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Tutorial 1: Case Study – Business in Bhopal. Roshanak Moradi Nadimian Munira Jessa SY DE 142 – May 10, 2004 Introduction to Human Systems Engineering Waterloo, Ontario, Canada. Outline. Introductions What should you expect from Tutorials? Business in Bhopal: Questions

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Tutorial 1: Case Study – Business in Bhopal

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Tutorial 1:Case Study – Business in Bhopal

Roshanak Moradi Nadimian

Munira Jessa

SY DE 142 – May 10, 2004

Introduction to Human Systems Engineering

Waterloo, Ontario, Canada


Outline

  • Introductions

  • What should you expect from Tutorials?

  • Business in Bhopal: Questions

  • Business in Bhopal: Group work

  • Business in Bhopal: Discussion


Goal of the Tutorials

  • Help students with material presented in class (look at FAQ on the website as well)

  • Provide opportunities for group work and discussions on readings

  • Answer questions students may have

  • Discuss Web assignments ( “THE BEST” Solutions)

  • Review before exams

  • And of course… meet your TAs

    • NOTE: You don’t need to take notes from the tutorial notes, they will be posted on the course website after each tutorial.


Notes regarding Assignments

  • Name Code: Be consistent through the whole term (abcd is not same as adbc)

  • Cover Page should include, see sample:

    • Full Names of group members (same as your ID, PLEASE, NO NICKNAMES)

    • ID number

    • Email address


Assignment Cover page

Assignment #:

TITLE

Submitted in Partial Fulfillment

of the Requirements for SYDE 142

Group ID: XXXX (first letter of last names)

Name 1, ID 1, Email 1

Name 2, ID 2, Email 2

Name 3, ID 3, Email 3

Name 4, ID 4, Email 4

Faculty of Engineering

Department of Systems Design Engineering

DATE


Format of the Tutorials

  • 8 Tutorials

  • Case review and Question

  • Group work

  • Discussions


Business in BhopalIntroduction

Time: Deep night in December 2, 1984

Place: Bhopal, India

Result:

  • More than 2,500 residents died

  • Tens of thousands more suffered irreparable respiratory and neurological damage

    Direct Reason: Maintenance crew flushed the lines of the MIC unit with water inducing volatile chemical reaction.


Business in BhopalQuestions

Questions:

1- Why did this incident happen?

2- What efforts were made to control the situation?

3- Analyse this case using the Fault Tree analysis. Note: see the FAQ on your course website regarding some useful hints for FTA.


Business in Bhopal:Why?

  • Long boring shifts of monitoring

  • No training in emergency procedures

  • Aging and deteriorating plant not being fixed

  • Unrepaired instruments and broken equipment

  • Staff layoffs of maintenance people, new and inexperienced staff


Business in Bhopal:Why?

  • Humans as living sensors for leak detection

  • Cultural issues: demanding English of employees

  • Temperature in tank missing or inaccessible (no history)

  • Operators had to enter a physiologically dangerous environment to turn valves off

  • Inadequate safety systems, soda scrubber, dismantled flame tower, shower curtain


Business in Bhopal:Efforts Made

  • Isolate the leak by closing various valves in the network of pipes – pressure was far too high

  • Reduce the temperature – no refrigeration coolant

  • Empty the tank 610 – no other free place available

  • Start up majors safety system – was not working

  • Divert the leaked plume to the flare tower – the connected pipe had been removed

  • Turn on the water curtain – water was not powerful enough to reach the plume


Note:

This is the correct tree, there should be no lines between the right hand branches and “AND” as the lower branches do not cause the higher branch’s failure, for example: the refrigeration unit not working do not cause the vent gas scrubber’s failure, these are both events occurring at different times and both causing the MIC spread over the village.


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