One of my goals for 2019 is to help spread the work of others in process safety, loss prevention, and combustible dust fire and explosion research.
Over the last seven years through my Ph.D. and three years through DustSafetyScience, I continue to see examples of information already available in our field that doesn’t make it out to the sources who need it the most.
As such, I have started a monthly ‘Book Club’ where I share the actual texts and publications I am reading. I hope you find these summaries useful. I encourage you to share your own experiences with these topics or resources in the comments section at the bottom of the page.
As always, please feel free to share any questions about the resources in this section or on the website with me directly as well ([email protected])!
Our first book review is “By Accident… A Life Preventing Them in Industry”, an autobiography by the late Trevor Kletz. I purchased and read this book for my “downtime” over the Christmas break, and finished it in January of this year. It was an excellent break from the sometimes overly technical writing associated with safety literature. The subject is a great look into the life and work of one of the forefathers within communication of process safety of our time.
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Book Summary
This modestly sized book gives an exceptional overview of the “view from middle management” with regards to safety in a large, and sometimes bureaucratic, company. Kletz shares lessons learned and recommendations around introducing change, getting buy-in for new processes and communicating safety in processing industries.
About The Author – Trevor Kletz
Trevor Kletz was born in 1922 in Darlington, England. He attended The King’s School in Chester and, later, Liverpool University during the Second World War. In 1944, he joined Imperial Chemical Industries (ICI) as a research chemist and started what would become a
In 1952, Kletz became a plant manager in the iso-octane, acetone and tar acid plants. In 1961, he became Assistant Works Manager for the Olefines department. Later, in 1968, he was appointed ICI’s first Technical Safety Advisor and spent the next 14 years improving the safety record of the company which, at the time, was one of the largest chemical manufacturers in Britain.
In 1982, Kletz left ICI to make a second career as a prolific writer, commentator, and lecturer on all aspects of process safety and loss prevention. In his own words, these topic lie at the heart of understanding the scientific study of safety in processing industries. Kletz is often said to be the ‘Founding Father’ of process safety. He was an enthusiastic advocate of concepts such as Inherent Safety, Hazard Analysis (Hazan), and Hazard and Operability Studies (HAZOPs). He wrote many books on these topics including:
- What Went Wrong?: Case Histories of Process Plant Disasters and How They Could Have Been Avoided (Kletz, 2009 – Affiliate Link)
- Still Going Wrong!: Case Histories of Process Plant Disasters and How They Could Have Been Avoided (Kletz, 2009 – Affiliate Link)
- Lessons From Disaster: How Organizations Have No Memory and Accidents Recur (Kletz, 1993 – Affiliate Link)
- Process Plants: A Handbook for Inherently Safer Design (Keltz and Amyotte, 2010 – Affiliate Link)
- Learning from Accidents (Kletz, 2001 – Affiliate Link)A
- Hazop and Hazan: Identifying and Assessing Process Industry Hazards (Kletz, 1992 – Affiliate Link)
- An Engineers View of Human Error (Kletz, 2001 – Affiliate Link)
Throughout his lifetime, Kletz was awarded several honours including a fellowship of the Royal Academy of Engineering and the Royal Society of Chemistry. He was also awarded medals by the Institute of Chemical Engineers (IChemE) and American Institute of Chemical Engineers. Kletz became a visiting professor of Chemical Engineering at Loughborough University and an adjunct professor at Texas A&M University.
On a personal note, although I am very familiar with his body of work, I never got the chance to meet Trevor Kletz in person, as he passed away in 2013. However, I was fortunate to have attended a memorial lecture at Texas A&M University in that year to hear about his significant contributions to our field. The lecture was given by the now late Dr. Sam Mannan and, between the two of these individuals, the contributions to our understanding of safety today are immeasurable.
Review Of: “By Accident… A Life Preventing Them In Industry”
Early Life and Career
The first few chapters of the book are focused on why Kletz felt the need to write an autobiography and his early career transitions through ICI. In his own words, these chapters provide a “view of
Chapters One and Two
All management systems and all safety techniques are useless unless the people using them have knowledge, experience and ability.
Trevor Kletz, “By Accident… A Life Preventing Them In Industry”
Lessons Learned from Managing Process Plants
Chapters Three to Six cover the author’s move to the Oil Works section and subsequent management of Iso-Octane, Acetone, and tar-acid plants (with a brief stint at the ICI Technical Department).
In these chapters, Kletz described the “culture shock” of moving from one facility to the next as the dynamic makeup of workers in each plant and their approach to getting work done were very different. Kletz demonstrated a boots-on-the-ground attitude to managing process facilities
… managers and senior safety advisors cannot ask someone to read accident reports on their behalf and draw attention to significant messages. They should read a substantial proportion themselves and visit the scene, as this is the only way to get a feel for the sort of incidents that are occurring and why they occur.
Trevor Kletz, “By Accident… A Life Preventing Them In Industry”
In these chapters, Kletz shares the key stories that would come back to shape the way he viewed and communicated safety in the
On page 25, in a section on “Tackling Performance”, he shares a story of trying to decide whether to extend a plant shut down to replace catalysts tubes or close them off to wait for the next scheduled shutdown. On the suggestion of another manager, he calculated which would lose the most output to make the decision. This taught him to look at processing problems numerically, which was “later to play a large part in my career,” presumably for applying Hazan and Hazop processes.
On page 31, Kletz shares a 1955 ICI image showing an operator in the Acetone plant keeping watch over a large nitroglycerin reactor, sitting on a one-legged stool. The stool was there so that the operator could not fall asleep while looking at the potentially dangerous process. Kletz contrasts this to more recent operations which involve much smaller reactors and require less supervision. This highlights the beginnings of his thoughts around Inherent Safety (minimizing the amount of fuel) being better than procedural safety and the now-famous quotes in this area.
What you don’t have can’t leak and what you don’t have can’t explode.
Trevor Kletz, “By Accident… A Life Preventing Them In Industry”
Throughout these chapters, the reader is introduced to fire and explosion incidents that occurred in these plants. The circumstances and reactions allow the reader to get a sense of how they impacted Kletz’s thoughts about safety. On page 62, the reader is introduced to the first fatal accident Kletz had “on his patch”. In the subsequent pages, Kletz provides a detailed description of his conclusions about how the accident happened and
In these chapters, the reader is also offered a glimpse of the origin and creation of Hazard and Operability Studies (Hazop) within ICI. Kletz became an advocate for these processes as chemical processing plants continued to grow bigger and more complicated (and continue to do so today). These experiences lead to Kletz
Technical Safety Advisor Role
Chapters Seven, Eight, and Nine cover Kletz’s promotion to ICI’s first Technical Safety Advisor and the period of time at which he really started to flesh out ideas around loss prevention. Kletz worked towards reducing the ICI fatal injury rate at the same time.
Early in this section, the reader is introduced to Trevor’s thoughts on the importance of distinguishing ‘Process Safety’ from ‘Personal Safety,’ which was traditionally measured by lost-time accidents.
The lost-time accident rate, the usual measure of performance, was easily fiddled. It was the practice at the time to try to persuade injured men to come into work, even to just sit in an office, so that the accident did not count.
Trevor Kletz, “By Accident… A Life Preventing Them In Industry”
In this time, Kletz found that he had to “sell his ideas ‘softly’ but persistently” as he had neither real authority to impose them nor did he wish for any. He also found that “most accidents are due to a failure to apply well-known principles or knowledge” and that communication was a key missing factor in making facilities safer.
With this awareness, Kletz started sending Safety Newsletters in 1968. These began as internal documents but continued until Kletz left ICI in 1983. Over time, he found that the readership grew “spontaneously” with the final readership including more than 1000 individuals from several companies, associations, and organizations throughout the UK and elsewhere.
Trevor Kletz’s “Second Career”
On March 31, 1982, 38 years after he started with ICI, Kletz left the company. Instead of retiring, he spent much of his remaining 30 years dedicated to the communication of process safety topics and improving understanding of the available tools. The final section of the book, Chapter 10, briefly describes how Kletz’s thinking evolved during this time.
Much of the material for his textbooks, “Lessons from disaster – how organizations have no memory and accidents recur”, “What Went Wrong?: Case Histories of Process Plant Disasters and How They Could Have Been Avoided” and “Still Going Wrong!: Case Histories of Process Plant Disasters and How They Could Have Been Avoided” came from the many years he spent publishing his Safety Newsletter.
All of these books have a feature in common: I start with accident reports and draw the messages – the lists of what we should and should not do – out of them. Many writers do the reverse. They start with the codes and recommended practices and show how failures to follow them have resulted or will result in accidents.
Trevor Kletz, “By Accident… A Life Preventing Them In Industry”
Much of Kletz’s work in his later years involved communicating and promoting important safety topics such as inherent safety, the hierarchy of hazard controls, hazard analysis, and Hazop methods. He also provided detailed reviews of tragic incidents during that period, such as Piper Alpha, Flixborough, and Bhopal. Unfortunately, the lessons he learned early in his career were still playing out on the world stage.
Key Takeaways
The number of important takeaways in “By Accident…. A Life Preventing Them in Industry” are only outnumbered by the quality and quantity of the stories Kletz shares to highlight his concerns. This book is recommended for anyone interested in the “view of
This book also had a large influence on many of my ideas around building out DustSafetyScience and the Combustible Dust Incident Database:
- Process safety (or technical safety as Trevor calls it) is not personal safety. Lost-time incidents are not a good indicator of the chance of having a catastrophic fire or explosion happening.
- The need to “Sell his ideas ‘softly’ but persistently”. It was quite a surprise to hear that one of Kletz’s main ‘weapons’ was his safety newsletter. Having started DustSafetyScience on the back of an email newsletter two years ago (and not missing a week since!), this lets me know I might be on the right track with some of our work.
- Inherent safety is preferred over procedural safety or engineering controls. Why not reduce the size of the reaction vessel instead of needing an operator to sit on a one-legged stool? What you don’t have can’t explode.
- Empowering people is better than telling them what to do. This lesson is shown throughout Kletz’s autobiography. It is also an important part of the awareness and education campaigns we are sharing through the Combustible Dust Incidents Database.
- Last but not least, we need an appropriate measurement of technical or process safety loss. Near the end of the book (page 119), Kletz introduces one such measurement: the Fatal Accident Rate (FAR). The FAR is expressed in terms of fatalities per 100,000,000 working hours (or a group of 1000 people working a lifetime). For process risks, ICIs FAR peaked at 4 fatalities/100,000,000 working hours before Kletz became the Technical Safety Advisor with the company. This measurement gives a bar from which we can start to measure other companies. For example, 4 fatalities/100,000,000 working hours would be one fatality every 100 years for a company with 100 employees. My question is, for companies handling combustible dust, are we above or below this value?
Want to Purchase the Book?
You can purchase “By Accident… A Life Preventing Them in Industry” by clicking through the affiliate link given below or by going directly to the publishers website:
What is Your #1 Take-Away?
Please share it the comments below as it would be very interesting to hear about other people’s experiences reading this book!
