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7/24/2019 Bhopal Incident
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Incident CaseDescription
Bhopal, India1984
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Bhopal located in North CentralIndia
Very old town in picturesquelakeside setting
ourist centre
Industry encouraged to go to!adhya "radesh as part o# apolicy to $ring industry to lessde%eloped states
&nnual rent '4( per acre
Decision $y )nion Car$ide in19*( to $uild was welco+ed
Bhopal Capitol of
Madhya Pradesh
he etting
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Initially in quiet su$ur$
/ater the town e;pandedaround it
&ttracted a largesquatter ca+p, as in+any third worldcountries
he urroundings
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6VIN +anu#actured #ro+
Car$on !ono;ide 2C-5 i+ported $ytruck
!ono+ethyla+ine 2!!&5
Chlorine 2Cl
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2National @ire "rotection &ssociation5:ight ide op o# Dia+ond /e#t ide
6;tract #ro+ N@"& *(4
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:eaction yste+:eaction yste+
"hosgene till"hosgene till
"yrolysis"yrolysis
!IC :e#ining till!IC :e#ining till
!IC torage!IC torage
!!& "hosgene
Cl
Chloro#or+
ails:esidue
@lare and cru$$er Deri%ati%es "lant
i+pli#ied "rocess @low Chart
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!IC torage ank
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SAFEGUARD TYPE
10
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10 Ehy it was not categori?ed aspassi%eF It is per+anently installed
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"assi%e sa#eguards are those which aredesigned in and which do not require anyinitiation 2e0g0 concrete #ireproo#ing,ele%ated %ent stack #or dispersion5Both acti%e and passi%e sa#eguards can$e de#eated through inadequate a#ety!anage+ent yste+s
a#eguards
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&7Napthol plant shut down
6VIN production no longer +aking+oney, so cost sa%ings sought, andplant run inter+ittently!ini+u+ +aintenance
a#ety procedures si+pli#ied #ors+all Go$s
:e#rigeration unit shut down and@reon sold
cru$$er circulation stopped
!anning cut to ((
!orale lowlip $linding no longer +andatoryduring washing
igh te+perature alar+ shut7o## as now H 11 C
:V and "CV headers Goined
2#or +aintenance5 6+ergency #lare line
corroded, disconnected
198171984. accidents withphosgene or !IC
198< audit critical o# !IC
tank and instru+entation 1984 warning o# potential
runaway reaction ha?ard
"lant "ro$le+s "recursor toDisaster
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-ccurred late at night, soon a#ter shi#t change!IC tank o%erheated, o%er7pressured and %ented
through scru$$er
6le%ated discharge o# +assi%e quantity o# !IC2appro;i+ately
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,ource o# Eater
@ilters were $eing #lushed using high pressurewater
Drain line #ro+ #ilter was $locked, operatoro$ser%ed no #low to drain
@lushing continued despite $lockage
igh pressure could cause %al%e leakJ #orcewater into relie# header and thenF
Incident Causes
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:oute o# Eater:V and "CV headers were Goined $y Gu+per pipe,
no $linds
!IC tank could not $e pressurised $ecause tank"CV #ailed openF
/eakage through a single %al%e would allowwater #ro+ :V header to enter tank
ead o# water su##icient #or #low
low initial reaction would allow 1(( l$s0 toenter
Incident Causes
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Water Drain
PI
RV
Valve which let water in
Quench Filter pressure
safety valve lines
!at "round level#
Phosphene $trippin"
$till Filter pressure
safety valve lines
!at "round level#
%o VC$ RW& 'ine
%o V($ and FV& FV& 'ine
)*&eader Isolation Valve
Rupture
Dis+
Concrete Cover
Fro, MR$
Fro, Refri"eration
%o Reactor Conditioner
Refri"erator
%an+ )o- ./0
10 P$I
2ducator
MR$ MIC Reactor $ide
RVV& Relief Valve Vent &eader
PV& Process Valve Vent &eader
V($ Vent (as $cru33er
FV& Flare Vent &eader
Route of water in"ress
%o
VC$
PI
4u,per'ine
Slip Blind
required here
Eaterource&rea
Ultimate destination of water
"ro$a$le :oute o# Ingress o#Eater into ank 1(
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Water Drain
PI
RV
Valve which let water in
Quench Filter pressure
safety valve lines
!at "round level#
Phosphene $trippin"
$till Filter pressure
safety valve lines
!at "round level#
%o VC$ RW& 'ine
%o V($ and FV& FV& 'ine
)*&eader Isolation Valve
Rupture
Dis+
Concrete Cover
Fro, MR$
Fro, Refri"eration
%o Reactor Conditioner
Refri"erator
%an+ )o- ./0
2ducator
MR$ MIC Reactor $ide
RVV& Relief Valve Vent &eader
PV& Process Valve Vent &eader
V($ Vent (as $cru33er
FV& Flare Vent &eader
Route of "as lea+a"e 3efore 0050
%o
VC$
PI
10 P$I
4u,per
'ine
Rupture dis% )ursts
!n(reased rate of release
"ro$a$le :oute o# as /eakagea#ter ((( hrs
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No alar+ or warning to pu$licVery sta$le at+osphere and low wind
directly into town
urrounding population asleep
-%er
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Che+istry causing incident is not in
dispute
41 tonnes o# !IC in storage reacted with3(( to 9(( kg water plus conta+inants
:esultant e;other+ic reaction reached4(( to 48(M@
2
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No uni%ersally accepted cause0a$otage theory
Disgruntled e+ployee
<ernati%e theory in%ol%es connection o#water hose to storage tank 1(
6%idence said to include the #inding o# the
disconnected pressure gauge #ro+ tank 1(a#ter the disaster
& rough drawing #ound, said to depict a hoseconnected to a pressure %essel
!anage+ent syste+s theoryInadequate sa#ety +anage+ent allowed water
entry through inadequate slip7$linding anduncontrolled plant +odi#ications
Design sa#eguards should ha%e pre%entedthe disaster o# either case
**
*
*
*
+R ,
Incident Causes
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!any theories can $e put #orward and all+echanis+s gi%e insights into the %ulnera$ility o#the syste+
!ain o$Gecti%e is to learn #ro+ the consequencesJ
+ultiple possi$le causes only ser%e to highlightthe weaknesses
Incident Causes
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6arly sa#ety study would questionha?ardous in%entories and plantsiting
Detailed study would identi#yconta+ination pro$le+
a#ety tudies +ay propose atraining #unction, should in%ol%eparent co+pany sta##
a#ety tudies +ay re%iewprocedures, especially those
in%ol%ing ha?ards 2water washingF5
-essons
-earnt
Ehat Could a#ety tudies ha%edoneF
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a#ety tudies on +odi#ications.
Disconnecting #lare syste+
Not running re#rigeration
Ou+per pipe $etween %ent headers
topping scru$$er causticcirculation
a#ety tudies would e+phasise need#or e+ergency plans
-essons
-earnt
Ehat Could a#ety tudies ha%edoneF