Trevor Kletz, OBE, D.Sc., F.Eng. (1922-2013), was a process safety consultant, and published more than a hundred papers and nine books on loss prevention and process safety, including most recently Lessons From Disaster: How Organizations Have No Memory and Accidents Recur and Computer Control and Human Error. He worked thirty-eight years with Imperial Chemical Industries Ltd., where he served as a production manager and safety adviser in the petrochemical division, also holding membership in the Department of Chemical Engineering at Loughborough University, Leicestershire, England. He most recently served as senior visiting research fellow at Loughborough University, and adjunct professor at the Mary Kay O’Connor Process Safety Center, Texas A&M University. Paul Amyotte is a Distinguished Research Professor and Professor of Chemical Engineering at Dalhousie University (Halifax, Canada). He is a chemical engineering graduate of the Royal Military College of Canada (Bachelor’s), Queen’s University (Master’s), the Technical University of Nova Scotia (PhD) and a registered professional engineer in Nova Scotia. Dr. Amyotte is a member and past president of Canadian Society of Chemical Engineering, a member of American Institute of Chemical Engineers, a Fellow of Chemical Institute of Canada, the Engineering Institute of Canada, Canadian Academy of Engineering, Engineers Canada, and the Canadian Academy of Engineering. Dr. Amyotte has an extensive record of authorship, with six books, several book chapters, and over 350 papers published in peer-reviewed journals or presented at national and international conferences. He has presented invited plenary lectures at symposia in Canada, France, Italy, Malaysia, Netherlands, Norway, Poland, Qatar, Taiwan, and the United States. He is the current editor of the Journal of Loss Prevention in the Process Industries, and a past president of the Canadian Society for Chemical Engineering, Engineers Nova Scotia, and Engineers Canada. He has also served as chair of the Canadian Engineering Qualifications Board, member of the Canadian Engineering Accreditation Board, and co-chair of the Materials and Chemical Engineering Evaluation Group of the Natural Sciences and Engineering Research Council of Canada. Dr. Amyotte has consulted on numerous industrial projects involving hazard analysis, incident investigation, and material explosibility. Dr. Amyotte is a recipient of distinct awards including Cybulski Medal from the Polish Academy of Sciences, the Trevor Kletz Merit Award from the Mary Kay O’Connor Process Safety Center, and the Process Safety Management Award from the Canadian Society for Chemical Engineering.

• INTRODUCTION1. Case Histories and Their Use in Enhancing Process Safety Knowledge2. Bhopal 3. Opportunities for Reflection MAINTENANCE AND OPERATIONS4. Maintenance: Preparation and Performance5. Operating Methods6. Entry to Vessels and Other Confined Spaces7. Accidents Said to Be Due to Human Error8. Labeling9. Testing of Trips and Other Protective Systems10. Opportunities for ReflectionEQUIPMENT AND MATERIALS OF CONSTRUCTION11. Storage Tanks12. Stacks13. Pipes and Vessels14. Tank Trucks and Tank Cars15. Other Equipment16. Materials of Construction17. Opportunities for ReflectionHAZARDS AND LOSS OF CONTAINMENT 18. Leaks19. Liquefied Flammable Gases20. Hazards of Common Materials21. Static Electricity22. Reactions – Planned and Unplanned23. Explosions24. Opportunities for ReflectionKNOWLEDGE AND COMMUNICATION26. Poor Communication27. Accidents in Other Industries28. Accident Investigation – Missed Opportunities29. Opportunities for ReflectionDESIGN AND MODIFICATIONS30. Inherently Safer Design31. Changing Procedures Instead of Designs32. Both Design and Operations Could Have Been Better33. Modifications: Changes to Equipment and Processes34. Modifications: Changes in Organization35. Reverse Flow, Other Unforeseen Deviations, and Hazop36. Control37. Opportunities for ReflectionCONCLUSION38. An Accident That May Have Affected the Future of Process Safety39. An Accident That Did Not Occur40. Summary of Lessons LearnedAPPENDICES1. Relative Frequencies of Incidents2. Why Should We Publish Accident Reports?3. Some Tips for Accident Investigators4. Recommended Reading5. Afterthoughts

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