Tutorial 1: Case Study

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Tutorial 1Case Study Business in Bhopal

• Roshanak Moradi Nadimian
• Munira Jessa
• SY DE 142 May 10, 2004
• Introduction to Human Systems Engineering
• Waterloo, Ontario, Canada

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Outline

• Introductions
• What should you expect from Tutorials?
• Business in Bhopal Questions
• Business in Bhopal Group work
• Business in Bhopal Discussion

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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 dont need to take notes from the
  tutorial notes, they will be posted on the course
  website after each tutorial.

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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

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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

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Format of the Tutorials

• 8 Tutorials
• Case review and Question
• Group work
• Discussions

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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.

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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.

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Business in BhopalWhy?

• 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

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Business in BhopalWhy?

• 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

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Business in BhopalEfforts 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

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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 branchs failure, for example the
refrigeration unit not working do not cause the
vent gas scrubbers failure, these are both
events occurring at different times and both
causing the MIC spread over the village.