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Journal of Loss Prevention in the Process Industries 25 (2012) 770e774

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Journal of Loss Prevention in the Process Industries

journal homepage: www.elsevier .com/locate/ j lp

A tribute to Trevor Kletz: What we are doing and why we are doing it

Bruce K. Vaughen*

Salus Scio Risk Management, PLLC, 1102 Sterling Drive, Champaign, IL 61821, USA

a r t i c l e i n f o

Article history:Received 4 December 2011Accepted 20 March 2012

Keywords:Process hazardsRisk reductionIncident investigationInherent safety

* Tel.: þ1 217 355 1821; fax þ1 217 355 1821.E-mail address: bruce_vaughen@cabot-corp.com.

0950-4230/$ e see front matter � 2012 Elsevier Ltd.doi:10.1016/j.jlp.2012.03.006

a b s t r a c t

The goal of my tribute to Trevor Kletz is to show a view of his overall influence on many of the elementsof process safety: how he helped establish a strong foundation on which we are building our futureprocess safety risk reduction efforts.

� 2012 Elsevier Ltd. All rights reserved.

1. Prologue e the dwarves meet the giants

Sir IsaacNewton (1675)wrote, “If I have seen a little further it is bystanding on the shoulders of Giants.” Its Latin origin, first recorded inthe twelfth century by Bernard of Chartres (ca.1120, 2008), is “Dwarfsstanding on the shoulders of giants (nanos gigantium humeris insi-dentes).” In 2012, we pay tribute to one of the giants in the processsafetyfield, TrevorKletz, aswe celebrate his 90thBirthday. I hope thatmy thoughts provide you, the reader, withyet another perspective onhow his enthusiasm and desire to make this world a better and saferplace still encourages us to do the same today.

Mypaper’s title derives from a table entitled “What I Did andWhyI Did It” in his autobiography (Kletz, 2000). My tribute and reflectionfocuses on updating this title from the past tense to the future tense. Ihope that what I convey in this tribute helps show that we must:

1. remember and understand our past,2. recognize our present state (what we are doing today), and3. anticipate our future state (where we may be going).

We are doing what we are doing because of what Kletz andmany other giants have done before us, and we continue on ourjourney with their encouragement today.

2. Our history e the dwarves forget to remember

Our process safety risk reduction journey has been filled withsignificant incidents that have caused fatalities, damaged theenvironment and destroyed plants. Kletz discovered that through

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a combination of errors in design, fabrication, installation, opera-tion or maintenance, many things went wrong when managingchemical hazards. He asked over and over, “What went wrong?” Heinvestigated process plant disasters, discovered how they couldhave been avoided and then shared his findings with us (Kletz,2009). He learned that many of the fires and explosions resultedfrom the loss of containment of hazardous materials and energies.And he shared with us that “what you don’t have can’t leak,”helping establish the concepts and technologies of inherently saferdesign (Kletz & Amyotte, 2010).

With his permission, I have rearranged his “What I Did andWhyI Did It” table’s themes into two tables (Table 1, before 2000;Table 2, after 2000), with some of the basic elements of our processsafety risk reduction efforts listed in the rows. I added columnsrepresenting the year that his books were issued andmapped thesesubjects with each element, as well (the list of his work is shown inTable 3). Although I have not read all of his publications, I do hopethat my “Total Element Count” shown in Table 2 helps provide anoverall view of his insights across these process safety elements.

In the decade since Kletz sharedwith us what he did andwhy hedid it, we have seen history repeat with more fatalities, environ-mental damage and business upsets due to fires, explosions, andtoxic releases. For this reason, Kletz (2009) added with a tone ofsadness several new case studies, re-emphasizing that things arestill goingwronge that incidents keep repeating becausewe do notshare our experiences or we forget our learnings. As shown inTable 2, the studies and discussions in his 2009 book cover to someextent everyone of the process safety elements. And as GeorgeSantayana (1905) wrote, “Those who cannot remember the pastare condemned to repeat it.”

Based on the count shown in Table 2, I hope that the followingstatement helps portrays one element of Trevor Kletz: an investigator

Table 1A historical view of Trevor Kletz’s works before 2000.

"What I Did"

1984

1989

1990

1991

1993

1994

1995

1996

1998

1998

1999

Element"Count"by 2000

01 Technology Inherently safer design 3941

27pozaH

Hazan 1

03 Changes Control of modifications 1

04 Handovers 1

05 Integrity and Reliability 1

06 Procedures 1

07 Contractors

08 Emergencies

09 Training

10 Audits Audits and inspections

Better investigations of accidents 2016

A new attitude of human error

Accident case histories 101

Better publicity for accident reports

12 DisciplineBetter ways of remembering the lessons of the past

2015

13 Leadership Myths of the chemical industry 3832

Year

Process Safety Risk Reduction

Element

02 Hazards and Risks 11

10Preparation for maintenance

11 Investigations

B.K. Vaughen / Journal of Loss Prevention in the Process Industries 25 (2012) 770e774 771

who continues to spend his time looking for causes, analyzing forhazards, reducing risks, and proposing better technologies to reduceprocess safety risks. Part of his conclusion is for us to be able to create,implement and maintain risk management systems with disciplinefrom everyone in the organization, from top to bottom: managers,engineers, purchasers, supervisors, operators, mechanics, and elec-tricians. He understands that discipline is required by all levels ofleadership.

3. Our future e the dwarves as spiders on the web

Our process safety journey continues. Since our dwarf wishes fora better view, I envision him climbing a “Process Safety Skyscraper”

for his future perch. The process safety elements/Kletz Themes listin Table 2 are inverted in Fig. 1, with each of the process safetyelements noted as the Process Safety Skyscraper’s floors.

As is shown in Fig.1, the Global Process Safety Skyscraper is builton solid ground. Sincewemust have adequate understanding of thehazards of the materials, the design of the process and the design ofthe equipment before we can build the floors above, we must havea strong foundation e the Technology floor. The Skyscraper’sdifferent elevators help communicate information between eachfloor (each element). However, note that the Design, Apply, andLearn elevators do not reach every floor. The first three floors arelinked with the Design Elevator, floors 8 through 11 use the LearnElevator and the floors in between 3 and 8 use the Apply Elevator.

Table 2A historical view of Trevor Kletz’s works after 2000.

"What I Did"Element"Count"by 2000

"Why I Did It"Conclusions reached by 2000

2001

2001

2003

2009

2010

01 Technology Inherently safer design 3

Flixborough (and then Bhopal) made us realize what should have been obvious: it is better to remove a hazard than to keep it under control. What you don't have can't leak. We can't fall down stairs that aren't there.

5

2pozaH The obvious need to find out what can go wrong without waiting until it has gone wrong. HAZOP is the preferred technique for the process industries. 4

1nazaHThe need to set priorities. We need a defensible method of deciding which hazards to remove or reduce first, which to leave alone, at least for the time being, what risks are intolerable and what are acceptable.

3

03 Changes Control of modifications 1 Flixborough (and other less serious incidents). 2

1srevodnaH40 2

05 Integrity and Reliability 1 2

1serudecorP60 2

07 Contractors 1

08 Emergencies 1

09 Training 1

10 Audits Audits and inspections

Outsiders can spot hazards that we do not see as the hazards are too familiar or we lack the time or the specialized knowledge. 1

Better investigations of accidents 2

The realization that many accident investigations are superficial, dealing only withthe immediate causes and not looking for ways of avoiding the hazard or weaknesses in management.

431

A new attitude of human error

The realization that most accidents could be prevented (or made less likely) by managers' actions. To say that accidents are due to human failing is true but is as helpful as saying that falls are due to gravity.

241

Accident case histories 1

The realization that (a) case histories grab our attention much more effectively than advice and (b) people may not agree with my advice but they can hardly ignore the accidents. We should start with the accidents and draw the lessons out of them.

3

Better publicity for accident reports

For four reasons: (a) moral (b) so that others will tell us about their accidents (c ) so that they will make changes we make and (d) because in the eyes of the public the industry is one.

2

12 DisciplineBetter ways of remembering the lessons of the past

2 Both major and minor accidents are repeated after a few years, even in the same organization. 4

13 Leadership Myths of the chemical industry 3 We all accept unthinkingly beliefs that are not wholly true and can lead to

accidents and wrong decisions. 4

02 Hazards and Risks

Year

Process Safety Risk Reduction

Element

Total Element "Count"by 2011

Sum 7

Preparation for maintenance

The fire in 1967 which was due to poor procedures for the preparation of equipment for repair. It made ICI realize that safety advisers should have experience in the technology.

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16

17

11 Investigations Sum 12

15

B.K. Vaughen / Journal of Loss Prevention in the Process Industries 25 (2012) 770e774772

Hence, it is essential that we have the fourth elevator connectingour Discipline floor to all of the other floors. This elevator is part ofthe continuous improvement loop, a similar approach inherent inboth the Six Sigma “Define, Measure, Analyze, Implement, andControl” and the “Plan, Do, Check, Act” strategies, as well.

Notice that Leadership e upper management e has beenstashed in the attic. All of the elevators must be maintained byLeadership for healthy information flow, helping guaranteea successful process safety risk reduction system. Although leadersexist on every floor, leadership should visit every floor often andnot remain hidden away in the attic.

Based on the Process Safety Skyscraper model shown in Fig. 1,we can envision that our future includes:

1) developing better theories and sharing our practices of ourelements (the floors),

2) establishing more robust communication bridges between ourfloors (the elevators),and

3) continuingour efforts to improve our safety culture (the ground).

In addition, our dwarves and giants must understand and useweb-based Internet tools to enhance our collaborative continuous

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Inverted List From Table 2: Kletz's Publications in The Process Safety Elements (1984 - 2010)

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Table 3A summary of books published by Trevor Kletz.

1 1984 Cheaper, safer plants, or wealth and safety at work: notes oninherently safer and simpler plants (1984) IChemE,ISBN 0852951671

2 1989 Improving Chemical Engineering Practices: A New Lookat Old Myths of the Chemical Industry (1989) Taylor & Francis,ISBN 0-89116-929-6

3 1990 Critical Aspects of Safety and Loss Prevention (1990) Butterworths,ISBN 978-0408044295

4 1991 Plant Design for Safety e a user-friendly approach (1991)Taylor & Francis, ISBN 978-1560320685

5 1993 Lessons from Disaster e How Organizations Have No Memoryand Accidents Recur (1993) IchemE, ISBN 0-85295-307-0

6 1994 Learning from Accidents (1994/2001) Butterworth-Heinemann,ISBN 0-7506-4883-X

7 1995 Trevor Kletz, Paul Chung, Eamon Broomfield and ChaimShen-Orr (1995) Computer Control and Human Error IChemE,ISBN 0-85295-362-3

8 1996 Dispelling Chemical Engineering Myths (1996) Taylor & Francis,ISBN 1-56032-438-4

9 1998 Process Plants e a handbook for inherently safer design (1998)Taylor & Francis, ISBN 978-1-56032-619-9

10 1998 What Went Wrong? Case Histories of Process Plant Disasters(1998) Gulf, ISBN 0-88415-920-5

11 1999 Hazop and Hazan 4th ed. (1999) Taylor & Francis,ISBN 0-85295-421-2

12 2000 By Accident. a Life Preventing them in industry(2000) PFV, ISBN 0-9538440-0-5

13 2001 Learning from Accidents (1994/2001) Butterworth-Heinemann,ISBN 0-7506-4883-X

14 2001 An Engineer’s View of Human Error 3rd ed. (2001) IchemE,ISBN 0-85295-430-1

15 2003 Still Going Wrong: Case Histories of Process Plant Disasters andHow They Could Have Been Avoided (2003) Gulf,ISBN 0-7506-7709-0

16 2009 What Went Wrong? Case Histories of Process Plant Disastersand How They Could Have Been Avoided 5th ed. (2009)Butterworth-Heinemann/IchemE, ISBN 1856175316

17 2010 Trevor Kletz, Paul Amyotte (2010) Process Plants: A Handbook forInherently Safer Design 2nd ed., CRC Press, ISBN 1439804559

B.K. Vaughen / Journal of Loss Prevention in the Process Industries 25 (2012) 770e774 773

improvement energies. How we do this will help us determine ourfuture.

4. Epilogue e the dwarves save the starfish

Among the books in Trevor Kletz’s library, there are manydescribing beautiful local and global country sides and trails wherehe loves to walk. I will end my tribute to him with the followingstory by Loren Eiseley (1979):

Whilewandering adesertedbeachatdawn, stagnant inmywork, Isawaman in the distance bending and throwing as hewalked theendless stretch toward me. As he came near, I could see that hewas throwing starfish, abandoned on the sand by the tide, backinto the sea. When he was close enough I asked himwhy he wasworking so hard at this strange task. He said that the sun woulddry the starfish and theywould die. I said to him that I thought hewas foolish. Therewere thousandsof starfishonmiles andmilesofbeach. Oneman alone couldnevermake adifference. He smiled ashe picked up the next starfish. Hurling it far into the sea he said, ‘Itmakes adifference for this one.’ I abandonedmywriting and spentthe morning throwing starfish.

Imet TrevorKletz as Iwaswalking down the beach. Because ofmyless experienced legs, I have towalk very fast to keep upwith him, ashe is still finding stranded starfish and throwing them back in.

As you read more about other process safety risk reduction casestudies, I hope that you will recognize your own element-specificcontributions on our journey (“why I am doing it”), and that youcontinue to encourage others to join us on this journey: one personat a time; one process at a time; one day at a time; one starfish ata time.

I hope that I have met my goal in this tribute to show you howTrevor Kletz has and continues to influence us. I know I speak formany when I say: “Thank you, Trevor!”

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References

Chartres, B. (ca. 1120). (2008). Complete dictionary of scientific biography. FromEncyclopedia.com. http://www.encyclopedia.com/doc/1G2-2830900396.htmlAccessed 03.12.11.

Eiseley, L. (1979). The star thrower. Harvest/HBJ Books,Mariner. Also “The Starfish Story.”http://www.goodreads.com/author/quotes/56782.Loren_Eiseley Accessed 03.12.11.

Kletz, T. A. (2000). By accident. a life preventing them in industry. PFV.

Kletz, T. A. (2009). What went wrong? Case histories of process plant disasters andhow they could have been avoided (5th ed.). Butterworth-Heinemann/IChemE.

Kletz, T. A., & Amyotte, P. (2010). Process plants: A handbook for inherently saferdesign (2nd ed.). CRC Press.

Newton, I. (1675). Letter to Robert Hooke, February 5, 1675. From. http://www.quotationspage.com/quotes/Isaac_Newton Accessed 03.12.11.

Santayana, G. (1905). The life of reason, Vol. 1, From. http://www.quotationspage.com/quotes/George_Santayana Accessed 27.11.11.