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.