human factors

Remembering Trevor Kletz

Professor Trevor Kletz, OBE, FREng, FRSC, FIChemE (1922 – 31 October 2013).

In 2004 I presented at the IChemE “Hazards” conference in Manchester, UK – the 18th event in this conference series that had been running since 1960.

The title of my presentation was “Behavioural Safety and Major Accident Hazards: Magic Bullet or Shot in the Dark?“.

At the end of my talk, an elderly gentleman, seated on the front row, slowly rose from his chair to ask the first question. I admit to being somewhat suddenly nervous, wondering what his question might be and whether I would have a suitable response, as I recognised this gentleman as Professor Trevor Kletz. The same Prof. Kletz who had published so widely on safety and human factors for many years and embodied the purpose of the IChemE Hazards conferences.

But he did not ask me a question. Prof. Kletz turned to face the audience and said that every manager and leader in the industry should have heard my presentation. This comment from an established thinker, author and speaker was much more preferable to a difficult question!

I had several conversations with Prof. Kletz in the years following that conference in 2004. His knowledge, determination to share valuable lessons and a passion for the safety of people that he would never meet, was overwhelming. I described him above as a gentleman; which he certainly was. We can learn as much from his approach to others, as we can from his teachings.

In mid-2013 we relocated to Australia; where I exchanged my role with the UK Health and Safety Executive (HSE) for an opportunity to lead the human factors capability in an oil and gas company. I was saddened to hear shortly afterwards that Professor Trevor Kletz had passed away, aged 91.

The new generation of safety and engineering specialists are not all familiar with the work of Prof. Trevor Kletz. On this anniversary of the loss of this safety hero, it is timely to remind ourselves of his achievements.

Prof. Kletz worked at ICI (Imperial Chemical Industries) for 38 years, managing various plants, and becoming the first Technical Safety Advisor; before “retiring” in 1982. ICI had an enviable safety culture and I think that this was partly due to the company’s practice of promoting senior engineers such as Prof. Kletz into senior safety roles.

This wasn’t a normal retirement though – he spent the next 30 years in his second career as an author and speaker; until retiring for the final time in 2012, following a career of almost 70 years. Simply remarkable.

In 2009 whilst receiving an award for services to health and safety, he was described by the Society of Chemical Industry as a ‘founding father’ of the modern safety processes and culture within the chemical industry. At the time of receiving this award, he was 87 years young.

Professor Trevor Kletz, OBE (right) receiving the SCI Mond Award for Health and Safety from past president Lord Dholakia in 2009.
Professor Trevor Kletz, OBE (right) receiving the SCI Mond Award for Health and Safety from SCI past president Lord Dholakia in 2009.

Prof. Kletz is recognised for creating the idea of inherent safety. In 1978 he published an article called “What you don’t have, can’t leak”; based on his learnings from the 1976 Flixborough disaster in the UK. Shortly after his retirement from ICI, he expanded this paper into the book which launched the concept of inherent safety.

Over many years, the writings of Prof. Kletz on human factors had a significant impact. His thoughts on human error and accident investigation shifted industry’s emphasis on individuals and moved it instead towards organisational failures and safety in design. He often spoke of understanding the organisational or system causes, rather than assigning blame to individuals. Some of his early teachings are currently being popularised as a ‘new’ view of safety.

“For a long time, people were saying that 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.”

Professor Trevor Kletz

Prof. Kletz had many professional interests, but one of his passions was around learning lessons from incidents.

Organisations have no memory

In his book “Lessons from Disaster” (1993) Prof. Kletz focuses on the failure of organisations to learn lessons from accidents, even those lessons from events within a company. He noted how the same incidents were repeated again and again – numerous case studies can be found in his books. My experience as a Regulator and consultant is that many companies confuse communicating lessons with actually learning lessons. Safety alerts, briefings, newsletters and learning meetings are all useful ways of sharing the details of incidents and the lessons; but for lessons to be embedded in an organisation, something has to change; for example, by engineering-out the possibility of a repeat event. Sharing is not the same as learning !

“If nothing changes in terms of the way the people in the organisation think, behave or react to future events and situations, nothing has been learned”

Learning from Adverse Events, CIEHF (2020, p.28)

Inherent safety and human error

Although inherent safety is often summarised by the now-famous quote “What you don’t have, can’t leak”, we can apply the same philosophy to managing the behaviours of people. If we assume that people will make errors (see my Ten facts article) then the principles of inherent safety would suggest that we remove situations that are error-prone; and remove the conditions that set people up to fail (i.e. the Performance Influencing Factors). We instead need to set people up to succeed, and this starts at the earliest stages of design.

What next?

I was inspired by the ability of Prof. Kletz to communicate complex issues in such a simple way, and by his lifetime commitment to making a real difference. He was a pioneer in safety and human factors. He taught us to think about safety differently. Although I mourn his passing, I’m grateful for the teachings that he left us with, and hope that in a small way this website continues his legacy.

Prof. Kletz said that “Accidents are not caused by lack of knowledge, but by a failure to use the knowledge that is available”. Your organisation can continue his lifetime of work by:

  1. reviewing your approach to incident investigations, and
  2. asking whether you really do have an effective lessons-learned process.

If you’re new to the work of Prof. Kletz, I highly recommend the following books as an introduction:

  • An engineer’s view of human error, 3rd ed (2001), IChemE, ISBN 0-85295-430-1
  • What went wrong? – Case histories of process plant disasters and how they could have been avoided, 5th ed (2009), Butterworth-Heinemann/IChemE, ISBN 1-85617-531-6
  • By accident… a life preventing them in industry, (2000), PFV, ISBN 0-9538440-0-5.

The Chartered Institute of Ergonomics and Human Factors (CIEHF), recently published a guide to Learning from Adverse Events. This document centres around nine principles for incorporating human factors into learning investigations, and is an excellent place to start.