“Safety management is not rocket science”

“Some years ago I went to a conference at

which a newly appointed director of

Safety began his presentation with the

assertion that “Safety management is not

‘rocket science’.” And he was right.

‘Rocket science’ is a trivial pursuit

compared to the management of

Safety.”

James Reason, renowned psychologist who worked for

Royal Air Force Institute of Aviation Medicine, and later at

the U.S. Naval Aerospace Medical Institute, quoted by Trevor Kletz (2003)

IChemE.org

Let me carry on with two questions:

How many of you are Safety professionals?

“If the senior managers are not interested, the problems can’t be important.“ Trevor Kletz (2001)

Targets:

� ‘make senior managers to be interested in Safety’ and...

Is there any CEO, member of the Board, General Manager, Vice-President or Site Director at the conference?

� ‘make Safety one of the things to be senior managed ’.

“Today everyone agrees that the Safety record of a company, likeits output, sales, quality and profit, depends on the ability of its directors and senior managers." Trevor Kletz (1993)

“If I were 20 years old today, and I had a desire to become Vice-President of a major corporation, I would become a Safety engineer. (…) If I were a Board Chairman on a corporation today, the first thing I would do is get someone of vice-presidential status in charge of Safety. The corporations that don’t do this are going to have an unfavourable profit and loss picture.”

Harry M. Philo (1924-2012) Prestigious American lawyer

One dose of optimism:

The American Association for Justice annually recognizes individuals who contribute to the civil justice and advance the Safety and protection of American people with the Harry M. Philo award.

“(Some) Directors and senior managers emphasise the important of Safety; they exhort their staff to do better (…) but often they do not give to Safety the same detailed attention as they give to othermanagement functions.“ Trevor Kletz (1993)

Trevor A. Kletz (1922-2013)

A Life Preventing Accidents In The IndustryA Life Preventing Accidents In The IndustryA Life Preventing Accidents In The IndustryA Life Preventing Accidents In The Industry• Trevor Asher Kletz keeps on being after his death one of the

biggest authorities on the topic of engineering Safety.

• Kletz, British, graduated in chemistry, worked almost 40 years for ICI (Imperial Chemicals Industries) mostly as Technical Safety Advisor.

• Member of the Royal Academy of Engineering, the Royal Society of Chemistry, the Institution of Chemical Engineers, and the American Institute of Chemical Engineers.

• In 1997 he was awarded the Officer of the British Empire for services to industrial safety.

• Active promoter of HAZOP, HAZAN (QRA) and inherently safer design.

• If we follow conclusions of Mr. Kletz’s experience who dedicated his life to prevent them, we will be making the best tribute to his figure and our shared aim: AVOID ACCIDENTS.

“I did not collect incident reports to illustrate or support my views on Prevention, I developed my views as the result of investigating accidents and reading accident reports.” (2001)

What is Safety all about?“Safety is the study of failures (…) We learn more from failures than from successes.”Trevor Kletz (1993)"Safety is not an intelectualexercise to keep us at work. It is a matter of life and death. It is the sum of our contributions to safety management that determines wether the people we work with, live or die." Sir Brian Appleton, Technical Assessor to the public inquiry of Piper Alpha.

167 workers killedin an offshore platform. (1988)

Learning from accidents

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• November 1997, at a Danish brewery an operator mixed up filling nozzles for two commonly used acid cleaning agents and transferred nitric acid into a tank with P3, a proprietary phosphoric acid based cleaner.

• 10-15 minutes later the mixture exploded violently.

• The stainless steel tank disintegrated with such force that fragments lodged in walls of concrete.

• The explosion ravaged the cellar, destroyed equipment, blew out a masonry wall and released large amounts of nitrous oxide fumes.

• None was injured.

• A review carried out more than 15 years later (2014) by DTU* found basic accident data corrupted and no evidence of broad learning.

DTU*-Technical University of Denmark

Past experience is one of the foundations of Safety

“I do not wish to discourage those who spend their days researching on safety. There is still much we need to know. (…) But 'How are we going to persuade people to use the new knowledge we are going to give them, when they are not using the knowledge we already have?'. ”Trevor Kletz (1993)

We look for new strategies, new approaches, new technologies, etc. to meet basically old problems. “Failure to learn from past experience is a major cause of accidents ”. “It might seem to an outsider that industrial accidents occur because we do not know how to prevent them. In fact, accidents occur because we do not use the knowledge that is available. ”Each individual learns by his experience, and this is usually enough for preventing the same accident to occur to the same person twice, but it seems more difficult for us to learn from the experience of others.

Do not ignore the accidents and look beyond rates

“(…) lost-time accidents are now so few in most companies that their rate measures luck and the willingness of injured people to continue at work. A low lost-time accident rate does not indicate that technical safety problems are under good control.” Trevor Kletz (2001)

Early societies saw history as cyclical. Although the Bible was the first book to see history as linear, we still can find some old references:‘What has happened before will happen again. What has been done before will be done again. There is nothing new in the whole world.'Ecclesiastes, 1:9 (Good News Bible)“Please do not ignore the accidents. They will happen yet again unless we take action to prevent them happening.”“Accidents do come round again every few years but no law of nature says they must do so. They will happen yet again unless we break out of the cycle and take action to prevent them happening”

BASF-Ludwigshafen-Germany - 4 workers killed and 24 injured – October 17, 2016

Bonus slide (not expounded in Antwerpen)According to a new report from the Associated Press, BASF says that the Oct. 17 explosion at the Ludwigshafen plant in Germany was likely caused by a contractor error.The world's largest chemical company says that, prior to the blast, workers were "carrying out scheduled maintenance on an empty pipeline connecting storage tanks to an area where liquids are unloaded" from the vessels on the Rhine river.According to a BASF board member, investigators found a cut in a nearby pipeline containing flammable gas . As such, BASF says the first fire was likely caused when a contractor mistakenly cut the wrong pipeline . The deadly blast occurred six minutes later possibly as a result of the first fire .

www.manufacturing.net/news

‘ACCIDENTS IN THE COMING YEAR’“The wrong pipeline will be opened . During the coming year, someone will be given a permit to break into a pipeline, or weld a branch of a pipeline, which has been prepared for maintenance. The line will be shown to him, he will go for his tools and then he will break into the wrong line. Or he will know the plant so well that he does not need to be shown the line. Or he will be marked with chalk but the chalk will be washed off by rain or he will go to the wrong chalk mark.” Trevor Kletz (1993)

Breaking news

It is not a coincidence that CSB (Chemical Safety Board) investigation report, published on October 19, 2016 , about the accident occurred June 13, 2013 at Williams Geismar Olefins Plant in Geismar, Louisiana in which 2 workers were killed and 167 were injured by the reboiler rupture and failure, begins quoting Trevor Kletz :

"We would never knowingly tolerate a situation in which accidental operation of a valve resulted in the overpressuring of a vessel . We would install a relief valve. In the same way, accidental operation of a valve should not be allowed to result in explosion (…)" Trevor Kletz (2009)

“Another cause of overpressure is a heat exchanger blocked-in onthe cold side while the flow continues on the hot side.” CCPS (2012)

How to learn from accidents?

“Wise men learn by others’ experience; fools by their own.” Trevor Kletz (1981)

• IncidentsIncidentsIncidentsIncidents that by good luck do not injure anyone should be investigated as thoroughly as those that have should be investigated as thoroughly as those that have should be investigated as thoroughly as those that have should be investigated as thoroughly as those that have caused injury. caused injury. caused injury. caused injury.

• In our culture, storiesstoriesstoriesstories can make us change our behavior much better than any standard or procedurebetter than any standard or procedurebetter than any standard or procedurebetter than any standard or procedure.

• Accident stories have much more impact than statistics, stories have much more impact than statistics, stories have much more impact than statistics, stories have much more impact than statistics, sheer figures or codessheer figures or codessheer figures or codessheer figures or codes.

• Communicate stories, with implicit or explicit advicesimplicit or explicit advicesimplicit or explicit advicesimplicit or explicit advices.

• Link the stories to codes or standardsLink the stories to codes or standardsLink the stories to codes or standardsLink the stories to codes or standards you want to promote, to facilitate understanding of their origin, and to facilitate understanding of their origin, and to facilitate understanding of their origin, and to facilitate understanding of their origin, and the reasons whythe reasons whythe reasons whythe reasons why they should be implemented.

• We usually give more value to conclusionsconclusionsconclusionsconclusions we find out by by by by our ownour ownour ownour own, rather than those already proposed by other people.

“In learning the sciences, examples are of more use than precepts.” IsaacNewton (1707)

Learning from accidents

Other details of the accident:• The P3, the phosphoric acid based cleaner,

also contained 5-15% isopropanol.• The nozzles for nitric acid and P3 were

identical. Nozzles for other (caustic) substances used in the CIP process were different.

• Ambiguous SDS information on chemical incompatibilities, emphasizing that possible reactions may produce toxic red-brown colored fumes of nitrous oxides and mixing with chlorine (hypochlorite) cleaners could liberate chlorine gas, and that reaction with certain metals could produce hydrogen, an explosive gas.

All accidents are due to ‘human error’� due to error by those who decide what to do,

� error by those who decide how to do it or manage how to do it,

� or error by those who actually do it.

• What does a report usually mean when says that an accident was due to ‘human errorhuman errorhuman errorhuman error’?

• What is an ‘equipment failureequipment failureequipment failureequipment failure’?

• Are the concept ‘organizational errororganizational errororganizational errororganizational error’ a kind of euphemism?

TERM SUBJECT OF ERROR CONCLUSION

Human error Operator or maintenance worker Human error

Equipment failure Designers or those who operate, install or maintain the equipment

Human error

Organizational error

Managers Human error

� ‘Human error’ should not be listed as a cause in the accident reports.

“Managers and designers, it seems, are not human or do not fail.”Trevor Kletz(2001)

“(..) the failing of (senior) managers – like those of other people – might be due to incompetence rather than wickedness (..) Managers are not supermen; they are like the rest of us.”Trevor Kletz(1993)

The man in the middle

“Human error’ is one of those phrases that discourage critical thought, and seems to imply we can do nothing or little more than tell people to take more care”. Trevor Kletz (2001)

• Saying an accident is due to ‘human failing’ ‘human failing’ ‘human failing’ ‘human failing’ is like saying

falls from height and accidents caused by falling objects are

due to earth gravityearth gravityearth gravityearth gravity, true but it does not lead to constructive

action.

• These are some of the reasons why people may fail:

o Lack of training or instructions

o Lack of physical or mental ability

o Lack of motivation

• Let us suppose that we have eliminated all these causes of

failure. Will we always do it? NONONONO.

• Telling people to take more care will not prevent an accidentto take more care will not prevent an accidentto take more care will not prevent an accidentto take more care will not prevent an accident

happening again.

Types of ‘human error’

“Today we still do blame “human failing” and use that as an excuse for taking no action to improve our hardware, instructions, operating methods and so on.” Trevor Kletz (1969)

1.1.1.1.MistakesMistakesMistakesMistakes: : : : Person does not know what to do, how to do it or thinks he knows but he does not. Intention fulfilled but intention is wrong.

2.2.2.2.MismatchesMismatchesMismatchesMismatches: : : : The task is beyond the physical or mental ability of the person asked to perform it (or anyone’s). Impossible tasks, Over/under-load, Habit breaking, Mind-sets.

3.3.3.3.Violations or nonViolations or nonViolations or nonViolations or non----compliancescompliancescompliancescompliances: : : : Person does not want to carry out a task or not to carry out in the way instructed or expected – Poor motivation – Deliberate decision not to follow instructions or practices.

4.4.4.4.Slips or lapses of attentionSlips or lapses of attentionSlips or lapses of attentionSlips or lapses of attention: : : : Intention correct but wrong action or no action is taken – ¡InevitableInevitableInevitableInevitable! – We know what we should do, want to do it, and are physically and mentally capable of doing it, but we forget or we fail to do it. Even well-trained and well-motivated people make from time to time.

What to do about ‘human error’?

“We cannot change the human condition but we can change the conditions in which humans work.”James Reason (2000)

• Well-trained, well-motivated people, physically and mentally capable, make occasional failures .

• Telling them to be more careful will not prevent their failure.

• In a normal day’s work there are a lot of opportunities for error .

• To take reasoned decisions, we should estimate the likely error rate asking “How often will an average man do what we expect him to do?” and then either o Modify the work situation , that is, change the design of

the plant or the method of working, oro Accept the occasional mistake .

• If their consequences are serious or we cannot accept an occasional accident; we have to redesign the work situation.

Estimating ‘human error’

“Better management will have little effect on slips and lapses of attention, which are due to innate weaknesses in human nature. To prevent them, or make them less likely, we have to remove or reduce opportunities for human error, a task for designers as well as managers.”Trevor Kletz (1999)

• The failure to close a valve in the required time may be due mistakes, violations, mismatches or (and this is the more likely reason) to a momentary slip or lapse of attention.

• It is difficult to estimate the probability of the first three causes.

• But the probability of a slip or lapse of attention can be estimated roughly . The answer will depend on the degree of stress and distraction .

• Assumed that the operators are well trained, capable and willing.

No more missed opportunities

“Accident investigations reports afford to prevent a lot of damages. They are the best bargain you will ever have.” Trevor Kletz (1982)“Like waves in a pond, the effects of an accident decrease with distance.” Trevor Kletz (1993)

• Having paid the price of an accident, minor or serious, we should use the opportunity to learn from it.

• Usually when we check details of an accident, we realize the same accident or another similar one has happened in the past . That means accidents are not caused by lack of knowledge, but a failure to use the available knowledge .

• Failures should be seen as educational experiences and the best chances for improvement .

• Much more transparency should be promoted by Authorities in order we know details about accidents, they could be used to avoid recurrence of similar events. Potential benefits of sharing that information are clearly more important from a social point of view than legal right to protection of affected people and their data.

Things to improve

“(…) there is something seriously wrong about accident investigations, safety training and the availability of information.” Trevor Kletz (1982)

• Accident investigations with a single cause .• Accident investigations often superficial . • Human error as a cause .• Accident reports look for people to blame .• Reports with causes difficult or impossible to

remove .• Changing procedures rather than designs.• We do not let others learn of our experience .• We receive only overviews .• We forget lesson learnt and allow the accident to

happen again.• Sometimes we may go too far.

Learning from accidents

More details of the accident:• A specifically contracted laboratory revealed that:

62% nitric acid and isopropanol (2-propanol), reacted to produce isopropyl nitrate (nitric acid 1-methylethyl ester), an explosive used as rocket propellant .

• In the most recent edition (KS, 2010) the SDS for nitric acid only mentions spontaneous ignition and liberation of nitrous fumes in case of accidental mixing, not the formation of a potent explosive .

• P3 SDS dated in 2005 and 2006 with a product composition similar to the Danish 1994 DS have been found, so it seems that an unmodified product was sold at least in Sweden and Czech R. nine years after the Danish accident .

Had already occurred a similar accident in the past?

• Yes, and even with more dramatic consequences

• (1 fatality and 1 injured ).

• In 1984, in Phoenix, AZ, USA, minimum amounts of both chemicals inside a glass bottle make it to burst and some glass pieces cut the carotid artery of a worker, killing him.

• But there were more cases.

“No esoteric knowledge or detail study was required to prevent the most of incidents – only a knowledge of what had happened before.” Trevor Kletz (1998)

But there are more radical cases…

Train cabin pierced by a trunk of a tree• The trunk was in the track due to strong storms in the area during the night before. • Some Safety professionals in Spain tried to use case #1 for defending some

accidents cannot be prevented, and in which there is almost nothing we can do. • Others we disagree, putting on the table the public investigation report about the

accident in UK more than 4 years before.• Is there anything we can do or not? Of course, we can learn from past experience .

“Unfortunately, people forget the lessons of the past and allow the same failures to happen again (…) most of which could have been prevented if people were more aware of past experience.” Trevor Kletz(2008)

that keep on occurring anywhere…

“We must learn from the experience of others rather than learn the hard way.” Jesse C. Ducommun, Vice-President of Manufacturing Amoco, quoted by Trevor Kletz (1993)

“Those interested in industrial safety will find that the study of railway accidents is an enjoyable way of increasing their knowledge of accident prevention” Trevor Kletz (2001)

If we talk about railway accidents…One of the immediate causes(today still the only causefor the Court): Lack of attention by the driver while he answering a phone call from a supervisor

Santiago de Compostela (Spain) - 81 people killed and 144 injured – July 24, 2013

“In the early days of railways and today as well, there are methods of working which places too much reliance on people. It is inevitable in the end that somebody will forget to do something he must do a lot of times and in the same way when he must do something very important but just in one precise moment.” Trevor Kletz (1993)

“A railway accident shows very clearly how concentration on the immediate cause of an accident and blaming the person involved can distract attention from the underlying causes and the responsibilities of senior managers.” Trevor Kletz(1993)

In 1990, the British Railway Inspectorate set about an accident in which 5 people were killed and 88 injured due to a train driver passed a caution signal without slowing down, that "The responsibility for the accident lies with those who failed to provide the equipment which could have prevented it, not with the man at the bottom of the pile...” Trevor Kletz (1993)

Two accidents, two stories…

April 2005 (5 workers killed and 14 injured). ‘FLOURS’ PORTA, in Huesca, Aragón (Spain).Flour factory explosion.

February 2008 (14 workers killed and 36 injured). IMPERIAL SUGAR, in Port Wenworth, Georgia (USA).Sugar factory explosion.

“No plant is an Island, entire of itself; every plant is a piece of the Continent, a part of the main. Any plant's loss diminishes us, because we are involved in the Industry…”. John Donne quoted by Trevor Kletz (2001) .

Some more data about the accidents

• No electronic way to find any official investigation report about the accident.

• Conclusions of investigations are not disseminated.

• Only one court sentences (civil proc.) is available.

• 3 different versions.• 3 different group of causes (1 per version).

• Investigation carried out by Chemical Safety Board (CSB), a federal independent agency.

• The US CSB determined that the first dust explosion initiated in the enclosed steel belt conveyor located below the sugar silos, implemented due to ‘food safety’ reasons.

• The explosion lofted sugar dust that had accumulated on the floors and elevated horizontal surfaces, propagating more dust explosions through the buildings.

Both accidents in the media

“(…) the processof prosecution and punishment by the criminal courts is largely an irrelevancy.The real need is for a constructive means of ensuring that practicalimprovements are made and preventative measures adopted.” Safety and Health at Work: Report of the Committee 1970-1972 (The Robens Report), 1972, UK.

We do not let others learn from our experience

“It makes good sense to share the lessons learned from unwanted outcomes in order to minimize the number of times the same lessons have to be ‘learned’” Hedlund and Andersen, (2006); Danish risk experts.

• Many companies (and Authorities) restrict the circulation of incident reports.

• However, this will not prevent the incident from happening again.

• We should circulate the essential messages widely, in the company and elsewhere, so that others can learn from them, for several reasons as follows:o Moral.o Pragmatic.o Economic.o The industry is one .

• When information is published, people do not always learn from it. A belief that our problems are different is a common failure.

What to do?

“Lightning and other so-called Acts of God cannot be avoided but we know they will occur and blaming them is about as helpful as blaming daylight or darkness.”Trevor Kletz (2001)

• Encouragement from the top (primary importance).• A blame-free atmosphere is a previous condition.• Thinking in fate, blaming weather or behaving as

accidents were ‘Acts of God ’ is absolutely useless.• Disseminate all the details and learnings internally .• Sharing information with other similar companies, we are

pushing us each other to be the ‘best in category’.• We share reputation of the industry.• Our problems are not different from the rest of the world’s.• Find your way : Publish near misses reports, use

anonymity, publish at least details of the actions taken as a result of the accident. Better a few than nothing .

Do we actually learn from accidents?• CSB (Chemical Safety Board) report Ammonium

Nitrate explosion on April 17, 2013 in West, Texas (USA). 15 people killed, more than 250 injured and a vast devastation in the area.

• Explosion caused by between 40 and 60 tonnes of AN (Fertilizer grade – FGAN).

• Members of the public killed at apartments placed at aprox. 140 m from the blast .

• Have Public Authorities in Europe taken appropriate note and adapted regulations in order to prevent similar situations happen again?

• Checking current European (Spanish) regulations we realize that authorized quantities are higher (1350 ton) than limits in US and applicable safety distances to housing (100 m if stored quantities are less than 200 ton ) are quite lower than those that reality has shown as safe distances.

Learning from accidentsGoing back to Denmark

“What was a mistake in the case of the Titanic would without doubt be negligence in any similar case in the future.” Official report on the sinking of Titanic, quoted by Trevor Kletz (1975)

Some lessons learned• The dominant perception at the time was that the brewery gave

insufficient managerial attention to workplace safety and health issues.

• Investigations carried out by Authorities after an occupational accident should not follow a standard police crime scene procedure, but a Health & Safety at Work accident investigation procedure , paying attention to process safety issues, and to basic causes and underlying systemic deficiencies (root causes).

• Detected some barriers to reporting, investigation and dissemination of information about the accident, which makes difficult a broad spreading of lessons learned. There is no evidence of investigation, dissemination, broader learning, or organizational memory by Authorities.

• Only site specific learning took place, opportunities for broader learning were wholly missed .

We forget lessons learned“Companies and industries need a conscious systematic approach to make sure that they learn from experience and do not forget what they have learned.” Trevor Kletz (1968)

“Memory, of all the powers of mind, is the most delicate and frail' Ben Johnson (1572 –1637) English playwright, poet, actor, and literary critic.

• Even when we make a good report and circulate it widely, too often it is read, filed, AND FORGOTTEN.

• Procedures introduced after an accident are allowed to lapse , and some years later the accident happens again, even on the plant where it happened before. If by good fortune the results of an accident are not serious, the lessons are forgotten even more quickly.

• Once we forget the origins of our practices, they become cut flowers ; severed from their roots they wither and die.

• We remember stories about accidents far better than we remember disconnected advice. Whatever the subject, we build generalities from individual cases ; otherwise they have no foundations.

• Re-search is perhaps so-called because it so often re-discoversforgotten knowledge.

"Most discoveries are made regularly every fifteen years” George Bernard Shaw (1906), Irish writer, Nobel prize in Literatur e"One reason why history rarely repeats itself among historically conscious people is that the dramatis personae are aware at the second performance of the denouement of the first, and their action is affected by that knowledge.” E.H. Carr (1892 - 1892), English historian, diplomat and journalist.

Some actions can prevent the same accidents from recurring so often:

“Disasters… happen when the decisions are made by people who cannot remember what happened last time” City comment, Daily Telegraph 1990 quoted by T. Kletz

• Notes on the reasons for instructions, codes, and standards.

• Never remove equipment or abandon a procedure before knowing their origin .

• Describe all accidents, yours and others’, in safety bulletins and at meetings.

• Are recommendations made after accidents being followed ?

• The first step to an accident is when someone turns a blind eye .

• Sometimes we gradually accept a lower standard of performance until the lower standard becomes the norm .

• Include important accidents of the past in the training of employees.

• Keep a folder of old accident reports (memory book or black book ). Compulsory reading for recruits and others from time to time.

• Read books, magazines, newspapers, and internet to know the past and news .

• Experienced people should write down their know-how, especially the information rest of employees are not aware of.

• Devise better retrieval systems so that we can find details of past accidents, and the recommendations made afterward.

Learning from accidentsGoing back to Denmark again

“’Every dog is allowed one bite’. Until it has bitten somebody we could plead that we did not know it was liable to bite. As far as industry is concerned, we are expected to muzzle our dog if a similar dog has bitten someone.” Trevor Kletz (1975)

Countermeasures implemented o TBI• Isopropanol is no longer an ingredient in the vendor’s

cleaner. Isopropanol was acting as a solvent and stabilizer and this functionality could be achieved using other additives.

• Store the two chemicals in a separate building .• The receiving nozzles to the tanks must be of different

dimensions.• Deliveries by two different vendors .• Access to a nozzle should require two keys of which the truck

driver must bring only one.• SDS should include all hazards revealed by real accidents.• Broad dissemination of lessons learned from this accident,

that mixing of two common industrial chemicals can produce a potent explosive with multiple fatalities potential.

• Demand the necessary institutional support to reinforce accidents investigation dissemination in order to make easier the learning of appropriate lessons.

Breaking cultural and psychological blocks & barriers

“The recipe for perpetual ignorance is: Be satisfied with your opinions and content with your beliefs.” Elbert Hubbard (1859 – 1915) North American writer, editor, artist and philosopher.

• Accept everybody fails . • Treat failures as learning experiences.• Try to change old beliefs and ways of thinking.• Old is not synonymous of obsolete.• Failures of engineering provide the seeds for its

future development if failures are disseminated.

• Past experience is the foundation of learning in Safety.

• Promote changing environments and open-minded people , ready to progress and who believe everything can be improved.

Conclusions

“Humans simply rely on our belief that if there is no previous case of loss of life due to incidents of this nature, nothing we must do”“… men often wait for the inevitable tragedy, before deciding that it may possibly occur”Report on disaster at Aberfan quoted by Trevor Kletz(1968 & 1969).

• Senior managers should be trained in Health and Saf ety issues.• The information contained on accidents reports is extre mely

important to prevent similar situations.• Details about accidents and learning obtained as consequence of its

investigation should be broad disseminated . • Safety professionals should demand better retrieval systems of Authorities in order

to make easier our difficult task. Past experience is one of the foundations of safety.• All accidents are due to ‘human error’ . It should never be listed as a cause .• Telling people to take more care will not prevent a n accident happening again.• If we accept everybody fails, accidents should be viewed as learning experiences .• We should estimate the likely human error rate and then either modify the work

situation, or accept the occasional mistake .• Information about past accidents allows for preventing accidents, so we should never

protect more the data (confidentiality) than the people .• Safety documentation must be always reliable and should reflect all known hazards

and be compulsorily updated when new ones are revealed by accidents.• We should use accidents as training key resources . They will have much more

impact than rules, sheer figures or statistics.. If we cannot remember the advice, perhaps we will remember what happened to people wh o failed to follow the advice. The aim is to prevent accidents.

A very small tribute for a huge legacy

This presentation just collect, put together and take advantage of a few pieces of the great work done by one of the best Safety professionals ever.

So it is just a very small tribute, more

than deserved, for a huge legacy, the Trevor Kletz’s legacy.

Thanks always Mr. Kletz.

Thank you very much for your attention!

“It should not be necessary for each generation to rediscover principles of safety which the generation before discovered. We must learn from the experience of others rather than learn the hard way. We must pass on to the next generation a record of what we have learned.” Amoco booklets quoted by Trevor Kletz(1968)

“Today is the past of the future. We and our successors can learn from today'saccidents only if we investigate them, reportthem widely and make sure that theirlearnings are not lost.” Trevor Kletz (1993)

References• Hedlund, Frank Huess; Nielsen, Merete Folmer; Hagen Mikkelsen, Sonja; K.

Kragh, Eva (risk experts working for COWI, a leading consulting group in Denmark, the Technical University of Denmark (DTU) and the Danish Emergency Management Agency (CBRN Institute)), Dec. 2014, Report ‘Violent explosion after inadvertent mixing of nitric acid and isopropanol – review 15 years later finds basic accident data corrupted, no evidence of broad learning’, Safety Science, Elsevier Scientific Publishing Company, Amsterdam, The Nederlands.

• Hedlund, Frank Huess; Andersen, Henning B., 2006, ‘Institutional Support of Learning from Accidents: Some Obstacles to Getting a Useful Community-wide Database in the EU’. Technical University of Denmark [Orbit.dtu.dk], Denmark. Paper presented at Conference Society of Risk Analysis, Ljubljana, Slovenia.

• Kletz, Trevor A., 2001, ‘Learning from accidents’, Routledge, New York, USA, 3rd Ed. • Kletz, Trevor A., 1988, ‘What went wrong? – Case Histories of process Plant Disasters’, Gulf,

Houston, Texas, USA, 2nd Ed.• Kletz, Trevor A., 1991, ‘An Engineer’s View of Human Error’, Institution of Chemical Engineers,

London, UK, 2nd Ed.• Kletz, Trevor A., 2003, ‘Still Going Wrong! Case Histories of Process Plant Disasters and How

They Could Have Been Avoided’, Gulf Professional Publishing, Burlington, Massachusetts, 1st Ed.

• Kletz, Trevor A., 1993, ‘Lessons From Disaster. How Organizations Have No Memory And Accidents Recur’, Institution of Chemical Engineers, Davis Building 165-171 Railway Terrace, Rugby, Warwickshire CV21 3HQ, UK, 1st Ed.

• Kletz, Trevor A., 1990, ‘Critical aspects of safety and loss prevention’, Butterworths, Sevenoaks, Kent, UK, 1st Ed.

• CSB investigations mentioned.• OSHA webpage.• Media articles.