In 1968, following ten years in which ICI’s fatal accident rate had worsened, I was appointed a safety adviser to the Heavy Organic Chemicals (later Petrochemicals) Division with responsibility for improving what we now call process safety. I had spent the previous 16 years in production, including a short period in process design, and it was a most unusual appointment at the time for someone with such experience. If the reason for my appointment had not been so obvious I would have wondered what I had done wrong.
There were two parts to the job: deciding what advice to give and deciding how to give it. As well as talking to individuals and in meetings I held frequent discussions on the causes of accidents and what we should do to prevent them happening again (for details see “How we Changed the Safety Culture”, Hazards XIX – Process Safety Environmental Protection; What do we Know? Where are we Going?, IChemE, 2006) and also started a monthly Safety Newsletter.
In 1968 I sent copies of No 1 to about 30 colleagues. Gradually, over the next fourteen years, the circulation and contents grew spontaneously. I did not advertise it, but added people to the circulation list at their request. By the mid-1970s, the circulation was several thousand, including all ICI Divisions, many outside companies, universities and the Health and Safety Executive. The Newsletters were not intended primarily for safety experts but for all those involved in design, operations, maintenance and construction, at all levels but especially at the professional level.
It was made clear to those who received the Newsletters that they could be copied for circulation within their organisation but not offered for sale.
Within ICI it was seen by directors, managers, foremen and, in some works, operators. Some other companies photocopied it and distributed it widely. The contents came to consist mainly of reports on accidents of general and technical interest from ICI and from other companies, supplied in exchange for the Newsletters. I did not copy the original reports, but rewrote them to bring out the essential messages. Many later Newsletters were devoted to specific themes, such as accidents due to plant modifications, preparation for maintenance, static electricity, human error. After I retired from ICI I edited many items from old Newsletters and published them in a book called What Went Wrong? Now in its 4th edition and my best-selling book, I have added many later reports and also written a supplementary volume, Still Going Wrong? Both books are available from IChemE (see www.icheme.org/shop).
ICI was willing to let me send reports of our errors all over the world for several reasons:
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: and therefore never send to know for whom the inquiry sitteth; it sitteth for thee.
Colleagues and other companies were willing to let me describe their accidents and so-called “near misses” (actually near accidents), which usually reflected no credit on them, because I did not say where they occurred (except when the location was stated in the title of a published report). The Newsletters were also an early example of “open access” though the phrase was not then used. After I retired, ICI gave me permission to reproduce or quote from them provided I did not say where they occurred or in which company. If anyone asked me – only a few did – where an accident had occurred I apologised for my poor memory. Now, as a further step in open access, IChemE are making the Newsletters available on the Internet.
The information in them is given in good faith but without warranty. Much of the advice is decades old and better methods of prevention may be available today. However, the accidents happened, many are still being repeated today, and readers should therefore ask themselves, “Could this occur where I work and, if so, how should I prevent it?”
In the period covered by the Newsletters (1968-1983) the Factory Inspectorate, and after 1974 the Health and Safety Executive, had a lighter touch than today. For this reason here are fewer references to the law than there would be if I was writing today.
ICI in recent years was very different the ICI I knew. Except for the paint factories, with which I had little contact, all the plants owned in 1982 when I retired have been closed or sold to one of a large number of different companies. None of the incidents described occurred on plants operated or owned by ICI in recent years.
I wrote everything in the Newsletters myself except for the engineering articles in the later issues most of which were written by Harland Frank, an outstanding engineer. After I retired from ICI in 1982 the Newsletters continued for 18 months, written by my successor, Alan Rimmer, and were then abandoned when he retired.
[NOTE: MKOPSC, with Dr. Kletz’s permission and blessing, have slightly modified the his newsletters with illustrations.]