BSMH5053

MANAGING OCCUPATIONAL SAFETY AND HEALTH

INDIVIDUAL ASSIGNMENTS

Hazard Identification, Risk Assessment

and Risk Control ( HIRARC ) in workplace

Prepared For:
Dr. Munauwar bin Mustafa

Prepared By:
Purani a/p Verasamy (822022)

Submission date:
7th April 2018
Contents

1.0 OVERVIEW OF BHOPAL GAS TRAGEDY ..........................................................................................3

2.0 ROUTE TO TRAGEDY .....................................................................................................................4

3.0 HAZARD ANALYSIS........................................................................................................................6

Physical Hazard (Human Hazard) ....................................................................................................6

4.0 ROOT CAUSE OF THE INCIDENT .....................................................................................................7

5.0 HOW TO MAKE SURE IT NEVER HAPPEN AGAIN? ...........................................................................8

6.0 CONCLUSION ................................................................................................................................8

7.0 REFERENCES .................................................................................................................................9

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1.0 Overview of Occupational Safety and health

The Bhopal Gas tragedy is the worst air pollution episode ever witnessed in India. It happened in
Bhopal on December 3, 1984. The Union Carbide factory is located in Bhopal, a town in Madhya
Pradesh. The fateful incident happened due to the leakage of lethal gas called methyl isocyanate
(MIC) gas from three storage tanks of Union Carbide factory, a Multinational Corporation.

On the night of the incident, December 2, 1984, at 11:00 p.m. local time, while many of the Bhopal
residents were asleep, it was reported that a plant operator noticed a small MIC gas leak and
increased gas pressure inside a storage tank. This leak and pressure were due to water that had
entered the storage vessel. At the time, critical refrigeration for the storage system had been moved
to another area in the plant, and without refrigeration to slow the reaction of MIC with water, the
temperature and pressure rapidly rose within the storage vessel. As the temperature rose, the MIC
began to self-polymerize, adding to the heat and pressure. The vapor was first routed to a scrubber
for the vent gas that should have neutralized at least some portion of the vapor, but this unit was
not active. The vapor should then have passed to a flare tower to be destroyed, but the tower was
out of service for maintenance because of pipe corrosion. Shortly after midnight, a safety valve
opened, sending a MIC gas plume into the air (Broughton, 2005). An emergency water curtain
intended to react with the MIC in case of such a release was not designed to manage a release of
that scale and was also suffering from corrosion, which likely reduced its efficacy.

MIC is an intermediate used in the manufacture of pesticides. Methyl isocyanate (MIC) is

produced by combination of phosgene, a deadly poisonous gas used in the First World War with
methyl amine. In the accident nearly 36 tones of poisonous MIC gas released into the air of Bhopal.
MIC gas causes burning sensation in the eyes, removes oxygen from the lungs resulting in
breathing trouble and chest tightness, and also cyanide generation in the body, which ultimately
turn fatal and leads to death.

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2.0 ROUTE TO TRAGEDY

i. When employees discovered the initial leak of methyl isocyanate at 11:30 P.M. on
Dec. 2, a supervisor believing, he said later, that it was a water leak, decided to deal
with it only after the next tea break, several workers said. In the next hour or more,
the reaction taking place in a storage tank went out of control. ''Internal leaks never
bothered us,'' said one employee. Indeed, workers said that the reasons for leaks
were rarely investigated. The problems were either fixed without further
examination or ignored, they said.
ii. Several months before the accident, plant employees say, managers shut down a
refrigeration unit designed to keep the methyl isocyanate cool and inhibit chemical
reactions. The shutdown was a violation of plant procedures.
iii. The leak began, according to several employees, about two hours after a worker
whose training did not meet the plant's original standards was ordered by a novice
supervisor to wash out a pipe that had not been properly sealed. That procedure is
prohibited by plant rules. Workers think the most likely source of the contamination
that started the reaction leading to the accident was water from this process.
iv. The three main safety systems, at least two of which, technical experts said, were
built according to specifications drawn for a Union Carbide plant at Institute, W.
Va., were unable to cope with conditions that existed on the night of the accident.
Moreover, one of the systems had been inoperable for several days, and a second
had been out of service for maintenance for several weeks.
v. Plant operators failed to move some of the methyl isocyanate in the problem tank
to a spare tank as required because, they said, the spare was not empty as it should
have been. Workers said it was a common practice to leave methyl isocyanate in
the spare tank, though standard procedures required that it be empty.
vi. Instruments at the plant were unreliable, according to Shakil Qureshi, the methyl
isocyanate supervisor on duty at the time of the accident. For that reason, he said,
he ignored the initial warning of the accident, a gauge's indication that pressure in
one of three methyl isocyanate storage tanks had risen fivefold in an hour.

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vii. The Bhopal plant does not have the computer system that other operations,
including the West Virginia plant, use to monitor their functions and quickly alert
the staff to leaks, employees said. The management, they added, relied on workers
to sense escaping methyl isocyanate as their eyes started to water. That practice
violated specific orders in the parent corporation's technical manual, titled ''Methyl
Isocyanate,'' which sets out the basic policies for the manufacture, storage and
transportation of the chemical. The manual says: ''Although the tear gas effects of
the vapor are extremely unpleasant, this property cannot be used as a means to alert
personnel.''
viii. Training levels, requirements for experience and education and maintenance levels
had been sharply reduced, according to about a dozen plant employees, who said
the cutbacks were the result, at least in part, of budget reductions. The reductions,
they said, had led them to believe that safety at the plant was endangered.
ix. The staff at the methyl isocyanate plant, which had little automated equipment, was
cut from 12 operators on a shift to 6 in 1983, according to several employees. The
plant ''cannot be run safely with six people,'' said Kamal K. Pareek, a chemical
engineer who began working at the Bhopal plant in 1971 and was senior project
engineer during the building of the methyl isocyanate facility there eight years ago.
x. There were no effective public warnings of the disaster. The alarm that sounded on
the night of the accident was similar or identical to those sounded for various
purposes, including practice drills, about 20 times in a typical week, according to
employees. No brochures or other materials had been distributed in the area around
the plant warning of the hazards it presented, and there was no public education
program about what to do in an emergency, local officials said.
xi. Most workers, according to many employees, panicked as the gas escaped, running
away to save their own lives and ignoring buses that sat idle on the plant grounds,
ready to evacuate nearby residents.

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3.0 HAZARD ANALYSIS

Physical Hazard (Human Hazard)

From my point of view, the hazard occurred because of the introduction of water into the tank,
which contained about 42 tons of methyl isocyanate. The water caused an exothermic reaction in
the pesticide, thus causing the temperature to rise to about 200 C and caused a sharp increase in
pressure, this caused toxic gases to be released out and blown around by winds toward Bhopal.
After the initial gas leak, people went in to figure out what happened, by trying to recreate the way
a water could have entered a tank. They cannot figure it out, and are pointing fingers at angry
workers who manually poured water in.

The risk of this disaster occurring was definitely affected by the employment of un-/undereducated
workers, the plant’s location in proximity to living area (it was inside of urban area), inadequate
emergency action plans, the reduction of safety management (turning off safety alarms). Economic
problems with the plant caused them to put themselves at an even greater risk. Since they weren’t
well off economically, the plant had been cutting corners. They stopped promoting people so they
didn’t have to pay them more, making people angry and slacked off at work, looser safety rules
(workers were actually told not to worry about broken pipes), those who needed more training
were neglected, they also forced workers to use English language manuals, while only a few
understand it at all.

Like similar human hazards, multiple generations were affected by the gas leak in Bhopal. The
indirect effects were very strong, resulting in a plethora of fetal mutations and still-births. People
lost their eyes as a direct effect, and children were most susceptible, as they did not know how to
react even more than their parents.

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 4.0 ROOT CAUSE OF THE INCIDENT
I. Quite a number of investigation team from the company, government, NGOs investigate
the case and reported in different way:
II. Initial investigation of Union Carbide and a committee of Indian government reported that
huge quantity of water was input into a MIC tank which caused chemical reaction and
pushed the release valve to open followed by gas leaked.
III. A self-governing investigation by Arthur D. Little reported that water might be introduced
intentionally as control system was in place and more water not possible to enter
accidentally.
IV. The plant was running by newer employees and they were not aware about the safety
system.
V. Various safety systems (Vent scrubber, flare, valves) of the plant were not in sound & in
operating condition.
VI. Firewater spraying systems failed to spray water until the top of the flare stack.
VII. The alarm was not rising continuously to warn residences which increase the casualty rte.
VIII. The flare supposed to be handling larger leaks but insufficient to deal huge leak.
IX. Refrigeration system was unable to cool the tanks as the Freon was used for other purpose.
X. Workers failed to insert a slip blind & bleeder valves at the bottom of the pipes to stop back
flow of water to storage tank.

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5.0 HOW TO MAKE SURE IT NEVER HAPPEN AGAIN?
The similar case of Bhopal tragedy could be happening again if proper safety measures not been
taken accordingly. From safety point of view, the following steps can be taken:

i. The design of factory must be considering and if possible operate in remote place where
less human resides.
ii. Before assigning any task ensure the employees are trained and competent to do so.
iii. Emergency response plan must be in place and employees must be familiar with it.
iv. Create awareness to Neighbour & other stakeholders about the emergency contingency
plan of gas leakage or such cases.
v. All the control & safety valve must be in working condition and must be checked by
assigned personnel to ensure they are ready to work.
vi. Automatic alarm could be an engineering control to warn and ensure the alarm to ring
continuously.
vii. Proper maintenance regime must be in place
viii. Proper personal protective equipment (i.e. BA, Air fed musk, anti-chemical clothing) shall
be provided to the employees who handle chemicals specially to stop leakage
ix. Crisis management policy & procedure must be in place.
x. Company should have emergency response team to handle this situation in primary phase.
xi. Management of chemical plant must be committed to OHS.

6.0 CONCLUSION
Bhopal case is a thread and lesson learning example for chemical industry. It shows us how an
industrial disaster effect community, environment and business generation after generation. So
safety factors must be considered and crises management not only for the plant but also related
stakeholders must be developed when operating such industry. Government also must make strong
laws and enforce so that company will bound to follow in order to operate his business.

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7.0 REFERENCES

Retrieve from: Documentary The Bhopal Disaster INDIA Nat Geo

https://www.youtube.com/watch?v=HsuUQzhP2Ds&feature=youtu.be

Retrieve from: BBC One Night In Bhopal

https://www.youtube.com/watch?v=rJg19W8x_Ls&feature=youtu.be

Retrieve from: Bhopal: A Prayer for Rain

https://www.youtube.com/watch?v=96hxBTQbV88&feature=youtu.be

M.J. Peterson, Bhopal Plant Disaster – Situation Summary. March 20, 2009

Bhopal: The Inside Story –Carbide Workers Speak out on the World’s Worst Industrial Disaster,
op cit, p.94.

Dhara, R., “Health Effects of the Bhopal Gas Leak: A Review,” New Solutions,
Spring 1994, p.37