Description of the failure
The time line
Identifications of blocks in the lines, orders from supervisor to continue washing
Tank 610 fails to get pressurized
Change of shift
Water entry, logging of the pressure by the operator
Detection of first leakage of MIC, high pressure and the leak of MIC were notified to the supervisor.
Supervisor ordered to stop washing
Pressure gauge has over reading, with hot concrete tanks
Operator of MIC reports the escape of MIC gas through the vent line
Alert through alarm was done about the leakage of toxic gas but switched off, police official on patrol reported about the UCIL to police control room and police chief of the city.
Reports from UCIL stated that every thing was normal
Works manager of UCIL was informed by the additional district magistrate about the leak
Between 2.00 to 2.30 am, the safety valve was reseated, but before that, 40-45 tons of MIC escaped into the atmosphere. Nearly 55,000 people were hospitalized in 3-4 December.
Errors associated with system
Analysis of failure
• All the steps need to be formalized in such a way that adhoc decisions taken by the operators are minimized. During the emergencies, there will be severe stress to operators and operators’ interference should be minimal at the beginning stages of emergency. In a situation, where there is any unusual happening, all parameters should be logged and monitored including the ones that are considered unnecessary by the operators. The gas tragedy would have been avoided if there is a thorough investigation prior to attempting repressurisation again. (Otway and Misenta ,1980).
• Beginning from the stage of formulation of project, it is important for the proposers of project to be open to the approach with regard to nature of hazard as well as precautions. (Kunreuther and Linneroth 1984). In accident systems with low probability, sharing of information greatly helps in the reduction of hazards. In the MIC gas tragedy, the open attitude of corporation to workers of government, public around the plant and the authorities of public health would have lowered the loss of people.
• Conducting a detailed rehearsal emergency on the hazardous facilities in which all levels of management are actively associated in a continuous manner should be mandatory. Inadequacies in the system are evaluated in such a way that a corrective action is initiated.
• The facilities associated with accident prone hazard causal structure are such that there are more escapes before a disaster. (Lees 1982). The management should investigate the near misses in a detailed manner. Monitoring system in hazardous facilities should such that there is a higher level of unwanted things through duplicated monitoring of instrumentation, reduced intervention of operators through automated warning system. It is necessary to eliminate non formalized intervention of operators that activates the early warning signal system.
• Conventional management structures that are utilized for facilities that are non hazardous are not effective for hazardous management facilities as the safety is considered at somewhat lower level at the facilities that are non hazardous. Safety management status at the corporate level should be higher and the prime objective of the corporation should not be associated with production or financial at the hazardous facilities. A subservient safety system cannot be activate the corporation to get committed for a safety of higher levels.
• It is important to formulate risk assessment at the project feasibility phase in an effort to obtain consent for planning. Internal staff should study a detailed account of hazard operations or hazard analysis that could be used for safety management in operations on a day to day basis. The work related to safety management in operations should be done only by the people who were there during installation and have a detailed knowledge and experience on that particular operation.
• In complex facilities, it is difficult to predict the likelihood of disasters, even then, there is a near certainty as is the case with Bhopal gas tragedy where there were near miss accidents, unidentified safety lapses by the audit in addition to the poor corrective measures. It is essential to make auditing by hazard operators and hazard experts.
Kleindorfer P and H Kunreuther,(1986) Insuring and Managing Hazardous Risks (IIASA Laxenburg,
Kunreuther. H and J Linnerooth,(1984) Low probability acci-, dents", Risk Analysis, 4, pages 143-152.
Lees, F.P (1982), The hazard warning structure of major hazards, Transactions of the Institute of Chemical Engineering, 60, pages 21 1-221,
Morehouse.W and A Subramaniam,(1986) The Bhopal Tragedy Council on International and Public Affairs, New York,
Otway.H. and R Misenta,(1980) Some human performance paradoxes of nuclear operations, futures, 18, pages 340-357, 1980.
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