UNIVERSITY OF

KARACHI

PRESENTED TO
ENGR. MALIKA
PROCESS PRESENTED

SAFETY
BY:
SHARIQ
10 MISBAH IBRAHIM
September RUBA TARIQUE
2024
MANAGEMENT AWAIS
Overview
Introduction 01

Background 02

Events prior to tragedy 03

The Sevin’s Process 04

Plant Production Process 05

Leak Timeline 06

NEXT
MIC Toxicity 07
MIC Storage tank 08
Equipment and instrumentation faliure 09

Factors leading to the Gas Leak 10

lessson Learned 11

Conclusiion 13
INTRODUCTION
Incident: Bhopal gas tragedy, chemical accident on the night of December 2–3,
1984

Location: Union Carbide India Limited (UCIL) pesticide plant, Bhopal, Madhya
Pradesh, India

PAGE 1
Gas: Methyl isocyanate (MIC)

Cause: Leak from Union Carbide's insecticide plant

Immediate Impact: Thousands killed, panic-stricken evacuation

Death Toll: Estimated 15,000 to 20,000

Survivors: Around 500,000 with respiratory issues, eye irritation, or blindness

 BACKGROUN
D
Establishment: Union Carbide Corporation established a pesticide plant in India due to its central location.
Pesticide: The plant was intended to produce Sevin, a pesticide.

PAGE 2
Ownership: Union Carbide held a 50.9% share; Indian investors held 40.1%.

Production Start: UCIL. began producing pesticide in 1979.

Toxic Byproduct: Production also generated Methyl Isocyanate, a highly toxic chemical requiring strict maintenance.
Disaster Date: December 3, 1984, around 1:00 a.m.

Immediate Impact: People sleeping peacefully were overwhelmed; many could not escape, leading to deaths and severe injuries.
Previous Issues: Prior complaints about plant maintenance; MIC leakage had occurred before, causing deaths and injuries.
Neglect: Authorities ignored maintenance issues; worn-out machinery was not replaced.
 EVENTS PRIOR TO TRAGEDY
Dec 1981 May 1982 1983
May 1982 Report
onwards
Plant Operator
Killed By Gas by Americans on All energy
Leak UCC plant concentrated
(Phosgene) on cost cutting

Reported leaks of 200 skilled workers asked

PAGE 3
phosgene MIC and to resign.
Medical Officer brought chloroform.
into notice the hazard Only 1 person in control
posed by the factory. room.
Ruptures in pipework and June 1984 30-ton
sealed joints. refrigeration cooling the
Jan 1982, 24 persons MIC system was
affected by phosgene. shutdown.
Poor adjustment of certain
devices where excessive Oct-1984 vent scrubber
Feb 1982, 18 persons pressure could lead to was turned off, flare was
affected by MIC leak. water entering the circuits. extinguished.
 The

Art And Design '50 Year 2023

sevin’s
process

PAGE 4
• Carbide produced the pesticide Sevin
(Carbaryl) using MIC as an
intermediate.
• The chemical process used in the
bhopal plant was to react methyl
amine with phosgene to form MIC
which was then reacted with 1-
naphthol to form the final product.
Plant production
process

PAGE 5
 02 DECEMBER 03 DECEMBER
12:15 P.M.
9:30 P.M.
• MIC storage tank pressure rises rapidly from 3.1 bar to 4.8
• Operator begins water washing of
bar.
pipes.
• Operator senses heat radiating and rumbling noises from
10:30 P.M.
tank.
• Water escape into main process,
• Supervisor starts vent gas scrubber circulation pump.
pipe system and eventually MIC
12:25 P.M.
storage tank E-610.
• Chemical reaction between MIC and water becomes
• Chemical reaction between MIC
uncontrolled.
and water begins.

PAGE 6
• MIC gas starts escaping from VGS stack.
11:00 P.M.
12:45 P.M.
• MIC storage tank pressure rises to
• All plant operations are suspended.
1.7 bar, which is still within safe
1:00 P.M.
operating time of 1.1 bar to 2.7 bar.

LEAK
• MIC gas reaches nearby residents.
• Toxic gas alarm sounded by operator.

TIMELINE
MIC Toxicity
• Clear, colorless, sharp smelling
liquid
• Highly flammable

PAGE 7
• Extremely toxic
• Volatile reaction with water in
about 10 minutes
• Union Carbide used MIC to
produce a insecticide called
Carbaryl.
• MIC reacts with 1-naphthol in a
hydrolysis process to produce
Carbaryl.
MIC

PAGE 08
STORAG
E TANK
 Equipment and
instrumentation
 Pressure gauge failures
was thought to be faulty, hence
its readings were ignored by the operators
 tank temperature was not logged
 the MIC storage tank was not pressurized due to a

PAGE 9
leaky valve
 the refrigeration system was turned off
 vent gas scrubber (VGS) was under maintenance
 VGS could not handle the large influx of MIC even if it
were in operation
 flare tower was disconnected from the plant pipe system
 water curtains which were 10 metres high were not tall
enough to reach the stack of VGS which was 30 meters
high
FACTORS LEADING TO THE GAS
LEAK

PAGE 10
LESSON
LEARNED

PAGE 11
Inherently safer design Process Hazard Analysis Leading and lagging indicators
(ISD) (PHA)
• From the start, neither the company • Negligence on earlier minor MIC
• Minimize, or use small
nor the local authority considered leakages or ‘near misses’ that
quantities of hazardous
hazard assessment for rare events caused burns and deaths;
substances
in the UCIL plant.
• Moderate, or reduce the • Failure to address previous
strength of an effect • Ignoring safety of a toxic facility near
a railway and population center. inspection concerns about leaks,
• Simplify, or eliminate ruptured pipes, faulty gauges, and
• Government errors: permitting the poor instructions.
unnecessary complexity to
MIC plant near homes without
reduce risk of human error
assessing risks.
Continue…

PAGE 12
Emergency response
Employee participation Safety as a prime concern
planning (ERP)
• Hazards and treatment methods • Cutting safety training and staff led
were not communicated, and no to poor risk management and a • The Bhopal accident highlights that
knockdown tank was provided for tragic incident. management failures and a focus
MIC. on production often lead to
• Minor accidents revealed declining neglected safety and expertise
• Operators’ ad hoc responses were
operator performance. issues.
error-prone due to severe stress • Safety management and
impairing decision-making. regulatory compliance must be
• Ensure safety through employee
• Simplify, or eliminate unnecessary involvement, regular training, and strict at both corporate and
complexity to reduce risk of procedure reviews. governmental levels.
human error
CONCLUSION
Conclusions were made that a malicious
worker with the knowledge of the Bhopal
plant directed pipe water into the tank.
However, earlier leaks, claims of
underinvestment in safety measures, and

PAGE 13
allowing substandard inputs to save on
costs provided a clear link to a possible
disaster.
If the corporate management had taken
safety measures to respond to the
sudden addition of water to the MIC tank,
the disaster would have minimal impacts.
The Bhopal gas disaster had numerous
effects on the population of India, both
direct and indirect.
Thank you