bhopal 20 yrs later
TRANSCRIPT
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The Accident in Bhopal:
Observations 20 Years Later
Ronald J. Willey, Northeastern University, Boston, MA,[email protected]
Dennis C. Hendershot, Chilworth Technology Inc., Plainsboro,
NJ, [email protected] Berger, CCPS Director, AIChE, New York, NY,
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Introduction
The most influential process safety
accident in our history passed its 20th
anniversary on Dec 3, 2004 This accident occurred before most
current college students were born
Educators and the Process SafetyCommittee must keep the memory of
this accident alive
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A chemical plant in
Bhopal, India
producing a
pesticidetradename Sevin
So ± What Happened?
Bhopal
from C&E News, 1985
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Map of Bhopal
Map reprinted from C & E News Vol 63 (7), p 17, 1985
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Bhopal Railroad Station
4 December 2004
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Upper Lake Adjacent to the City
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Plant Entrance Early 1985
Wil Lepkowski photographer, from C&E News, 1985
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1-NAPHTHYL-N-METHYLCARBAMATE
(CARBARYL OR TRADE NAME SEVIN
®
)
METHYLISOCYANATE
AND
ENAPHTHOL
TO
O
O-CNHCH3
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AN INTERMEDIATE IN THE
PROCESS
METHYL ISOCYANATE,
MICCH3-N=C=O
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Relevant Properties
PROPERTIES of MIC BOILING POINT 39.1°C
VAPOR PRESS AT 20°C 348 mm HG
MOLECULAR WEIGHT 57 VAPOR DENSITY (Rel to Air) 2
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METHYL ISOCYANATE
MIC
IS AN EXTREME TOXINHAS A TLV-TWA OF 0.02
PPM
(ONE OF THE LOWEST!)
LC50 of 5 PPM FOR RATS
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Storage of MIC
Stored three-41 ton storage
tanks.
One of these tanks became
contaminated with water
resulting in overheating A runaway reaction
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Over view Visual of the Storage
Tanks
Adapted from Chemical Week/November 26, 1986 p 8.
Original Source: Union Carbide
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Tank 610 Over Pressurized
Adapted from Chemical Week/November 26, 1986 p 8.
Original Source: Union Carbide
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Piping at the Top of a Storage
Tank
Relief Valve
Adapted from A. S. Kalelkar in I. Chem.E. Symposium Series No. 110The Institution of Chemical Engineers 1988, p 575, Figure 7
Top of Tank
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Relief Valve Opened as Designed
Relief Valve
Adapted from Ibid
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Downstream Relief System
CAUSTIC
RVVH
PVH
KNOCK
OUT DRUM
VENT GAS SCRUBBER SYSTEM
ROUTE OF GAS
TOATMOSPHERE
FLARE TOWER
VENT GAS SCRUBBER
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The release passed across a
scrubber as designed
The release passed through a flaretower as designed
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Unfortunately, neither of these
mitigating units were operating at
the time of the release
One of the largest man-madereleases of a toxin followed
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Escaping
Gas
BlanketedMuch of
Bhopal
Map reprinted from C & E News Vol 63 (7), p 17, 1985
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As a result«
Gaseous methyl isocyanate entered theenvironment which had very stableatmospheric conditions
The plume formed was heavier than air and dispersed little as it flowed towardspopulation centers
Over 200,000 humans were exposed tomethyl isocyanate.
Over 10,000 deaths occurred
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Time 17 Dec 1984 (photo side credits Tucci/Liaison)
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TWO MAJOR EXPLANATIONS
1. WATER ACCIDENTLY ENTERED
TANK THROUGH A WATER
FLUSHING OPERATION
2. SABOTAGE
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The Water Washing Theory
Original Diagram is from ASK Fig 4
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Overview of the Entire the
Process Vent and Relief Vent Lines
Adapted from ASK figure 3
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Sabotage Theory
WATER INTRODUCED
TESTIMONY
INDICATED THAT THE
PRESSURE GAUGE
(PRESSUREINDICATOR) WAS
MISSING ON T-610
Adapted from ASK.
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Pipe Run 20 years ago
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Pipe Run 4 Dec 2004
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International Conference on
the 20th Anniversary of theBhopal Gas Tragedy
On December 1
to 3, 2004, Prof. J.Gupta of the Indian Institute of
Technology ± Kanpur organized this
conference in Kanpur, India
Afterwards, we made an overnight trip
by rail to the Bhopal site
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Presentation by Chief of Police
Swaraj Puri
Described how he was exposed to MIC
vapors
Risked his life seeking answers in thedark night to manage the chaos of
evacuation.
Obtained medical help for the victims,and eventually oversaw the removal
and disposal of bodies.
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Poor communications
Less than 10,000 telephones for
900,000 residents at the time.
Hampered the discovery of what wasaffecting the multitudes
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Presentation from a Plant
Operator Workers prided themselves working atthe plant.
However, change was underway, drivenby UC India decision to close itsBhopal operations.
Pressure to eliminate costs resulted in
personnel layoffs, and decisionsmentioned above compromised whatcould have been a safely run plant.
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Additionally,
Other speakers discussed the long-
term health effects, and epidemiologystudies and monitoring of the long term
health impacts of the disaster haveunexpectedly ceased.
Finally, many papers related to process
safety and how this accident influencedprocess safety practice across theworld were presented.
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Conditions we found at the plant
site
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The plant operator
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Tank 610
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Top of Tank 611Relief Valve for
Tank
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Filter Area up Close
Filter area
valve to process vent header
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Valve Connecting to Vent Header
Stem is inClosed Position
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End of pipe rack where jumper
pipe was located
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The Scrubber
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The Flare Tower
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The Control Room
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Sign
Inside
the
Control
Room
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Close up of the sign details
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Other environmental concerns
presence of mercury droplets
Mercury Droplet~1 INCH
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A corroded tank whose contents
are unknown
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Observations
The Bhopal disaster began long
before the actual event, and its
effects continue today, twenty-oneyears later.
It is clear today that the initiating
event is basically irrelevant.
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3 Strikes and you are«
If even one of the basic protections
functioned «e.g.
The refrigeration system Or the scrubber,
Or the flare,
Many, many lives could have beensaved.
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Importance of
Communications If communications between the plant
and corporate management had been
stronger, and if local management had
better information and supported
There may not have been flawed
decisions about fundamental safety
principles.
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The Root Cause Extends
Beyond Local ManagementDecisions
Optimistic market-size
expectations led to an oversizedplant by a factor of three
Failure of state and local
government to control growth near the plant
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Consequences extend well
beyond December 3, 1984
Thousands of people injured that day
continue to suffer
And, because Union Carbide wasbanished so abruptly from the site, the
chemicals remaining on site were never
properly removed
This has lead to additional significantenvironmental and health impacts
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Serious accidents are not
common It is easy to fall into the mindset that
they cannot happen.
This is a common human failing, and itexplains many risky behaviors from
driving too fast on the highway to
failure to maintain critical safetysystems in a chemical plant.
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Bhopal clearly disproves this
In no circumstances does ³unlikely´
mean ³impossible,´
Some possible consequences areclearly so significant that ³unlikely´
still leaves one with unacceptable risk
that must be addressed more
aggressively.
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A Silver Lining
Bhopal has lead to improved process safetypractices
AIChE¶s Safety and Health Division and
Center for Chemical Process Safety, andthroughout many other organizations aroundthe world.
Fundamental principles such as Managementof Change, Mechanical Integrity, HazardAnalysis, and Layers of Protection are now inthe toolbox of most practicing chemicalengineers around the world.
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So«
It would be a stretch to say that an
accident like Bhopal could never
happen today, but as we work together
to build a global culture of process
safety, the use of the process safety
tools ± and the strength of process
safety practices ± will help preventfuture Bhopals.
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Conclusions
Every business decision has
safety consequences.
A negative safety outcome is anegative business outcome.
In order to do the right thing,
politics and the local communitymust be assessed, understood,
and protected.
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Questions???