tutorial 1 case study business in bhopal
Skip this Video
Download Presentation
Tutorial 1: Case Study – Business in Bhopal

Loading in 2 Seconds...

play fullscreen
1 / 12

Tutorial 1: Case Study – Business in Bhopal - PowerPoint PPT Presentation

  • Uploaded on

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

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

PowerPoint Slideshow about 'Tutorial 1: Case Study – Business in Bhopal' - roch

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
tutorial 1 case study business in bhopal

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

  • Introductions
  • What should you expect from Tutorials?
  • Business in Bhopal: Questions
  • Business in Bhopal: Group work
  • Business in Bhopal: Discussion
goal of the tutorials
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
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 Cover page

Assignment #:


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


format of the tutorials
Format of the Tutorials
  • 8 Tutorials
  • Case review and Question
  • Group work
  • Discussions
business in bhopal introduction
Business in BhopalIntroduction

Time: Deep night in December 2, 1984

Place: Bhopal, India


  • 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 bhopal questions
Business in BhopalQuestions


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
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 why1
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
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

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.