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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Roshanak Moradi Nadimian
SY DE 142 – May 10, 2004
Introduction to Human Systems Engineering
Waterloo, Ontario, Canada
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
Time: Deep night in December 2, 1984
Place: Bhopal, India
Direct Reason: Maintenance crew flushed the lines of the MIC unit with water inducing volatile chemical reaction.
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.
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.