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The Setting
Bhopal located in North Central India Very old town in picturesque lakeside setting Tourist centre Industry encouraged to go to Madhya Pradesh as part of a policy to bring industry to less developed states Annual rent $40 per acre Decision by Union Carbide in 1970 to build was welcomed
Bhopal Capitol of Madhya Pradesh
The Plant
Operator : Union Carbide India Ltd. Half owned by Union Carbide USA (50.9%) Plant built to produce carbonyl pesticide : SEVIN-DDT substitute Very successful initially - part of Indias Green Revolution Initial staff 1000
The Surroundings
Initially in quiet suburb Later the town expanded around it Attracted a large squatter camp, as in many third world countries
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imported by truck
made on site
Process route CO + Cl2 COCl2 (Phosgene) COCl2 + MMA MMC + MIC MIC stored in three 15,000 gal tanks MIC + AN SEVIN
Properties of MIC
Flammability Toxicity Reactivity
NFPA Diamond
DOT = US Dept of Transport CAS = Chemical Abstracts No. ID = United Nations Ref No.
M I C Hazards
Toxic, flammable gas Boiling point is near to ambient Runaway reaction with water possible unless chilled below 11 C
HCl
Residue
Pyrolysis
Tails
MIC Refining Still
MIC Storage
Derivatives Plant
TYPE
Passive Active Active Active Active Active Passive Active Passive + Active Active
Accidents are normally characterised by a sequence of events leading from the initiating event, propagation of the accident, and realisation of the undesired outcome Safeguards may be equipment items or procedures designed to prevent the initiating event, limit or terminate the propagation, or mitigate the outcome Active safeguards are those which require human procedures or mechanical initiation to operate (e.g. work permit procedures, scrubber caustic circulation)
Safeguards
Safeguards
Passive safeguards are those which are designed in and which do not require any initiation (e.g. concrete fireproofing, elevated vent stack for dispersion) Both active and passive safeguards can be defeated through inadequate Safety Management Systems
The Incident
Occurred late at night, soon after shift change MIC tank overheated, overpressured and vented through scrubber Elevated discharge of massive quantity of MIC (approximately 25 tons) Operational staff retreated upwind, no casualties Staff from other plants evacuated, few casualties
Incident Causes
Source of Water Filters were being flushed using high pressure water Drain line from filter was blocked, operator observed no flow to drain Flushing continued despite blockage High pressure could cause valve leak; force water into relief header and then?
Incident Causes
Route of Water RV and PCV headers were joined by jumper pipe, no blinds MIC tank could not be pressurised because tank PCV failed open? Leakage through a single valve would allow water from RV header to enter tank Head of water sufficient for flow Slow initial reaction would allow 1600 lbs. to enter
FVH Line
MIC Reactor Side Relief Valve Vent Header Process Valve Vent Header Vent Gas Scrubber Flare Vent Header Route of water ingress
To VCS
PI
Rupture Disk
From Refrigeration
40 PSI
From MRS
Refrigerator
Phosphene Stripping Still Filter- pressure safety valve lines (at ground level) Water Drain
Educator
Concrete Cover
MIC to vent
MIC Reactor Side Relief Valve Vent Header Process Valve Vent Header Vent Gas Scrubber Flare Vent Header Route of gas leakage after 0030
PI
Rupture Disk
From Refrigeration
To VCS
40 PSI
From MRS
Refrigerator Quench Filter - pressure safety valve lines (at ground level) Phosphene Stripping Still Filter- pressure safety valve lines (at ground level) Water Drain Tank No. 610 To Reactor Conditioner
Educator
Concrete Cover
Reaction
PI
PI
Rupture Disk
From Refrigeration
To VCS
40 PSI
From MRS
Refrigerator
To Reactor Conditioner
Educator
Concrete Cover
The Incident
No alarm or warning to public Very stable atmosphere and low wind directly into town Surrounding population asleep Over 2,500 fatalities Over 250,000 sought medical treatment Panic
Incident Chemistry
Chemistry causing incident is not in dispute 41 tonnes of MIC in storage reacted with 500 to 900 kg water plus contaminants Resultant exothermic reaction reached 400 to 480F (200 to 250C) Tank pressure rose to 200+ psig (14+ bar) - tank was designed for 70 psig (4 bar) Venting caused ground to shake!
Incident Causes
No universally accepted cause. Sabotage theory
Disgruntled employee Alternative theory involves connection of water hose to storage tank 610 Evidence said to include the finding of the disconnected pressure gauge from tank 610 after the disaster A rough drawing found, said to depict a hose connected to a pressure vessel
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OR
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Incident Causes
Many theories can be put forward and all mechanisms give insights into the vulnerability of the system Main objective is to learn from the consequences; multiple possible causes only serve to highlight the weaknesses
Lessons Learnt