Flores, Dharyl C. CHE 428N Safety in Process Industry Instructor: Dr.

Angelo
Cabije
BS ChE - 4 6:00 7:30 TTh November 17, 2017

Bhopal Tragedy

The Bhopal Union Carbide Factory Disaster is still considered as one of the worlds most lethal
industrial disaster. The accident was caused by the spillage of methyl isocyanate (MIC), which is a very
toxic substance, to the atmosphere and would have rapidly condensed and fallen ground wards that lead
to an immediate fatalities in the northern city of Bhopal as a result of the toxic fumes inhalation. According
to the investigation, the worst industrial disaster was a result of poor hazard management, poor safety
management practice, poor use of early warning system, and poor perception of the risk involved.

For employers working in this kind of process facility and other manufacturing industries, one
must develop needed expertise, experience, and judgement in the field to properly address an effective
process safety management (PSM) program. Basically, PSM is a framework in order to identify and
manage process risks. Also, this aims to prevent the occurrence of a potential devastation of a
dysfunctional system. However in terms of PSM, the Bhopal tragedy breached the following elements of
PSM employee participation, process safety information, operating procedures, training, mechanical
integrity, management of change, and emergency planning and response. Taking a closer analysis,
seven elements of PSM were breached.

Basically, the employee participation plays a vital role in the prevention of incidents. In the Union
Carbide factory, the operator working during the time of the incident had a poor perception of the
seriousness of risk of leak. He didnt communicate well about the critical information on the rapid pressure
build up at the MIC facility. He failed to inform the manager as soon as the leak started and did not confirm
the leak when the police officials asked about it. Also, he failed to operate the warning serin until the
release of MIC was severe. The use of a non-trained superintendent for the factory adds to the fact that
even in the corporate level, they had a very poor concern on safety.

Process safety information was also breached due to lack of information, formalization of
procedures, communication, and awareness about the toxicity of the various chemicals in the factory.

Operating procedures and mechanical integrity were violated during the time when the pressure
alarms had become unreliable that the workers kept ignoring it. The temperature alarms within the facility
had failed to work and the tanks were filled over their required capacity. Moreover, workers training was
undeniably poor.
 Management of change was also violated since it was not applied to assess the possible effects
of shutting down of safety equipment which was the scrubber. The scrubber should be kept in active
mode in order to neutralize the MIC in case of release by spraying alkali as long as the plant is operating.
Unfortunately, before the disaster occurred, it was decided to keep it in passive mode and to shut down
the refrigeration plant which is strictly against the safety manual instructions.

Emergency planning and response was breached the fact that there was no emergency plan in
the plant resulting to a panic reaction, no emergency plan for the city, the information to minimize the
effects of the said toxic substance was not properly disseminated, not informing the public on the
importance of alarm siren, and no risk analysis before plant modification.

The analysis of the Bhopal accident in correlation to the elements of PSM breached is very
important for this kind of facilities because it gives a clearer view for future companies to have safety as
a top management commitment.