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Universiti Malaysia Sabah Chemical Engineering Programme: Title: Case Study: Process Control Failure

This document provides a case study on the 1984 Bhopal disaster in India, one of the world's worst industrial accidents. Over 500,000 people were exposed to a gas leak at a Union Carbide pesticide plant, which caused many deaths and injuries. The main causes were identified as reduced training and manpower, and a lack of proper process control to regulate the plant. Key failures included faulty indicators that did not alert workers to a methyl isocyanate gas leak in a storage tank. A robust maintenance regime and safety culture could have prevented this tragedy.

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308 views3 pages

Universiti Malaysia Sabah Chemical Engineering Programme: Title: Case Study: Process Control Failure

This document provides a case study on the 1984 Bhopal disaster in India, one of the world's worst industrial accidents. Over 500,000 people were exposed to a gas leak at a Union Carbide pesticide plant, which caused many deaths and injuries. The main causes were identified as reduced training and manpower, and a lack of proper process control to regulate the plant. Key failures included faulty indicators that did not alert workers to a methyl isocyanate gas leak in a storage tank. A robust maintenance regime and safety culture could have prevented this tragedy.

Uploaded by

Aneesch Preetha
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Universiti Malaysia Sabah

Chemical Engineering Programme


Semester 2 2014/2015
KC31403 Process Control

Title : Case Study : Process Control Failure

Group Members :

Name Matric No Signature


Aw Boon Pin BK 12110034
Tie Hieng Yik BK 12110365

Submission Date : 8th of May 2015

Lecturer : Dr. Tham Heng Jin


Bhopal incident India

Bhopal disaster, which was a gas leak incident in India, occurred on 2 and 3
of December 1984 at the Union Carbide India Limited (UCIL) pesticide plant in
Bhopal. There were over 500,000 people exposed to methyl isocyanate (MIC) gas
and other chemicals, which caused them died or injured severely. The reduction in
training and manning levels and the lack of process control in regulating the whole
plant process were the main causes of the tragedy.

The direct cause of the accident was the failure in installation of the
indicators throughout the whole process. It did not alert the worker about the
leakage of MIC gas immediately. A jumper line connected to a relief valve header
to a pressure vent header enabling water from a washing operation to pass to MIC
storage tank. The too high level of water flow created an uncontrollable runaway
exothermic reaction. Once it happened, the MIC gas passed through atmosphere
through the atmospheric vent line and discharged for a long time.

Therefore, a reserve storage tank should be emptied for filling the excess
MIC gas. There should have been a setpoint in the control process for the continuous
production. Once the flow level of MIC gas exceeds the setpoint, workers should be
alerted by alarming system and thus proper action can be taken to adjust the level of
MIC gas back to normal line. The blow-down valve of the MIC 610 tank was
malfunction during the leakage of MIC gas. Thus, periodic maintenance of the unit
processes should have been done from time to time. For example, the valve should
have repaired or replaced once it was malfunctioned.

Gauges measuring temperature and pressure in some parts of the processes


were so unreliable. Hence, a robust maintenance regime, coupled with a safety
culture should be implanted. The refrigeration unit for keeping MIC at low
temperatures and thus overheating and expansion process were less likely to
happen. This caused the MIC gas tank to be shut off for some time and the
dangerous signals cannot be detected at a certain time.

As a conclusion, a systematic process control should have been installed to


detect the dangerous signals and to adjust them back to the normal for earlier time.
This can minimize the risk of injury and maximize the profit gain from the factory
production.
Figure 1: Fault tree analysis

References

Chouhan TR (2005). The Unfolding of Bhopal Disaster. Journal of Loss Prevention in the
process industry (46): 205208

Eckerman, Ingrid (2011). Bhopal Gas Catastrophy 1984: Causes and consequences (in
Nriagu JO ed. Encyclopedia of Environmental Health, volume 1, and pp. 302316).
Burlington: Elsevier.

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