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.     

Trends in chemical hazards in Japan

In the past, the chemical industry in Japan has been the cause of a number of major industrial accidents. Subsequent to each accident, specific lessons have been learned. These lessons learned have been implemented in terms of safety education of the employees and/or safety measures of the equipment and facilities resulting in a rapid decrease of corresponding accident frequencies. In this paper, we summarized both recent and past major accidents caused by chemical substances in fixed installations in Japan. Case studies show that runaway reactions are among the main causes of major accident occurrences in the chemical process industry in Japan. A recent fatal poisoning accident caused by H₂S gas generated during maintenance work again highlights the necessity of adequate safety management in a chemical factory. Therefore, even if hazard evaluation of chemical substances and chemical processes is necessary to prevent runaway reactions, human error is also an important factor contributing to reaction hazards [Wakakura, M. (1997) Human factor in chemical accidents, J. Safety Eng. High Press. Gas. Safety Inst. Japan, 34, 846].     

On the use of probabilistic and deterministic methods in risk analysis

Risks to human beings arise from an inherent characteristic to make plans and try to make them happen, while external forces resist and tend to move our endeavours away from the plan. Any such “endeavour” is a complex ensemble of a bewildering variety of interacting elements which together form something “whole”, usually called a “system” (e.g. a chemical process plant, a nuclear power plant, the stock market, air traffic control). A system has a certain state in the present and subsequent states in the future. There are deterministic and probabilistic systems and corresponding approaches to analyse them, that is to make their current states apparent and predict their future behaviour. In this paper, it is shown in which ways both analyses appear in risk analysis and it is hypothesised that both approaches are modelling the same process, though probabilistic analysis may reveal more information since it explicitly incorporates uncertainty in the form of numbers (and “there is safety in numbers”). The overall objective of this paper is to make clear what the differences between the two approaches really are. Their respective main strengths and weaknesses are discussed. A more refined objective is to discuss the specific role of probabilities in risk analysis. Examples of both approaches are given from applications in the nuclear power and chemical process industries, and some of the main problems encountered thereby are identified. Further, the challenge to system analysis posed by “chaos theory” is discussed. Due to its non-linear dynamic character, the future behaviour of a “chaotic system” is difficult to predict over a long period of time because it depends on arbitrarily small and thus not observable variations in the current state. Such behaviour might have serious consequences for human operators involved in the control of such systems. The paper concludes that, although both approaches to risk analysis can provide adequate safety levels to systems if applied in a correct and non-biased way, probabilistic methods seem to be more cost-effective and the results easier to communicate to decision- and policy-makers.     

石化企业危险化工工艺风险等级评估指标分解

伴随石化企业的迅猛发展,危险品越来越多,生产条件越来越苛刻,同时带来的是更为重大的风险隐患以及安全事故,因此对危险工艺的风险评估就显得尤为重要.考虑到目前还没有什么好的方法来判别某种工艺就一定是危险化工工艺,因此本文在国家安监总局划分的15种危险化工工艺的基础上,根据危险化工工艺表征涉及的影响因素,结合化工工艺的实际情况,选择具有典型代表意义的重要性评价指标作为研究对象,建立了由67个具体指标形成的动态指标体系,并运用指标分类分解方法对各个指标进行量化,最后采用模糊数学综合评价对危险化工工艺进行了软件化评估,从而为政府和企业加强安全管理提供了便利,进一步实现石化企业的本质安全化.     

采用参与观察法对某石油化工厂安全文化的研究

安全文化是高风险组织安全控制理论研究的热点问题,特指高风险组织成员共享的价值观与行为规范系统,尤其强调安全的重要性。为探讨该类组织成员的行为规范,笔者采用参与观察方法对某石油化工厂进行研究。持续观察103天,记录现场发生的行为及其背景,然后把观察记录制成行为卡片,通过3名专家对现场观察行为进行分类发现,组织成员主要遵循包括:安全承诺、对规则的看法、对人性的看法、关系取向和权力影响等5类行为规范。其中:安全承诺,尤其是管理对安全的承诺是高风险组织安全文化的关键因素;中国的传统文化,如情境取向、关系取向对员工的不安全行为具有重要影响。     

The legacy of Bhopal: The impact over the last 20 years and future direction

Chemical process safety was not a major public concern prior to 1984. As far as chemical hazards were concerned, public fears focused on disease (cancer) and environmental degradation. Even a series of major process incident tragedies did not translate into widespread public concerns about major incidents in chemical plants that might disastrously affect the public. This situation changed completely after the December 1984 disaster at the Union Carbide plant in Bhopal. Not only was the public's confidence in the chemical industry shaken, the chemical industry itself questioned whether its provisions for protection against major incidents were adequate.

The recognition of the need for technical advances and implementation of management systems led to a number of initiatives by various stakeholders throughout the world. Governments and local authorities throughout the world initiated regulatory regimes. Has all that has resulted from the legacy of Bhopal reduced the frequency and severity of incidents? How can we answer this question? As we move into more and more globalization and other complexities what are the challenges we must address? According to the authors, some of these challenges are widespread dissemination and sharing of lessons learned, risk migration because of globalization, changing workforce, and breakthroughs in emerging areas in process safety.     

IEC61511标准及在石化行业安全管理中的应用

功能安全的定量评定技术已成为确保石化行业安全生产的重要手段。针对石化行业普遍存在的功能安全问题,笔者以国际电工学会(IEC)专门制定的功能安全评定标准IEC61508及IEC61511为指导,介绍其标准制定的背景、目的、体系结构以及如何利用标准开展石化行业安全联锁系统(Safety Instrumented System,SIS)的安全与误跳车定量分析。通过对SIS开展定量安全评估,可发现联锁功能存在的安全不足与误跳车现象,对于提高我国石化行业安全生产水平具有重要的促进作用,标准中有关寿命周期功能安全管理方法及重要的工程经验也对提高我国石化安全生产水平具有借鉴作用。     

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.     

Process safety data management program based on HAZOP analysis and its application to an ethylene oxide/ethylene glycol plant

HAZOP analysis is a process hazard analysis method that has been widely applied both within and outside the chemical processing industries. This paper presents a design method for a process safety data management program for petrochemical plants based on HAZOP analysis and demonstrates the steps of application involved in building a process safety data management system for an ethylene oxide/ethylene glycol production plant. Firstly, the production data files and relevant documents of the plants should be classified and stored in the program database as reference documents and treatment schemes for coping with abnormal situations should be collected and summarized as guidance documents. Secondly, the HAZOP analysis method is employed to identify all the dangerous deviations possibly existing in the production process of the ethylene oxide/ethylene glycol plant. Then, the relationships among the deviations, the reference documents and the guidance documents should be considered and evaluated. Finally, each dangerous deviation will be given a corresponding reference document and guidance document. The reference documents and guidance documents stored in the expert system can be utilized to help operators solve the corresponding technical problems and cope with abnormal situations. The process safety data management program will contribute to the identification, analysis and resolution of operation problems. When an abnormal situation occurs, according to the deviations exhibited in the system, the necessary reference documents and guidance documents will be quickly consulted by the operators, and an appropriate decision will be made to address the abnormal situation. Therefore, by using the process safety data management program, plant security and human safety in the petrochemical industries will be improved.     

Got a risk reduction strategy?

Process safety can be viewed as part of a triad that supports safety in a petrochemical facility. The other two parts are OSHA-type people safety (slips, falls, etc.) and industrial hygiene. The paper will look at process safety from a top down, plant centric view. Process safety can be distilled down to the basic concept of risk reduction. If we reduce risk, our facility will be safer. The obvious problem is that we have potential risks everywhere so how are we going to reduce all these risks to an acceptable level. Clearly we need a strategy or to use a less fancy word – a plan.Too many times it is easy to concentrate on certain aspects such as safety instrumented systems (SIS), layer of protection analysis (LOPA), behavioral safety, prevention, etc. and lose track of the whole picture of what risk reduction entails in a plant.This paper will look at risk reduction in a facility from a plant viewpoint and will cover the details and concepts of risk reduction across a wide spectrum of plant functionalities – safety climate and culture, process safety management, mechanical integrity and risk, layers of protection in risk reduction, loss of containment/hazard relationship, the risk reduction bow-tie diagram, developing a risk reduction strategy, risk reduction strategy elements, and sustainability.It will also discuss some key concepts in dealing with risk reduction in general.     

核电厂安全文化与发展

核电厂的安全问题必须得到应有的重视.核电厂的安全文化由以下两个方面组成:第1是体制,由单位的政策和管理者的活动所确定;第2是每个人的响应,这些人在上述体制中工作,并从中受益.提出了核安全文化的起源、特性和发展,以及核安全文化的建设与提高.     

A New Safety Risk Index for Use in Petrochemical Planning

Risk analysis is being used to evaluate and manage the potential of unwanted events in the chemical processing industry. The risk in this study is the risk posed by chemical plant accidents and it is presented in a simple quantitative form. A safety risk index is formulated that represents the maximum number of people that might be affected if an accident occurred that caused the release of all the plant inventory of a chemical. The index has four terms: frequency of accidents; hazardous effect of the chemical; inventory of the chemical released; size of the plant. The overall unit of the index is expressed as the number of people affected per year from the plant operation and is formed in a particularly simple manner so as to be suitable for the comparison of safety risk within a model for planning the development of the petrochemical industry.     

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.     

Learning from the Bhopal disaster to improve process safety management in Singapore

The Singapore process industry is mainly made up of chemical and energy companies such as Mitsui Chemicals, Clariant, Exxon Mobil, Shell, Sumitomo, Petrochemical Corporation of Singapore and Infineum. Majority of these companies are located on Jurong Island, southwest of Singapore. Jurong Island houses nearly 100 leading petroleum, petrochemicals and specialty chemicals companies and the total investment is about S$42 billion in total. With a land surface area of only 716 km² and a high concentration of process plants, the Singapore government places strong emphasis on safety and risk management. In this paper, four process industry veterans from the government, academic and private sectors were interviewed. Through the interviews, the authors sought to understand the veterans’ perspectives on lessons that the Singapore process industry should learn from the Bhopal disaster. The veterans expanded their thoughts beyond the Bhopal disaster and provided many insights and suggestions critical to process safety management in Singapore and other countries. A systemic model of process safety management was derived from the interviews and key elements of operational process safety management were identified. In addition, a research agenda was identified based on the inputs from the veterans.     

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.     

Chemical process route selection based upon the potential toxic impact on the aquatic,terrestrial and atmospheric environments

This paper proposes a method to estimate the inherent environmental friendliness of a chemical process plant by considering the potential toxicity impact on the aquatic, terrestrial and atmospheric environments. A worst-case scenario of a total loss of containment in the plant is assumed. The method proposed by [Gunasekera, M.Y., Edwards, D.W. (2003). Estimating the environmental impact of catastrophic chemical releases to the atomosphere: an index method for ranking alternative chemical process routes. Trans. IChemE., Part B, Process Safety and Environmental Protection, 81(B6), 463–474] for determining the inherent atmospheric environmental friendliness of a chemical plant is combined with the method proposed by [Cave, S.R., Edwards, D.W. (1997). Chemical process route selection based on assessment of inherent environmental hazard. Computers Chem. Engng., 21, S965–S970], which estimates the inherent friendliness to the aquatic and terrestrial environments.Application of this method to six routes to produce methyl methacrylate shows that the acetone cyanohydrin based route is potentially the least inherently environmentally friendly. The highest potential hazard is observed in the aquatic environment due to the chemicals associated with the acetone cyanohydrin route.     

Designing continuous safety improvement within chemical industrial areas

This article provides support in organizing and implementing novel concepts for enhancing safety on a cluster level of chemical plants. The paper elaborates the requirements for integrating Safety Management Systems of chemical plants situated within a so-called chemical cluster. Recommendations of existing Plant Safety Management System Codes of Good Practice are analyzed in relation to the needs of cluster chemical safety. The paper establishes comprehensive guidelines for gradually standardizing Plant Safety Management Systems through the design, the development and the installation of a Cluster Safety Management System within a group of chemical companies. A cluster organization framework is proposed and a scheme for continuously improving cluster and plant safety management via communication and cooperation at plant department level as well as at cluster level is suggested.     

Risk analysis of a cross-regional toxic chemical disaster by using the integrated mesoscale and microscale consequence analysis model

The rapidly growing capacity and scale of the world's petrochemical industries have forced many plants to have an even larger amount of hazardous substances. Once a serious leak occurs, the outcome of the effect zone could be very large or even uncontrollable just like the Bhopal disaster. In order to assess the risk of a cross-regional damage, this study aims to develop a model that can combine the benefits of both CFD model of the microscale simulation and the Gaussian dispersion model of the mesoscale simulation.The developed integrated model is employed on a toxic chemical tank leak accident of a process plant within an industrial park in order to explore the consequences and the risk of the toxic gas dispersion on three different scopes; one is the accident site, the second is the long-distance transmission route of the mesoscale area and the third is a target city. According to the simulation's results, it is obvious that the complexity of the structure surrounding the leaking tank will eventually affect the maximum ground concentration, the cloud shapes and cloud dilution rate, while the released gas is under dispersion. On the other hand, since the simple Gaussian dispersion model doesn't consider the above impacts, its calculation results will have many differences as compared to the realistic situation. This integrated model can be used as a tool for estimating the risk on a microscale or mesoscale areas and it can produce better results when an environmental impact analysis is required for a larger hazardous chemical process.     

Justice for Bhopal! And No More Bhopals! Three decades of national and international campaigning

Dissatisfaction with the responses of the responsible corporation, Union Carbide, and the Indian government to Bhopal resulted in a campaign by national and international NGOs (non-governmental organisations) over the past three decades. While initially the Indian and international campaigns were separate, over time greater international cooperation took place. In the immediate aftermath of the disaster local NGOs prioritised health, justice and rehabilitation issues, while international NGOs used Bhopal to question chemical industry process and environmental safety in their own countries, as well as internationally. Indian NGOs called on international NGO resources to gain legitimacy for their campaign, to use NGOs as proxies and to extend the geographical scope of the campaign, while international NGOs used Bhopal as an example to advance NGOs analyses and policies. Over the period of the campaign, Indian NGOs became more sophisticated in their campaigning. The international campaign has increasingly become an online campaign, involved in an image or reputational war with Dow Chemical, which took over Union Carbide, while the original campaign issues of justice and reparations over the process safety disaster were joined by similar issues related to environmental safety of abandoned toxic waste.