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 Case review and Question Group work Discussions

Business in Bhopal Introduction 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 Bhopal 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.