What went wrong? case histories of process plant disasters and how they could have been avoided

Detalles Bibliográficos
Autor principal:	Kletz, Trevor A. (-)
Formato:	Libro electrónico
Idioma:	Inglés
Publicado:	London : Elsevier 2009.
Edición:	5th ed
Materias:	Chemical plants > accidents.
Ver en Biblioteca Universitat Ramon Llull:	https://discovery.url.edu/permalink/34CSUC_URL/1im36ta/alma991009627505506719

Tabla de Contenidos:

Front Cover
What Went Wrong?
Copyright Page
Contents
Acknowledgments
Preface
Units and Nomenclature
PART A: WHAT WENT WRONG?
Chapter 1. Preparation for Maintenance
1.1 Isolation
1.2 Identification
1.3 Removal of Hazards
1.4 Procedures Not Followed
1.5 Quality of Maintenance
1.6 A Personal Note
Chapter 2. Modifications
2.1 Startup Modifications
2.2 Minor Modifications
2.3 Modifications Made during Maintenance
2.4 Temporary Modifications
2.5 Sanctioned Modifications
2.6 Process Modifications
2.7 New Tools
2.8 Organizational Changes
2.9 Gradual Changes
2.10 Modification Chains
2.11 Modifications Made to Improve the Environment
2.12 Control of Modifications
Chapter 3. Accidents Said to Be Due to Human Error
3.1 Introduction
3.2 Accidents That Could Be Prevented by Changing the Plant Design or Method of Working
3.3 Accidents That Could Be Prevented by Better Training
Chapter 4. Labeling
4.1 Labeling of Equipment
4.2 Labeling of Instruments
4.3 Labeling of Chemicals
4.4 Labels Not Understood
Chapter 5. Storage Tanks
5.1 Overfilling
5.2 Overpressuring
5.3 Sucking In
5.4 Explosions
5.5 Floating-Roof Tanks
5.6 Miscellaneous Incidents
5.7 Fiberglass-Reinforced (FRP) Tanks
Chapter 6. Stacks
6.1 Stack Explosions
6.2 Blocked Stacks
6.3 Heat Radiation
Chapter 7. Leaks
7.1 Some Common Sources of Leaks
7.2 Control of Leaks
7.3 Leaks onto Water, Wet Ground, or Insulation
7.4 Detection of Leaks
7.5 Fugitive Emissions
Chapter 8. Liquefied Flammable Gases
8.1 Major Leaks
8.2 Minor Leaks
8.3 Other Leaks
8.4 Safety in the Design of Plants Handling Liquefied Light Hydrocarbons
Chapter 9. Pipe and Vessel Failures
9.1 Pipe Failures
9.2 Pressure Vessel Failures.
Chapter 10. Other Equipment
10.1 Centrifuges
10.2 Pumps
10.3 Air Coolers
10.4 Relief Valves
10.5 Heat Exchangers
10.6 Cooling Towers
10.7 Furnaces
Chapter 11. Entry to Vessels
11.1 Vessels Not Freed from Hazardous Material
11.2 Hazardous Materials Introduced
11.3 Vessels Not Isolated from Sources of Danger
11.4 Unauthorized Entry
11.5 Entry into Vessels with Irrespirable Atmospheres
11.6 Rescue
11.7 Analysis of Vessel Atmosphere
11.8 What Is a Confined Space?
11.9 Every Possible Error
Chapter 12. Hazards of Common Materials
12.1 Compressed Air
12.2 Water
12.3 Nitrogen
12.4 Heavy Oils (Including Heat Transfer Oils)
Chapter 13. Tank Trucks and Cars
13.1 Overfilling
13.2 Burst Hoses
13.3 Fires and Explosions
13.4 Liquefied Flammable Gases
13.5 Compressed Air
13.6 Tipping Up
13.7 Emptying into or Filling from the Wrong Place
13.8 Contact with Live Power Lines
Chapter 14. Testing of Trips and Other Protective Systems
14.1 Testing Should Be Thorough
14.2 All Protective Equipment Should Be Tested
14.3 Testing Can Be Overdone
14.4 Protective Systems Should Not Reset Themselves
14.5 Trips Should Not Be Disarmed without Authorization
14.6 Instruments Should Measure Directly What We Need to Know
14.7 Trips Are for Emergencies, Not for Routine Use
14.8 Tests May Find Faults
14.9 Some Miscellaneous Incidents
14.10 Some Accidents at Sea
Chapter 15. Static Electricity
15.1 Static Electricity from Flowing Liquids
15.2 Static Electricity from Gas and Water Jets
15.3 Static Electricity from Powders and Plastics
15.4 Static Electricity from Clothing
Chapter 16. Materials of Construction
16.1 Wrong Material Used
16.2 Hydrogen Produced by Corrosion
16.3 Other Effects of Corrosion
16.4 Loss of Protective Coatings.
16.5 Some Other Incidents Caused by Corrosion
16.6 Fires
16.7 Choosing Materials
Chapter 17. Operating Methods
17.1 Trapped Pressure
17.2 Clearing Choked Lines
17.3 Faulty Valve Positioning
17.4 Responsibilities Not Defined
17.5 Communication Failures
17.6 Work at Open Manholes
17.7 One Line, Two Duties
17.8 Inadvertent Isolation
17.9 Incompatible Storage
17.10 Maintenance: Is It Really Necessary?
17.11 An Interlock Failure
17.12 Emulsion Breaking
17.13 Chimney Effects
Chapter 18. Reverse Flow, Other Unforeseen Deviations, and Hazop
18.1 Reverse Flow from a Product Receiver or Blowdown Line Back into the Plant
18.2 Reverse Flow into Service Mains
18.3 Reverse Flow through Pumps
18.4 Reverse Flow from Reactors
18.5 Reverse Flow from Drains
18.6 Other Deviations
18.7 A Method for Foreseeing Deviations
18.8 Some Pitfalls in Hazop
18.9 Hazop of Batch Plants
18.10 Hazop of Tank Trucks
18.11 Hazop: Conclusions
Chapter 19. I Didn't Know That…
19.1 Ammonia Can Explode
19.2 Hydraulic Pressure Tests Can Be Hazardous
19.3 Diesel Engines Can Ignite Leaks
19.4 Carbon Dioxide Can Ignite a Flammable Mixture
19.5 Mists Can Explode
19.6 The Source of the Problem Lay Elsewhere
Chapter 20. Problems with Computer Control
20.1 Hardware and Software Faults
20.2 Treating the Computer as a Black Box
20.3 Misjudging the Way Operators Will Respond
20.4 Other Problems
20.5 Unauthorized Interference
20.6 New Applications
20.7 Conclusions
Chapter 21. Inherently Safer Design
21.1 Bhopal
21.2 Other Examples of Inherently Safer Design
21.3 User-Friendly Design
Chapter 22. Reactions-Planned and Unplanned
22.1 Lack of Knowledge
22.2 Poor Mixing
22.3 Contamination
22.4 Reactions with Auxiliary Materials.
22.5 Poor Training or Procedures
22.6 Use-By Dates
PART B: STILL GOING WRONG
Chapter 23. Maintenance
23.1 Inadequate Preparation on a Distant Plant
23.2 Precautions Relaxed Too Soon
23.3 Failure to Isolate Results in a Fire
23.4 Unintentional Isolation
23.5 Bad Practice and Poor Detailed Design
23.6 Dismantling
23.7 Commissioning
23.8 Other Hidden Hazards
23.9 Changes in Procedure
23.10 Dead-Ends
Chapter 24. Entry into Confined Spaces
24.1 Incomplete Isolation
24.2 Hazardous Materials Introduced
24.3 Weaknesses in Protective Equipment
24.4 Poor Analysis of Atmosphere
24.5 When Does a Space Become Confined?
24.6 My First Entry and a Gasholder Explosion
24.7 Failure of a Complex Procedure
24.8 Epidemics of Unsafe Entries
Chapter 25. Changes to Processes and Plants
25.1 Changes to Processes
25.2 Changes to Plant Equipment
25.3 Gradual Changes
25.4 Changes Made Because the Reasons for Equipment or Procedures Has Been Forgotten
Chapter 26. Changes in Organization
26.1 An Incident at an Ethylene Plant
26.2 The Longford Explosion
26.3 The Texas City Explosion
26.4 Outsourcing
26.5 Multiskilling and Downsizing
26.6 How to Lose Your Reputation
26.7 Administrative Convenience versus Good Science
26.8 The Control of Managerial Modifications
26.9 Some Points a Guide Sheet Should Cover
26.10 Afterthoughts
Chapter 27. Changing Procedures Instead of Designs
27.1 Misleading Valve Layouts
27.2 Simple Redesign Overlooked
27.3 Unimaginative Thinking
27.4 Just Telling People to Follow the Rules
27.5 Don't Assemble It Incorrectly
27.6 Tighten Correctly or Remove the Need
27.7 Should Improvements to Procedures Ever Be the First Choice?
Chapter 28. Materials of Construction (Including Insulation)
28.1 Rust
28.2 Insulation.
28.3 Brittle Failure
28.4 Wrong Materials of Construction
28.5 Corrosion Sends a Column into Orbit
28.6 Unexpected Corrosion
28.7 Another Failure to Inspect Pipework
28.8 How Not to Write an Accident Report
Chapter 29. Operating Methods
29.1 The Alarm Must Be False
29.2 A Familiar Accident-But Not as Simple as It Seemed
29.3 More Reluctance to Believe the Alarm
29.4 The Limitations of Instructions
29.5 The Limitations of Instructions Again
29.6 Empty Plant That Is Out of Use
29.7 A Minor Job Forgotten-Until There Was a Leak
29.8 Design Error + Construction Error + Operating Error = Spillage
Chapter 30. Explosions
30.1 An Explosion in a Gas-Oil Tank
30.2 Another Sort of Explosion
30.3 One + One = More Than Two
30.4 "Near Enough Is Good Enough
30.5 Another Explosion Ignited by a Carbon Bed
30.6 An Explosion in an Alternative to a Carbon Bed
30.7 Only a Minor Change
30.8 An Explosion in a Pipe
30.9 A Dust Explosion in a Duct
30.10 Obvious Precautions Neglected
30.11 A Drum Explosion
30.12 Foam-Over-The Cinderella of the Oil and Chemical Industries
30.13 Explosions of Cold Gasoline in the Open Air
30.14 The Inevitability of Ignition
Chapter 31. Poor Communication
31.1 What Is Meant by Similar?
31.2 More Similar Errors
31.3 Wrong Material Delivered
31.4 Packaged Deals
31.5 "Draftsmen's Delusions
31.6 Same Plant and Product, but No Communication
31.7 A Failure at the Design/Construction Interface
31.8 Failure of Communication between Marketing and Technology
31.9 Too Much Communication
31.10 No One Told the Designers
31.11 Conclusions
Chapter 32. I Did Not Know…
32.1 … That Metals Can Burn
32.2 … That Aluminum Is Dangerous When Wet
32.3 … That Rubber and Plastics Are Permeable.
32.4 … That Some Plastics Can Absorb Process Materials and Swell.

What went wrong? case histories of process plant disasters and how they could have been avoided

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