A Tribute to Trevor Kletz Inherent Safety an

A Tribute to Trevor Kletz - Inherent Safety an Lessons from Disaster OPERA, Annual General Meeting January 2014 John Munnings-Tomes & John Evans

Trevor Kletz, OBE : 1922 -2013 • BORN IN DARLINGTON 1922 • GRADUATED IN CHEMISTRY 1944 • ICI Ø 8 years research Ø 16 years production management Ø 14 years safety advisor • FROM 1978 INDUSTRIAL PROFESSOR AT LOUGHBOROUGH UNIVERSITY, FULL-TIME FROM 1982 • PUBLISHED 14 BOOKS AS SOLE AUTHOR AND OVER 100 PAPERS ON LOSS PREVENTION & PROCESS SAFETY • RETIRED AGE 90 IN 2012 • DIED 31 OCT. 2013 One of the most famous chemical engineers, who was not a chemical engineer 2

A Tribute to Trevor Kletz Trevor the Man Born: Darlington Trevor was, like so many School: Chester of Britain’s best engineers, from the North Uni: LIverpool Retired to : Cheadle Hulme Professor: Loughborough Trevor was, like so many of Britain’s Northerners, North / South Divide remembered with fondness and deep gratitude 3

Trevor Kletz – A Tribute Trevor at Loughborough • IT WAS VERY DIFFICULT TO GET HIM TO BILL LOUGHBOROUGH UNI FOR HIS TRAVEL FROM CHEADLE HULME TO LOUGHBOROUGH; • EVERYONE CALLED HIM “PROFESSOR” THOUGH HIS TITLE WAS SIMPLY “DOCTOR” SO HIS COLLEAGUES LOBBIED LOUGHBOROUGH TO HAVE HIM GIVEN THE TITLE OF “HONORARY PROFESSOR”; • HE THOUGHT OF HIS WORK SIMPLY SOMETHING HE SHOULD DO TO SAVE LIVES, LITERALLY A MAN WITH A MISSION TO MAKE THE WORLD A SAFER PLACE. THAT SEEMS TO HAVE BEEN ALL HE CARED ABOUT; • THE COLLEAGUES TO WHOM I SPOKE WERE AT THE BEGINNING OF THEIR CAREERS WHEN THEY FIRST MET HIM. THERE IS NOW A COHORT OF PROFESSIONALS WHO HAVE BEEN DIRECTED MENTORED BY HIM AND WHO HAVE CHALLENGED AND DEVELOPED HIS IDEAS. 4

Trevor Kletz: A Tribute Trevor and the bad old days - 1 • TREVOR STARTED WORK 12 YEARS BEFORE THE CLEAN AIR ACT; • 30 YEARS BEFORE THE HEALTH AND SAFETY AT WORK ACT; • 25 YEARS BEFORE THE FIRST ASBESTOS REGULATIONS; • 17 YEARS BEFORE THALIDOMIDE; • 30 YEARS BEFORE SEAT BELTS; • 6 YEARS BEFORE THE BMJ ARTICLE ON SMOKING AND CANCER. • SAFETY, IF IT MEANT ANYTHING, MEANT FIRE WATER AND FIRE WALLS. • TREVOR RETIRED FROM ICI IN 1982, AFTER 38 YEARS. 5

Trevor Kletz: A Tribute Trevor and the bad old days - 2 • TREVOR STARTED AT LOUGHBOROUGH 6 YEARS BEFORE BHOPAL, MEXICO CITY & CUBATAO; • 8 YEARS BEFORE CHALLENGER AND CHERNOBYL; • 10 YEARS BEFORE PIPER ALPHA; • 27 YEARS BEFORE TEXAS CITY. • TREVOR RETIRED FROM LOUGHBOROUGH IN 2012, AGED 90, AFTER 34 YEARS. 6

Trevor Kletz: A Tribute Trevor: Scientist or Engineer? WAS TREVOR MORE A SCIENTIST THAN AN ENGINEER? • HE WAS A CHEMIST BY TRAINING, NOT A CHEMICAL ENGINEER; • HE THOUGHT ABOUT THINGS FROM FIRST PRINCIPLES; • HE WAS A SYSTEMS THINKER; • HE BELIEVED THAT NATURE CANNOT BE FOOLED; • HE MADE PREDICTIONS; • HE LEFT SOME IDEAS UNFINISHED. PS: TO ENGINEERS IN THE AUDIENCE, THESE ARE GOOD THINGS. . . 7

Trevor Kletz: A Tribute Trevor’s Finished Work • HE WAS PART OF THE TEAM WHO BROUGHT THE WORLD HAZOP; • HE DEVELOPED THE IDEAS AROUND INHERENT SAFETY; • HE WROTE ONE OF THE FIRST PAPERS OUTLINING THE METHODS THAT WOULD EVENTUALLY BE CALL SIL ASSESSMENT (FOR HIGH INTEGRITY PRESSURE PROTECTION SYSTEMS); • HIS CAREER OF 68 YEARS IN PROCESS AND PROCESS SAFETY IS PROBABLY THE LONGEST CAREER OF ANY ENGINEER AND MORE REMARKABLE BECAUSE OF THE LEVEL OF CONTRIBUTION THAT HE MAINTAINED. • HE WAS, ABOVE ALL, A COMMUNICATOR. 8

Trevor Kletz: A Tribute Trevor’s Unfinished Work (so far identified) • HE WAS UNABLE TO LINK PROCESS SAFETY IDEAS AND AUTOMATIC METHODS FOR HAZARD RECOGNITION; • HE IDENTIFIED THAT CORPORATIONS WILL CONTINUE TO HAVE THE SAME ACCIDENTS, “ORGANISATIONS ALWAYS FORGET”, THOUGH HE INVESTED MUCH TIME IN COMPUTER SCIENCE DEVELOPING WAYS FOR ORGANISATIONS TO REMEMBER; • ONE OF HIS LAST TOPICS WAS THAT SOME ENGINEERS HAVE DEVELOPED A MACHO ATTITUDE TO GETTING THE JOB DONE, AT THE EXPENSE OF SAFETY. • IN THE LAST TWO AREAS HE IS UNCANNILY ACCURATE. AS EVER, HIS WORK IS BASED ON OBSERVATION. ONE WONDERS HOW HE COULD HAVE BEEN IN TUNE WITH INDUSTRY FOR THE LATTER ASSERTION, AS HE WAS 89 AND HAD SUFFERED A STROKE. 9

Trevor Kletz - Quotations …what you don’t have cannot leak …FOR A LONG TIME PEOPLE WHERE SAYING MOST ACCIDENTS WERE DUE TO HUMAN ERROR AND THIS IS TRUE IN A SENSE BUT IT’S NOT VERY HELPFUL. IT’S A BIT LIKE SAYING THAT FALLS ARE DUE TO GRAVITY… …organisations have no memory… …if you think safety is expensive, try an accident… 10

An Atlas of Safety Thinking 11

Inherent Safety 12

Incidents of the coming year • A TANK WILL BE SUCKED IN • A TRIP WILL FAIL TO OPERATE • A ROAD TANKER WILL BE OVERFILLED • A MAN WILL BE INJURED WHILE DISCONNECTING A HOSE • A ROAD OR RAIL TANKER WILL BE MOVED BEFORE THE HOSE HAS BEEN DISCONNECTED • THE WRONG PIPELINE WILL BE OPENED • A HEAVY OIL TANK WILL FOAM OVER • A PIPE WILL BE DAMAGED BY WATER HAMMER • EQUIPMENT WILL BE OPENED THAT HAS NOT BEEN ADEQUATELY ISOLATED • A MODIFICATION WILL HAVE UNFORESEEN RESULTS • CONFINED SPACE ENTRY FATALITY 13

Improving the corporate memory • SPREAD THE MESSAGE, BUT AN EMAIL BULLETIN IS NOT ENOUGH • DISCUSS, NOT LECTURE – MORE IS REMEMBERED • IN INSTRUCTIONS, CODES AND STANDARDS MAKE A NOTE OF WHY • REVISIT OLD INCIDENTS – GIVING A MESSAGE ONCE IS NOT ENOUGH • FOLLOW-UP ON RECOMMENDATIONS – HAVE THEY BEEN COMPLETED, ARE THEY EFFECTIVE AND ARE THEY REMEMBERED – SEE ABOVE • Foster a culture of “see it, own it” • Delete only when you understand why it was there in the first place – equipment, trip, procedure etc. • Ensure retrieval of loss and lessons learned information is easy and readily available • Ensure lessons learned training is part of formal education, training programmes, role inductions 14

http: //psc. tamu. edu/library/trevors-corner 15

Trevor Kletz: A Tribute Macho Engineering – Trevor’s last theorem 16

Thank You