1. 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

2. Outline Introductions What should you expect from Tutorials?
Business in Bhopal: Questions
Business in Bhopal: Group work
Business in Bhopal: Discussion

3. 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.

4. 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
address

5. 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, 1
Name 2, ID 2, 2
Name 3, ID 3, 3
Name 4, ID 4, 4
Faculty of Engineering
Department of Systems Design Engineering
DATE

6. Format of the Tutorials
Case review and Question
Group work
Discussions

7. 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.

8. 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.

9. 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

10. 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

11. 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

12. 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.