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Journal of Loss Prevention in the Process Industries 15 (2002) 159–162 www.elsevier.com/locate/jlp Book Reviews An engineer’s view of human error, 3rd edition T. Kletz; Institution of Chemical Engineers, 165-189 Railway Terrace, Rugby CV21 3HQ, England, UK, 2001, pp. 281, Price £45.00 Many accidents in the chemical process industries (CPI) occur due to human error, which can occur in many ways. This latest edition is an expanded revision of the previous two editions, and contains more examples of accidents caused by the various types of human error, and has extended chapters on errors made by managers and designers, an expanded chapter on error in computer-controlled plants, and a new appendix on “Some myths of human error.” The author’s purpose for writing this book was that he felt that much of the existing literature was too theoretical for the audi ence that he had in mind, or devoted to particular aspects of the problem. He felt that there was a need for a book which would suggest to engineers how they might approach the problem of human error and do so by describing accidents which at first sight might seem to be the result of human error. He uses a pragmatic approach, rather than theoretical, to suggest new ways of looking at accident prevention. The book contains fifteen chapters, a postscript, three appendixes, a list of additional references for further reading, and a good subject index. Chapter 1 is a short introduction to human error and the material discussed in the book. In chapter 2 the author describes errors due to simple slips or momentary lapses of attention, e.g., the intention is correct, but the wrong action is taken or no action is taken. Errors due to poor training or instruc- tion are discussed in Chapter 3. Chapter 4 reviews errors which occur because a task is beyond the physical or mental ability of the person asked to do it. Accidents due to failures to follow instructions (violations or non- compliance) are discussed in Chapter 5. In Chapter 6 errors are described that are made by managers, especially senior managers, because they do not realize that they could do more to prevent accidents. In Chapter 7 Dr. Kletz describes some of the attempts that have been made to quantify the probability of human error. An important section of this chapter, in my opi- nion, is his discussion of some pitfalls in using data on human reliability. Chapters 8 to 12 review some acci- dents due to human failing, classified as follows: acci- dents that could be prevented by better design, accidents that could be prevented by better construction, accidents that could be prevented by better maintenance, accidents that could be prevented by better methods of operation, and accidents in computer-controlled plants. These five chapters present some very common and interesting accidents and suggest some applicable methods of acci- dent prevention. In Chapter 13, the author looks at legal views and at the question of personal and managerial responsibility. Chapter 14 is a series of cartoons entitled “The Adventures of Joe Soap and John Doe” which depict various accidents caused by human error. These cartoons appeared over a number of years on an ICI page-a-month calendar. The last chapter contains some final thoughts of the author on human error. The three appendixes discuss (1) influences on morale, (2) some myths of human error, and (3) some thoughts on sonata form (the themes presented in this book can be likened to the structure of a sonata). I found this book to be very informative and a joy to read. Dr. Kletz prefaces each chapter with quotes from various sources (many from non-technical articles and books) that are relevant to the topic covered in that chap- ter. This lends an air of erudition that is not found in most other technical books. There are many references at the end of each chapter for additional follow-up read- ing. I believe that this book will be a valuable addition to the technical library of all process safety and loss pre- vention engineers, and highly recommend it. It will serve as a excellent guide for process hazard reviews. Stanley S. Grossel Process Safety and Design, Inc., 41 Sussex Road, Clifton, NJ 07012-2017, USA E-mail address: [email protected] Tel.: +1 973 779 8579; fax: +1 973 779 8579. PII:S0950-4230(01)00030-4 Electrical installations in hazardous areas (1998) A. McMillan; Butterworth-Heinemann, Oxford, UK and Woburn, MA, USA, pp. 649, £75.00 The proper classification of hazardous areas for the installation of electrical equipment is critical to avoid the possibility of fires and explosions from occurring. In the United States, classification criteria are given in Article

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Journal of Loss Prevention in the Process Industries 15 (2002) 159–162www.elsevier.com/locate/jlp

Book Reviews

An engineer’s view of human error, 3rd editionT. Kletz; Institution of Chemical Engineers, 165-189Railway Terrace, Rugby CV21 3HQ, England, UK,2001, pp. 281, Price £45.00

Many accidents in the chemical process industries(CPI) occur due to human error, which can occur inmany ways. This latest edition is an expanded revisionof the previous two editions, and contains moreexamples of accidents caused by the various types ofhuman error, and has extended chapters on errors madeby managers and designers, an expanded chapter onerror in computer-controlled plants, and a new appendixon “Some myths of human error.” The author’s purposefor writing this book was that he felt that much of theexisting literature was too theoretical for the audi encethat he had in mind, or devoted to particular aspects ofthe problem. He felt that there was a need for a bookwhich would suggest to engineers how they mightapproach the problem of human error and do so bydescribing accidents which at first sight might seem tobe the result of human error. He uses a pragmaticapproach, rather than theoretical, to suggest new waysof looking at accident prevention.

The book contains fifteen chapters, a postscript, threeappendixes, a list of additional references for furtherreading, and a good subject index. Chapter 1 is a shortintroduction to human error and the material discussedin the book. In chapter 2 the author describes errors dueto simple slips or momentary lapses of attention, e.g.,the intention is correct, but the wrong action is taken orno action is taken. Errors due to poor training or instruc-tion are discussed in Chapter 3. Chapter 4 reviews errorswhich occur because a task is beyond the physical ormental ability of the person asked to do it. Accidentsdue to failures to follow instructions (violations or non-compliance) are discussed in Chapter 5.

In Chapter 6 errors are described that are made bymanagers, especially senior managers, because they donot realize that they could do more to prevent accidents.In Chapter 7 Dr. Kletz describes some of the attemptsthat have been made to quantify the probability of humanerror. An important section of this chapter, in my opi-nion, is his discussion of some pitfalls in using data onhuman reliability. Chapters 8 to 12 review some acci-dents due to human failing, classified as follows: acci-dents that could be prevented by better design, accidentsthat could be prevented by better construction, accidents

that could be prevented by better maintenance, accidentsthat could be prevented by better methods of operation,and accidents in computer-controlled plants. These fivechapters present some very common and interestingaccidents and suggest some applicable methods of acci-dent prevention. In Chapter 13, the author looks at legalviews and at the question of personal and managerialresponsibility. Chapter 14 is a series of cartoons entitled“The Adventures of Joe Soap and John Doe” whichdepict various accidents caused by human error. Thesecartoons appeared over a number of years on an ICIpage-a-month calendar. The last chapter contains somefinal thoughts of the author on human error. The threeappendixes discuss (1) influences on morale, (2) somemyths of human error, and (3) some thoughts on sonataform (the themes presented in this book can be likenedto the structure of a sonata).

I found this book to be very informative and a joy toread. Dr. Kletz prefaces each chapter with quotes fromvarious sources (many from non-technical articles andbooks) that are relevant to the topic covered in that chap-ter. This lends an air of erudition that is not found inmost other technical books. There are many referencesat the end of each chapter for additional follow-up read-ing. I believe that this book will be a valuable additionto the technical library of all process safety and loss pre-vention engineers, and highly recommend it. It will serveas a excellent guide for process hazard reviews.

Stanley S. GrosselProcess Safety and Design, Inc., 41 Sussex Road,

Clifton, NJ 07012-2017, USAE-mail address: [email protected]

Tel.: +1 973 779 8579; fax:+1 973 779 8579.

PII: S0950 -4230(01 )00030-4

Electrical installations in hazardous areas (1998)A. McMillan; Butterworth-Heinemann, Oxford, UK andWoburn, MA, USA, pp. 649, £75.00

The proper classification of hazardous areas for theinstallation of electrical equipment is critical to avoid thepossibility of fires and explosions from occurring. In theUnited States, classification criteria are given in Article

160 Book Reviews / Journal of Loss Prevention in the Process Industries 15 (2002) 159–162

500 of the National Electrical Code (NEC), (the Class,Group, Division system). In the United Kingdom andmost of Europe, the classification is done according tocriteria established by the International ElectrotechnicalCommission (IEC) (the Class, Group, and Zone system).Article 500 of the NEC allows the use of the IEC classi-fication system as well now.

This very comprehensive book deals only with theIEC classification system and discusses many aspects ofthis technology in a thorough manner. The book has 22chapters, a glossary, and a good subject index.

Chapter 1 is an introduction to the book and coversexamples of historic accidents, technological approach,history of development, relevant UK and European legis-lation, certification (including a list of the 17 approvedorganizations for certification), and required certificateand labeling information. In Chapter 2 the author dis-cusses the principles upon which area classification isbased, the part played in area classification by thoseinvolved in design or operation of plants, locationswhere explosive atmospheres may be present, and theprocedures which need to be followed in the identifi-cation of hazardous areas. Area classification practice forgases, vapors, and mists in freely ventilated situationsare presented in Chapter 3. The topics covered are: con-tainment of flammable materials, generalized method ofarea classification, the source of hazard method of areaclassification (types of releases from pipe joints andmoving seals, and typical extents of a Zone 2 release),and other practical well-ventilated situations (releasesfrom tanks and other process sources). Chapter 4 is agood presentation of methods of calculation of releaserates and the extents of hazardous areas. The scenariosinclude: releases of gases and vapors, release of liquidbelow its atmospheric boiling point, release of liquidabove its atmospheric boiling point, a summary of theuse of the equations presented, and releases in areaswhich are not well ventilated.

Area classification practices for gases, vapors, andmists in areas which are not freely ventilated arereviewed in Chapter 5. The subjects discussed include:typical areas of restricted ventilation; effects of walls onhazardous areas; roofs without walls or associated withone, two, or three walls (e.g., canopies, loading andunloading dock areas); rooms above ground; roomsbelow ground; rooms without any internal release, butwhich abut external hazardous areas; particular circum-stances (paint spray booth and drying oven). In Chapter6, the author discusses area classification practice fordusts, covering hazardous poperties of dusts, area classi-fication for dust releases, and practical situations(cyclones and bag filters, loading hoppers within andoutside buildings). A thorough discussion of the designphilosophy for electrical apparatus for explosive atmos-pheres is given in Chapter 7, while general requirementsfor explosion protected apparatus (gas, vapor, and mist

risks) according to European standards (BS/EN 50014)are reviewed in Chapter 8.

The next 6 chapters, 9 through 14, discuss specificprotection concepts. Chapter 9 is on apparatus using pro-tection concepts of encapsulation ‘m’ , oil immersion ‘o’ ,and powder filling ‘q’ . In Chapter 10, apparatus usingthe concept of flameproof enclosure ‘d’ is discussed.Chapter 11 covers apparatus using the protection conceptof pressurization ‘p’ ; Chapter 12 is on apparatus usingthe protection concept of increased safety ‘e’ ; Chapter13 covers apparatus and systems using the protectionconcept of intrinsic safety ‘ i’ ; and Chapter 14 is onapparatus using the protection concept of ‘N’ (n’ ) inZone 2 areas only. Each one of these chapters has muchdetailed and useful information.

Protection concepts for apparatus for dust risks arediscussed in detail in Chapter 15, while other methodsof protection and future apparatus requirements are suc-cinctly reviewed in Chapter 16. Chapter 17 is a gooddiscussion of the selection of power supply, apparatus,and interconnecting cabling systems for bothgas/vapor/mist risks and dust risks. In Chapter 18, theauthor reviews installations in explosive atmospheres ofgas, vapor, mist, and dust. The topics include: standardsand codes (BS and BS/EN), basic installation require-ments, additional requirements or relaxations for parti-cular protection concepts, and electrical heating tapes.

Installation of pressurized apparatus and other uses ofthe pressurization technique is thoroughly discussed inChapter 19, while Chapter 20 reviews the installationof intrinsically safe apparatus/associated apparatus andintrinsically safe system ‘ i’ also in a comprehensivemanner. Documentation, inspection, test and mainte-nance of explosion protected apparatus, systems, andinstallations are discussed in Chapter 21, while Chapter22 is a succinct, but good, review of radio frequencyradiation and static electricity hazards (based primarilyon BS 5958 and BS 6656).

In my opinion, this is a very comprehensive and usefulbook that brings together information from various Bri-tish and European standards and presents them in oneplace. It will be not only very helpful to engineers fromthe UK and European countries involved with electricalinstallations in hazardous areas, but especially to USengineers who are not as conversant with the approachtaken in the UK and Europe. I can highly recommendit to all such engineers.

Stanley S. Grossel (President)Process Safety & Design, Inc., 41 Sussex Road,

Clifton, NJ 07012-2017, USAE-mail address: [email protected]

Tel.: +1-973-779-8579; fax: +1-973-779-8579.

PII: S 09 50 -4230( 01 )0 0038-9