', is published by Gulf Professional, Oxford, UK).
17. T.A. Kletz, H.G. Lawley, Safety technology in industry: chemical, in: A.E. Green (Ed.), High Risk Safety Technology, Wiley, Chichester, UK, 1982, pp. 317-352.
18. T.A. Kletz Hazards in chemicals system maintenance: permits H.H. Fawcett W.S. Wood Safety and Accident Prevention in Chemical Operations 1982 Wiley Chichester, UK 807 836
19. T.A. Kletz third ed. Learning from Accidents 2001 Gulf Professional Oxford, UK (Chapters 5 and 17 and Sections 14.4, 16.5 and 25.3)
20. T.A. Kletz Lessons from Disaster - How Organisations Have No Memory and Accidents Recur 1993 Institution of Chemical Engineers Rugby, UK