AECH 4112

PROCESS SAFETY DESIGN

ASSIGNED CASE STUDY

Bhopal Gas Tragedy, India

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TABLE OF CONTENTS
1 ROOT CAUSES OF BHOPAL TRAGEDY............................................................................1

2 UNION CARBIDE INDIA LIMITED (UCIL)............................................................................1

2.1 Plant Design..................................................................................................................1

2.2 Potential Hazards.......................................................................................................... 2

3 THREE-STEP PROCESS FOR BHOPAL GAS TRAGEDY..................................................4

4 INHERENT SAFETY DESIGN..............................................................................................7

5 References........................................................................................................................... 9

LIST OF TABLES
Table 1: Root Causes of Bhopal Gas Tragedy.............................................................................1
Table 2: Potential Hazards and associated Dangers of UCIL Plant Bhopal, India.......................3
Table 3: Inherent Safety Design for UCIL Bhopal, India...............................................................7

LIST OF FIGURES
Figure 1: Plant design of insecticide plant by Union carbide corporation.....................................2
Figure 2: Potential Hazards from UCIL Plant Bhopal, India.........................................................2
Figure 3: Series of Failure for Bhopal Tragedy............................................................................6
Figure 4: Inherent Safety Design Techniques..............................................................................7
 QUESTION NO. 1

1 ROOT CAUSES OF BHOPAL TRAGEDY

On 2nd December 1984, an incident happened in a factory owned by Union Carbide India
Limited. Almost 40 tons of methyl isocyanate were released into the environment. Almost
15,000 people were killed (Tze Lin Kok, 2019). The root cause of this tragedy is given in the
table below.

Table 1: Root Causes of Bhopal Gas Tragedy

Source: (Omar Basha, 2009)

Root Cause Source Description

Slip binds not Human error Due to the absence of these slip binds water reacts with
installed MIC. Which is an exothermic reaction and it initiates the
polymerization.
Pressurized tank Human error The pressure was raised from 3psi to 10psi. whereas the
operator did not consider it a serious issue.
Cooling system Process upset The cooling system was shut down and MIC which was to
be kept at 5oC was kept at ambient temperature.
Vent gas system Process upset At the time of the accident, these vents were not operating
just because they were under maintenance.
Flare system Process upset The Flare system was not operational at the time of the
accident. It took only 8 hours for maintenance but due to
lack of staff, it took more time than usual.
Storage Design error The plant was designed to store almost 5 tons of MIC on
daily basis. Whereas during the accident each storage
tank was holding 55 tons of MIC.

QUESTION NO. 2

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2 UNION CARBIDE INDIA LIMITED (UCIL)
2.1 Plant Design
UCIL was operated in Bhopal city for the production of Carbaryl Pesticide. Methyl Isocyanate
was produced as an intermediate during the process. The process chemistry goes through the
following stages.

Methylamine reacts with phosgene producing methyl isocyanate which then reacts with 1-
naphthol to yield carbaryl. The plant design for UCIL is shown in Figure 1.

Figure 1: Plant design of insecticide plant by Union carbide corporation

Source: (Labib, 2015)

2.2 Potential Hazards

The potential hazards for the UCIL plant are highlighted and tabulated in Figure 2 and Table 2
respectively.

CO, HCl, CH3NCO,

Caustic Soda
1-naphthyl
methylcarbamate

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 MIC

Figure 2: Potential Hazards from UCIL Plant Bhopal, India

Table 2: Potential Hazards and associated Dangers of UCIL Plant Bhopal, India

Potential Hazard Potential Danger Source

MIC  MIC is explosive when mixed with air (Omar Basha, 2009)
 Flammable
 Its reaction with water is exothermic
and it starts the polymerization
 MIC has high vapor pressure and has
toxic effects on organs
Caustic soda  Flammability (Omar Basha, 2009)
 Burn or damage the tissues
 Can damage lungs and eyes due to the
presence of caustic soda
 Explosive
CO  It is a silent killer (Wetchakun, 2011)
 Can bind with hemoglobin instead of
oxygen
HCl  Can be corrosive to the eyes and (DARMER, 1974)
mucus membrane
 Can cause gastritis, bronchitis, and
dermatitis
 Can cause dental colorization

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Potential Hazard Potential Danger Source
CH3NCO  Very toxic when inhaled (Rivetti, 2000)
1-naphthyl  Memory loss (Rivetti, 2000)
methylcarbamate  Headaches
 Cramps
 Mucus weakness
 Anorexia

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 QUESTION NO. 3

3 THREE-STEP PROCESS FOR BHOPAL GAS TRAGEDY

Step Identified Cause of Initiation Recommendation for the elimination of Initiation

Washing of Pipes The initiation of the accident could have been avoided
The disaster for MIC leakage began after the washing of if;
pipes was done for keeping the filter system clean by  Qualified and educated staff would have been
flushing the contaminants out from the water. hired.
 Proper training on Safety Measures was given
Absence of Slip Bind
to the staff.
There was no installation of slip binds for achieving an
Initiation  A proper Maintenance Check was done by the
impenetrable seal among the pipes. This was the
maintenance workers.
reason that water from washing flows back into the vent
 Safety Gadgets and proper SOPs were
system with the help of a leaking isolation valve and
followed.
starts reacting with the MIC tank.
 Maintenance workers had noticed and reported
the issue timely.
No Measurement of Pressure and Temperature  Proper monitoring and checking of pressure
The change in pressure gauges was not noticed by gauges and timely reporting of increased
staff. Moreover, no temperature measurement device pressure inside the tank.
was installed.  Installation of temperature measuring devices
Refrigeration System was Disabled and regular monitoring.
Propagation The refrigeration/cooling system was used for cooling  Proper and timely maintenance of safety
the tanks but unfortunately, the cooling system had gadgets and other equipment including
been switched off months earlier which led the thermal refrigeration system, gas vent scrubber, and

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 runaway reaction to take place. flare system.
Dysfunctional Gas Vent Scrubber
Gas vent scrubbers are used to neutralize toxic gases.
The gas vent scrubber which was installed inside the
plant was dysfunctional due to which hot MIC vapors
burst from the automatic pressure relief system and
then started escaping.
Flare System was under Maintenance
The flare system was also under maintenance which led
the toxic MIC gas to liberate from the plant.
Termination The replacement of initiation with termination events can The leakage of MIC gas could have been terminated
reduce the probability of accidents. as quickly as possible if the following actions were
implemented in the past.
 Hired staff was qualified and timely reported the
absence of Slip Binds.
 Safety Personnel was hired and have inspected
the plant operation with respect to safety
performance.
 The pressure and temperature of the MIC tank
have been reported timely.
 Proper SOPs have been followed by all the
staff.

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7|Page
The above-mentioned three steps process can also be demonstrated from figure 3 below
indicating a series of failures that causes the Bhopal Disaster.

INITIATION Slip Bind Not Installed

Pressure Guage Readings Ignored

Temperature
Not Available
Measurements
PROPAGATION

Pressurized Tanks Depressurized Tank

due to Valve Leakage

MIC Reaction

Cooling System Switched Off

Thermal Runaway
Reaction

In Maintenance
Vent Gas Scrubber

In Maintenance
Flare System

Not tall Enough

Water Curtain

Figure 3: Series of Failure for Bhopal Tragedy

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 QUESTION NO. 4

4 INHERENT SAFETY DESIGN

An inherent safety design is considered as the one that minimizes or diminishes the hazards as
compared to their control by reducing the number of hazardous materials and hazardous
operations within the facility.

There are four methods for accomplishing the inherently safer design. These include;

Simplify
Moderate
Substitute
Minimize

Figure 4: Inherent Safety Design Techniques

Table 3: Inherent Safety Design for UCIL Bhopal, India

Type Technique Justification

Minimize Reduction of Toxic Substances The toxic material must not be stored in a large
Storage amount inside the facility as one cannot be too
much careful regarding its storage. There are
always chances for leakage in case of even
minor negligence in safety.
Minimization of frequent changes in The changes in management and staff lead to
Management and Staff increase risks of accidents as newcomers may
commit minor mistakes which can turn into major
accidents.
Reduction in the amount of Inventory Process design needs to consider the reduced
amount of inventory that will help in the effective
and safe operation of the plant.
MIC intermediate inventory must be reduced as it
is not compulsory as raw material and product.

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 Type Technique Justification
Separately dealing of incompatible All the incompatible materials must be dealt with
materials and avoidance of using separately as their agglomeration with plant
water for washing design not only makes a system complex but
also unsafe.
Substitute Replacement of hazardous reactions Regardless of higher operational costs, usage of
with less hazardous reactions. the safer route with the reaction of alpha-
naphthol and phosgene following the
methylamine reaction for yielding carbaryl must
be done that will avoid MIC formation.
Reduction or moderating the Strength The location of the UCIL plant must be separated
of an effect from a significantly impacted population,
Moderate evacuation points along emergency response
facilities.
Segregated Storage of MIC The storage of MIC must be in multiple smaller
tanks regardless of storage in two jumbo-sized
concentrated tanks.
Simplify Elimination of redundant complexity The equipment must be designed for total
of plant operation for reducing human containment of MIC at ambient temperature or
error risk maximum achievable process temperature.

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5 REFERENCES
DARMER, K. K. E. a. D. L., 1974. Acute toxicity in rats and mice exposed to hydrogen chloride
gas and aerosols, s.l.: s.n.

Labib, A., 2015. Learning (and Unlearning) from Failures: 30 Years on from Bhopal to
Fukushima an Analysis through Reliability Engineering Techniques, s.l.: s.n.

Omar Basha, J. A. T. N., 2009. Bhopal gas Tragedy: A safety case study, s.l.: s.n.

Rivetti, F., 2000. The role of dimethylcarbonate in the replacement of hazardous chemicals, s.l.:
s.n.

So, J. P. C. D. H. J. P. J. U. R. K. a. Y. C., 2018. Adsorption of 1-naphthyl methyl carbamate in

water by utilizing a surface molecularly imprinted polymer, s.l.: s.n.

Tze Lin Kok, Y. J. C. C. K. L. a. J. H. S., 2019. Bhopal gas tragedy – the scar of process safety,
s.l.: s.n.

Wetchakun, K. S. T. T. N. L. C. S. C. K. V. W. A. T. A. a. P. S., 2011. Semiconducting metal

oxides as sensors for environmentally hazardous gases., s.l.: s.n.

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