An evaluation of risk assessment framework for industrial accidents in India

Due to rapid industrialization, with high population density and constraints of land, it is expected that level of risks arising from the hazardous industries will increase in India in the coming decades. However, 30 years after the Bhopal accident (1984), except a few discrete regulations, there is as yet no integrated system for assessing and managing risks arising out of these hazardous industries in India. The gravity of aspects related to the management of industrial risk still remains crucially important. In particular, there is no standard guideline on risk analysis methodology, acceptability or tolerability criteria, nor is there an accident database or a risk reduction strategy for the areas where risk levels are already high. On top of this, there are technical and legislative gaps in the institutional framework to implement any of the above mentioned issues. With the backdrop of the Bhopal gas tragedy, the objective of this paper is therefore to evaluate the effectiveness of a comprehensive risk assessment framework for the emerging economy of India, in order to control and/or to reduce the risk level that exists. In this context, regulations and policies pertaining to industrial risk assessment were reviewed.     

Bhopal disaster—a personal experience

Bhopal Gas Tragedy was the worst industrial accident in the world where several thousand persons lost their lives. It occurred at the Union Carbide plant located inside the city of Bhopal and close to the railway station, at midnight of December 2-3, 1984 due to the leakage of MIC gas which took the local sleeping and floating population unawares.

This paper describes the experience of a transit passenger who reached the Bhopal Railway Station by train at about the same time when the deadly gas leakage occurred.     

Lessons after Bhopal: CSB a catalyst for change

The Bhopal tragedy was a defining moment in the history of the chemical industry. On December 3, 1984, a runaway reaction within a methyl isocyanate storage tank at the Union Carbide India Limited pesticide plant released a toxic gas cloud that killed thousands and injured hundreds of thousands. After Bhopal, industrial chemical plants became a major public concern. Both the public and the chemical industry realized the necessity of improving chemical process safety.

Bhopal served as a wake-up call. To prevent the same event from occurring in the United States, many legislative and industrial changes were invoked—one of which was formation of the U.S. Chemical Safety and Hazard Investigation Board (CSB). The ultimate goal of CSB is to use the lessons learned and recommendations from its investigations to achieve positive change within the chemical industry—preventing incidents and saving lives.

Although it seems clear that the lessons learned at Bhopal have improved chemical plant safety, CSB investigations indicate that the systemic problems identified at Bhopal remain the underlying causes of many incidents. These include:

• Lack of awareness of reactive hazards.

• Lack of management of change.

• Inadequate plant design and maintenance.

• Ineffective employee training.

• Ineffective emergency preparedness and community notification.

• Lack of root cause incident investigations and communication of lessons learned.

The aim of this paper is to present common themes from recent cases investigated by CSB and to discuss how these issues might be best addressed in the future.

This paper has not been independently approved by the Board and is published for general informational purposes only. Any material in the paper that did not originate in a Board-approved report is solely the responsibility of the authors and does not represent an official finding, conclusion, or position of the Board.     

Literary and economic impact of the Bhopal gas tragedy

The 1984 Bhopal disaster is widely regarded as a watershed event in the field of process-safety and has been largely responsible for a paradigm shift in the outlook of both industry and the public towards risk management within the processing industries. The Bhopal disaster has led to increased regulations and awareness for process-safety related activities across the globe. This paper reports the effect of the infamous Bhopal incident on the research community and examines the performance of manufacturing industries following the disaster.

For this paper, databases of scientific publications were used to investigate research trends in the safety area following the 1984 Bhopal disaster. Our analysis focuses on prominent safety-related research fields that have emerged following the gas tragedy as well as economic indicators of the processing industries. The study reveals that the process industry has consistently progressed over the years, in spite of added regulations and a worsened public image following the Bhopal disaster, and promises to be a stable economy in the future.     

Fault propagation behavior study and root cause reasoning with dynamic Bayesian network based framework

The Bhopal disaster was a gas leak incident in India, considered the world's worst industrial disaster happened around process facilities. Nowadays the process facilities in petrochemical industries have becoming increasingly large and automatic. There are many risk factors with complex relationships among them. Unfortunately, some operators have poor access to abnormal situation management experience due to the lack of knowledge. However these interdependencies are seldom accounted for in current risk and safety analyses, which also belonged to the main factor causing Bhopal tragedy. Fault propagation behavior of process system is studied in this paper, and a dynamic Bayesian network based framework for root cause reasoning is proposed to deal with abnormal situation. It will help operators to fully understand the relationships among all the risk factors, identify the causes that lead to the abnormal situations, and consider all available safety measures to cope with the situation. Examples from a case study for process facilities are included to illustrate the effectiveness of the proposed approach. It also provides a method to help us do things better in the future and to make sure that another such terrible accident never happens again.     

The unfolding of Bhopal disaster

As an employee of Union Carbide India at the Bhopal plant, I know how the disaster happened. The merciless cost-cutting severely affecting materials of construction, maintenance, training, manpower and morale resulted in the disaster that was waiting to happen. Significant differences between the West Virginia, USA plant and the Bhopal, India plant show the callous disregard of the corporation for the people of the developing countries. The narrative below, if given a proper thought by the management and governments, should help in significantly reducing industrial accidents.     

The Bhopal tragedy: its influence on process and community safety as practiced in the United States

The chemical accident at 12:45 AM on December 3, 1984 in Bhopal India had a profound effect on the practice of chemical process safety in the United States. Fearing the possibility of similar events occurring in the United States, the United States Congress convened several hearings and investigations into the causes of the disaster. The inquiries focused both on the state of process safety within the US chemical industry and on the readiness of communities located near chemical operations to respond to sudden and dangerous toxic discharges. Of equal significance were concerns over the safety of workers in chemical plants. This paper reviews the major legislative, academic, and industrial changes initiated in the area of process safety after the event, their influence on saving lives, and on improving living conditions surrounding chemical complexes in the United States.     

Export inherent safety NOT risk

The author presents a personal view that production of bulk chemicals and the attendant risks are being transferred from developed to developing nations. Some evidence is presented on the transfer of production. The transferred risk is increased because of the larger scale plants that are now built in locales that are less able to cope with the increased hazards. Bhopal was an example of an inherently unsafe plant, with major hazards that could have been avoided or drastically reduced by design. It behoves the industry to adopt the inherently safer philosophy and practice in the new plants that it builds, in order to minimise the opportunity for another accident like Bhopal and the threat to our industry that such an accident would pose.     

The Bhopal gas tragedy: could it have happened in a developed country?

The Bhopal gas tragedy occurred in December 1984 wherein approximately 41 tonnes of deadly MIC was released in the dead of night. It caused the death of over 3000 people and continued life-long misery for over 300,000 with certain genetic defects passed on to the next generation. It happened in a plant operated by a multinational, Union Carbide Corporation, in a developing country, India. The tragedy has changed the chemical process industry (CPI) forever. The results have been new legislation with better enforcement, enhancement in process safety, development of inherently safer plants, harsher court judgements, pro-active media and NGOs, rights-conscious public, and a CPI management willing to invest in safety related equipment and training. These have already resulted in savings of several hundred lives and over a billion dollars in accident damages [Kletz, T. (1998a). Process plants: a handbook of inherently safer designs. London: Taylor & Francis. Sutton, I. Chemical Engineering, 106(5), (1999). 114]. However, thousands did not have to die for the world to realise the disaster potential of CPI. The question that still remains is whether such an accident could have happened in a developed country. The answer is ‘yes’, as a number of major accidents in the developed countries since 1984, such as the Piper Alpha oil platform fire (1988, 167 killed), the Zeebrugge ferry disaster (1987, 167 killed), Phillips petroleum fire and explosion (1989, 23 killed), the Challenger disaster (1986, 7 killed), Esso Australia Longford explosion (1998, 2 killed) have demonstrated. One or more of the following are the primary reasons for such disasters: The indifferent attitude of the management towards safety, the lax enforcement of the existing regulations by the regulatory bodies as well as unusual delays in the judicial systems. Such conditions can happen regardless of the level of development in a country. Hence, the Bhopal gas tragedy could have happened in a developed country too, albeit with a lower probability. This paper is concerned with the possibility and not with the probability value. It also points out that further significant advances in process safety will occur with fundamental research into the causes of accidents and with a move towards inherently safer design.     

Method for identifying errors in chemical process development and design base on accidents knowledge

It has been claimed that the high accident rate in the chemical process industry is due to poor dissemination of accident knowledge that affects directly the level of learning from accidents. In response to this situation, this paper utilized past accident knowledge as a basis to develop a safety oriented design tool whereby the accident information were directly disseminated into plant design. The method was developed based on our previous accident analysis of design error in which the common design errors were ranked in accordance to their frequency and its origins during normal plant design project. Based on the design error ranking and its origin at a specific design phases, a method for design error detection is proposed. The method is expected to be able to identify the possible design error and its causes throughout chemical process development and design. The main objective is to trigger safe design thinking at the specific design phases so that appropriate action for risk reduction could be timely implemented. The Bhopal and BP Texas tragedies are used as case studies to test and verify the method. The proposed method can detect up to 74% of design errors.     

Bhopal and its effects on the Canadian regulatory framework

Instead of legislating after the Bhopal accident, Canada choose to innovate by adopting a consultative approach. In 1987, Environment Canada set up the Major Industrial Accidents Council of Canada (MIACC), a non profit organization financed by the federal and provincial governments and industry.

MIACC was a process rather than a structure. Governments, industries, responders, trade unions, NGOs, etc. have shared their expertise. It has worked as a partnership for the development of standards, guidance documents, etc. in prevention, preparedness, response and recovery.

MIACC ceased to exist in 1999. Although, MIACC disappearance is unfortunate, it is not dramatic. A culture of partnership, of working together towards common objectives, is now well in place and influences the development of regulations.

Natural disasters and the 911 terrorist attack on New York triggered the publication of regulations.

The legislative process started in 2001 with the Province of Quebec adopting a new Civil Protection Act for the protection of persons and property against disasters.

Year 2003 saw major developments in the regulation of emergencies—changes that are likely to have significant influences on how companies operate in Canada. Surprisingly, however, these changes have received little attention in the media, and many companies may not be aware of their implications.

This paper will review these developments, and will examine what has already taken place. Topics include:

• The federal regulation of environmental emergencies under the Canadian Environmental Protection Act;

• Extension of the Criminal Code of Canada to allow criminal charges and possibly heavy penalties for senior officials and corporations, including an explicit legal duty to protect workers from harm;

• Quebec Civil Protection Act designed to identify and manage risks;

• Ontario‘s stepwise regulation of municipal emergency preparedness with the intended goal of NFPA 1600 compliance by 2007, and the implications for the process industries;

• Potential regulation at the municipal level.

Operational risk assessment: A case of the Bhopal disaster

Accidental releases of hazardous chemicals from process facilities can cause catastrophic consequences. The Bhopal disaster resulting from a combination of inherently unsafe designs and poorly managed operations is a well-known case. Effective risk modeling approaches that provide early warnings are helpful to prevent and control such rare but catastrophic events. Probability estimation of these events is a constant challenge due to the scarcity of directly relevant data. Therefore, precursor-based methods that adopt the Bayesian theorem to update prior judgments on event probabilities using empirical data have been proposed. The updated probabilities are then integrated with consequences of varying severity to produce the risk profile.This paper proposes an operational risk assessment framework, in which a precursor-based Bayesian network approach is used for probability estimation, and loss functions are applied for consequence assessment. The estimated risk profile can be updated continuously given real-time operational data. As process facilities operate, this method integrates a failure-updating mechanism with potential consequences to generate a real-time operational risk profile. The real time risk profile is valuable in activating accident prevention and control strategies. The approach is applied to the Bhopal accident to demonstrate its applicability and effectiveness.     

Method for identifying contributors to chemical process accidents

The paper presents a new method for identifying contributors to chemical process accidents by exploiting knowledge on causes of past accident cases. Accident reports from the Failure Knowledge Database were analyzed and utilized for hazard identification. The accident information gathered was used as a basis to develop an accidents ranking and points-to-look-for approach for the safe design and operation of chemical process equipment. In the method, accident contributors including technical, design and operation errors of major process equipment types and piping are identified. The method is applicable throughout the process lifecycle, even for process changes in the early design stages. The Bhopal tragedy is used as a case study to demonstrate and test the method. The proposed method can predict on average up to 85% of accident causes and design and operation errors.     

Systems-based accident analysis methods: A comparison of Accimap, HFACS, and STAMP

Three accident causation models, each with their own associated approach to accident analysis, currently dominate the human factors literature. Although the models are in general agreement that accidents represent a complex, systems phenomenon, the subsequent analysis methods prescribed are very different. This paper presents a case study-based comparison of the three methods: Accimap, HFACS and STAMP. Each was used independently by separate analysts to analyse the recent Mangatepopo gorge tragedy in which six students and their teacher drowned while participating in a led gorge walking activity. The outputs were then compared and contrasted, revealing significant differences across the three methods. These differences are discussed in detail, and the implications for accident analysis are articulated. In conclusion, a modified version of the Accimap method, incorporating domain specific taxonomies of failure modes, is recommended for future accident analysis efforts.     

Towards an evaluation of accident investigation methods in terms of their alignment with accident causation models

The purpose of this paper is to reflect on accident causation models and accident investigation methods. Theories on accident causation and the modelling of accident mechanisms, as well as a number of methods for accident investigation have been developed and described in the literature. The evolution of accident causation models over time shows a shift from the sequence of events to the representation of the whole system. Respectively, the evolution of accident investigation methods over time reveals a gradual shift from searching for a single immediate cause, to the recognition of multiple causes. In order to evaluate the accident investigation methods, specific plausible requirements were established in order to verify that a specific accident investigation method fulfils the principles of a specific accident causation model or give evidence to the degree of alignment between them. Since different models approach accident causation in different ways, methods linked to these models provide fragmentary information regarding the accident. It is therefore expected that using a combination of model-method pairs could provide a more reliable platform for accident analysis.     

Toward an integrative approach of the industrial risk management process in France

Management in the field of environmental protection and risk prevention has evolved to the increasing participation of all stakeholders in the decision-making process. It certainly results from the development of the Information society and the global increase of knowledge of the population, combined with the concerns of the populations related to a sustainable development of our civilisation. Our ‘risk society’, following the big industrial disasters (Flixborough,Tchernobyl, Bhopal, Challenger, and more recently Toulouse), has also developed a cautious attitude towards the role of the expertise when it comes to assessing risks, along with a question of the ability of science to give definite answers.

This has lead in particular to the adoption of the Aarhus convention in 1998 and the evolution of several regulations in the developed countries. For example, in France the new law no. 2003–699 of 30 July 2003 about the ‘prevention of the technological and natural risks and to the compensation for the damages’ has introduced an important innovation into the process of technological risks prevention.

This law has enabled the involvement of the stakeholders in the decision-making process related to risk prevention and has urged the development of specific tools to deal with the complexity of risk management issues, in particular for those related to land-use planning.

As technical support to decision-makers in risk management from both public and private sectors, INERIS has played an important role for the evolution of the French risk management system.

This paper describes an analysis on the difficulty to control major accident hazards in an evolving context where the industrial systems becomes more and more complex and where the expectations of the civil society has increased. Then, the authors describe how an integrated vision for industrial risk management has emerged in France and is being implemented in a new law adopted after the Toulouse disaster.     

Aftermath of the world''s worst chemical disaster: Bhopal, December 1984

Current practice in preventive environmental health action includes chemical analysis of land, water and air for known (controlled) toxic chemicals and comparison against standards for identification of breaches of regulatory limits. This methodology is also followed after an accident or disaster to ensure air, water and food safety. Some problems, not easily addressed by this methodology include: unidentified toxic chemicals; non-conventional uses of toxic materials, unexpected synergestic effects of toxic mixtures, and human health consequences of exposure to toxic materials with unusual and unidentified pathways of exposures. In Bhopal we were faced with a mixture of about 27 toxic substances, a variety of exposures related to activities of the persons, for example, remaining in their homes or running in the toxic cloud, and a variety of perceived injuries not all of which would have been predicted by analyzing the chemicals involved. In this paper we will present the advantages of combinations of approaches including examination of health, social and cultural environment and economic situation of the victims of the Bhopal disaster and their effect on health. This more broad analysis provides a clearer big picture of the problems in the aftermath of exposure, and also clues to effective treatment and alleviation of future problems. We will present two effective strategies for connecting health problems ten years after exposure to the original disaster, and understanding the biochemical reactions in the body when invaded by a mixture of toxic substances and how such an understanding will in turn affect public policy planning, emergency preparedness and emergency medicine.     

Evolution of road risk disparities at small-scale level: example of Belgium

PROBLEM: Road accident outcomes are traditionally analyzed at state or road network level due to a lack of aggregated data and suitable analytical methods. The aim of this paper is to demonstrate usefulness of a simple spatiotemporal modeling of road accident outcomes at small-scale geographical level. METHOD: Small-area spatiotemporal Bayesian models commonly used in epidemiological studies reveal the existence of spatial correlation in accident data and provide a mechanism to quantify its effect. The models were run for Belgium data for the period 2000-2005. Two different scale levels and two different exposure variables were considered under Bayesian hierarchical models of annual accident and fatal injury counts. The use of the conditional autoregressive (CAR) formulation of area specific relative risk and trend terms leads to more distinctive patterns of risk and its evolution. The Pearson correlation tests for relative risk rates and temporal trends allows researchers to determine the development of risk disparities in time. RESULTS: Analysis of spatial effects allowed the identification of clusters with similar risk outcomes pointing toward spatial structure in road accident outcomes and their background mechanisms. From the analysis of temporal trends, different developments in road accident and fatality rates in the three federated regions of Belgium came into light. Increasing spatial disparities in terms of fatal injury risk and decreasing spatial disparities in terms of accident risk with time were further identified. IMPACT ON INDUSTRY: The application of a space-time model to accident and fatal injury counts at a small-scale level in Belgium allowed identification of several areas with outstandingly high accident (injury) records. This could allow more efficient redistribution of resources and more efficient road safety management in Belgium.     

The post-Bhopal and post-9/11 transformations in chemical emergency prevention and response policy in the United States

The United States' approach to incident prevention and response to hazardous chemical facilities has undergone two major transformations in the last 20 years. The first was triggered by the Bhopal tragedy in 1984, which led to major changes within the US chemical industry and a series of Federal laws and regulations intended to prevent major chemical accidents. A more recent transformation is currently underway in the wake of the 9/11 attacks on New York and Washington. It involves the advent of various security-related requirements affecting many of the same facilities covered under the existing accident prevention rules. This paper provides an overview of these transformations and their impacts.     

A criterion for developing credible accident scenarios for risk assessment

Maximum credible accident analysis is one of the most widely used concepts in risk assessment of chemical process industries. Central to this concept is the aspect of ‘credibility’ of envisaged accident scenarios. However, thus far the term credibility is mostly treated qualitatively, based on the subjective judgement of the concerned analysts. This causes wide variation in the results of the studies conducted on the same industrial unit by different analysts.

This paper presents an attempt to develop a criterion using which credible accident scenarios may be identified from among a large number of possibilities. The credible scenarios thus identified may then be processed for detailed consequence analysis. This would help in reducing the cost of the analysis and prevent undue emphasis on less credible scenarios at the expense of more credible ones.