CCB2012

HEALTH, SAFETY AND ENVIRONMENT

GROUP ASSIGNMENT 3
SEPTEMBER 2012 SEMESTER

CASE STUDY :

BHOPAL GAS TRAGEDY

MEMBERS

LECTURER

STEPHEN LIEW CHEE SENG

14921

CE

VIKNESWARAN A/L ANALAGAN

14835

CE

KEK JIA HOW

14769

ME

NURUL IZYANI BINTI ZAKARIA

14779

ICT

SYINA ARMANI BINTI HASHIM

14971

ICT

: DR.OH PEI CHING

Certification of Originality

STEPHEN LIEW CHEE SENG

14921

CE

VIKNESWARAN A/L ANALAGAN

14835

CE

KEK JIA HOW

14769

ME

NURUL IZYANI BINTI ZAKARIA

14779

ICT

SYINA ARMANI BINTI HASHIM

14971

ICT

Summary
The disaster happened in the early morning hours of December 3, 1984. A poisonous grey
cloud (forty tons of toxic gases) from Union Carbide India Limited (UCIL's) 1 pesticide plant
at Bhopal spread throughout the city. Water carrying catalytic material had entered Methyl
Isocyanate (MIC) storage tank No. 610. What followed was a nightmare.
UCIL was the Indian subsidiary of Union Carbide Corporation (UCC) and it was a chemical
company established in 1934. UCIL was 51% owned by Union Carbide Corporation (UCC)
and 49% by Indian investors including the Government of India. UCIL produced batteries,
carbon products, welding equipment, plastics, industrial chemicals, pesticides, and marine
products. The UCIL factory in Bhopal was built in 1969 to produce the pesticide Sevin which
is the brand name by UCC for carbaryl. Methyl isocyanate (MIC) was used as an
intermediate. Later in 1979, a MIC production plant was built.
The chemical process employed in the Bhopal plant had methylamine reacting with
phosgene to form MIC, which was then reacted with 1-naphthol to form the final product,
carbaryl. In the early 1980s, the demand for pesticides had fallen, but production continued,
leading to buildup of stores of unused MIC.
It was estimated that over 500, 000 people were exposed to the gas and other chemicals.
About 3,000 were immediately killed after the accident and at least 15,000 to 22,000 died in
the following weeks. Even until today after a few decades, more than 50, 000 people are still
suffering. Each month, 10 to 15 people died from the illness related to the exposure of the
gas.
Considerable amount of investigation and research has been done to understand the cause
of the unforgettable tragedy. The events in Bhopal revealed that expanding industrialization
in developing countries without concurrent evolution in safety regulations could have
catastrophic consequences. National governments and international agencies must take
lesson by focusing more on widely applicable techniques for corporate responsibility and
accident prevention as much in the developing world context as in advanced industrial
nations. Specifically, prevention should include risk reduction in plant location and design
and safety legislation. The study of Health, Safety and Environment (HSE) itself has
identified that in order to maintain the wellbeing of the people and the environment,
numerous meticulous works must be done to each step in the process of production to
reduce the risks of accidents.

This case study aims to generate a complete scenario of detailed hazard analysis using the
fault tree analysis, event tree or Hazard and Operability review (HAZOP) analysis to
describe the scenario of the event. The problem is stated initially followed by the listing of the
possible sources of hazard. The possible risk associated with the hazards isthen identified
and assessed. It determines which human decisions and actions influenced the occurrence
of the events, and then identify the organizational roots of these decisions and actions.
These organizational factors are associated to other industries and engineering system.
They include flaws in the design guidelines and design practices, misguided priorities in the
management of the tradeoff between safety and productivity, mistakes in the management of
the personnel on the site, and errors of judgment in the process by which financial pressures
are presented in the production sector resulting in deficiencies in maintenance and
inspection operations.

Introduction
In the early morning hours of December 3, 1984, a poisonous grey cloud (forty tons of toxic
gases) from Union Carbide India Limited (UCIL's) 1 pesticide plant at Bhopal spread
throughout the city. Water carrying catalytic material had entered Methyl Isocyanate (MIC)
storage tank No. 610. What followed was a nightmare.
The killer gas spread through the city, sending residents scurrying through the dark streets.
No alarm ever sounded a warning and no evacuation plan was prepared. When victims
arrived at hospitals breathless and blind, doctors did not know how to treat them, as UCIL
had not provided emergency information.
It was only when the sun rose the next morning that the magnitude of the devastation was
clear. Dead bodies of humans and animals blocked the streets, leaves turned black, and the
smell of burning chilli peppers lingered in the air. Estimates suggested that as many as
10,000 may have died immediately and 30,000 to 50,000 were too ill to ever return to their
jobs.
The catastrophe raised some serious ethical issues. The pesticide factory was built in the
midst of densely populated settlements. UCIL chose to store and produce MIC, one of the
most deadly chemicals (permitted exposure levels in USA and Britain are 0.02 parts per
million), in an area where nearly 120,000 people lived. The MIC plant was not designed to
handle a runaway reaction. When the uncontrolled reaction started, MIC was flowing through
the scrubber (meant to neutralize MIC emissions) at more than 200 times its designed
capacity.
MIC in the tank was filled to 87% of its capacity while the maximum permissible was 50%.
MIC was not stored at zero degrees centigrade as prescribed and the refrigeration and
cooling systems had been shut down five months before the disaster, as part of UCC's
global economy drive. Vital gauges and indicators in the MIC tank were defective. The flare
tower meant to burn off MIC emissions was under repair at the time of the disaster and the
scrubber contained no caustic soda.

As part of UCC's drive to cut costs, the work force in the Bhopal factory was brought down
by half from 1980 to 1984. This had serious consequences on safety and maintenance. The
size of the work crew for the MIC plant was cut in half from twelve to six workers. The
maintenance supervisor position had been eliminated and there was no maintenance
supervisor. The period of safety-training to workers in the MIC plant was brought down from
6 months to 15 days.

Figure 1: Bhopal Gas Tragedy, 1984

chingaritrustbhopal.blogspot.com

The Development of Risk Scenario of Bhopal Tragedy

On December 2, 1984, it was a routine day at the Union Carbide India Ltds (UCIL) factory in
Bhopal. Methyl isocyanate (MIC) was stored in an underground tank.
Around 8pm to 9pm, as a routine maintenance operation, second-shift production superintendent ordered MIC plant supervisor to flush several pipes running from the phosgene
system to the scrubber via the MIC storage tanks. MIC unit workers were in charge of the
flushing, but maintenance department was responsible for inserting the slip bind (a solid
disk) into pipe above the water washing inlets as plant manual required. These take 30
minutes to 2 hours to install. The MIC unit workers were apparently not aware that
installation was a required safety procedure and slip bind was not installed. Temperature of
MIC in tanks was between 15 and 20 degree Celsius.
The pipeline washing started at 9:30 p.m. One bleeder valve (overflow device) downstream
from the flushing was blocked so water did not come out as it was supposed to. It
accumulated in the pipes. A worker shut off the water flow but the plant supervisor ordered
that the washing resume. By then water had risenpast a leaking isolation valve in the lines
being washed and got into the relief valve pipe 20 feet above ground.
By 10.30pm, water had flowed from the relief valve pipe through the jumperpipe into the
process pipe through valves normally kept open. Water got through an open blow-down
valve that was part of the nitrogen pressurization system. It was unclear whether the valve
had been left open or had failed to fully seal when last closed. Water then flowed into tank
E610 via a normally-open isolation valve.
10.30-10.45 pm Second shift went off work and third shift came on. Washing continued after
second shift worker briefed third shift worker on progress of the job. On 11pm, the workers
engaged in pipeline washing became aware of a leak. They noticed pressure gauge
connected to one of the tank had risen from a reading of about 2 psi at the start of the shift to
10 psi. Little attention was however paid considering it was within the normal 2-25psi range.
Control room lacks any reliable way of monitoring tank temperature.
About 11.30pm, workers in the area noticed MIC smell, saw MIC leak near the scrubber.
They found out that MIC and dirty water were coming out from a branch of the relief valve
pipe on the downstream side of the safety valve, away from the tank area. They set up a
water spray to neutralize the leaking MIC and informed control room personnel of situation
and their actions. They then continued to discuss the situation and what they should do next.

Around 12.15am to 12.30am, the pressure in the MIC tank about up to 25-30psi, and soon
was pinned to 55psi, which was the maximum the gauge could read. The temperature had
also shot up to 200 degree Celsius and was increasing. A control room operator went out to
tank area to check gauges on tank. While in tank area he hears a safety valve pop, hears
rumbling in tank, and felt heat emanating from it. He then saw that the concrete above the
tank was cracking.
About 12:30 a.m., the relief valve of the tank gave away and large quantities of MIC gas
leaked into the atmosphere. The workers at the factory realized the risk of a massive
disaster. They tried to activate the safety systems available at the factory. The three safety
systems available within the factory and their condition at that time were vent gas scrubber
(uses caustic soda to neutralize toxic gas exhaust from MIC plant and storage tanks before
release thru vent stack or flare), flare (burns toxic gasses to neutralize them), refrigeration
system (keep MIC at temperatures of 0-5 degrees C (32 to 42 degrees F) where it is less
reactive).
By 12.40pm, plant supervisor suspended operation of the MIC plant. Operators turned on
the flare tower to burn off toxic gas. This system was not working and water cannot reach
the gas cloud forming at the top of the scrubber stack as a piece of pipeline leading to the
tower had been removed for maintenance. Effort to cool the tank using refrigeration system
failed too because the Freon had been drained. Gas escaped for about 2 hours. They then
used the vent gas scrubber, which was considered the main line of defence. However it was
not in an operational condition. Caustic soda does not flow as it should. A cloud of gas
escapes from the scrubber stack.
Before 1am, the plant supervisor realised that the designated spare tank is not empty, hence
transferring the MIC from the tank into a nearby spare tank could not be done. The gauge of
the spare tank indicated that the tank already contained something. This gauge indicator
was found defective, later on.After failure in all the three safety systems, the workers
attempted to douse the leaking gas with water spray. The water spray reached a height of
100ft. from the ground, while the leak was at 120ft. above the ground.
At 1.00 a.m., the gas smell was obvious outside the plant. Realising that nothing could be
done to stop the leak, the workers at the plant fled. Thousands of people living around the
plant were awakened by the suffocating, burning effects of the gas. As on three sides, the
UCIL plant was-surrounded by slums and other poor settlements, the people living in these
colonies were the worst sufferers.There was no warning or guidance to the general public

around this time. There were two types of alarms in the factory, one mild siren for workers
and one loud public siren. The public siren was started only at about 2:30 a.m.
13. About 2.00 a.m., a large number of people were rushing out of the town through the
highways leaving Bhopal. The mad rush on the main roads of the city resulted in stampedes.
About two lakh people had fled the city by 3:30am.
About 3 am Army engineer units with trucks are mobilized after a retired brigadier general
requests help evacuating workers from his factory near the UCIL plant (but not under the
strongest gas concentrations). Army unit then expands operations to assist general populace
by transporting injured to hospitals and clinics. The gas clouds dissipated around 3:30 am.
By 4:00 a.m. hospitals were crowded with suffering people.Before 8am Madhya Pradesh
governor orders closure of plant plus arrest of plant manager and 4 other employees.
In the wake of the tragic disaster, a large number of people lost their lives and received
injuries, many to their lungs and eyes. According to the Government reports, 1754 persons
had died and 200,000 were injured.

Justification of the Method Used Supported with the Weaknesses and Advantages
Fault Tree Analysis
Fault Tree analysis (FTA) is an excellent troubleshooting tool. It is a top down, deductive
failure analysis in which an undesired state of a system is analyzed using Boolean logic to
combine a series of lower-level events. It can be used to prevent or identify failures prior to
their occurrence, however, it is more frequently used to analyze accidents or as an
investigative tools to pinpoint failures. Thus, the root cause of the negative event can be
identified when an accident or failure occurs.
The primary causes and the way they interact to produce an undesired event are identified
when each event is analyzed by asking, How could this happen? This logic process
continues until all potential causes have been discovered. A tree diagram is used to record
the events as they are identified throughout the process. The tree branches stop when all
events leading to the negative event are complete.
These are some of the FTA symbol used to represent various events and describe
relationships:
Gates Symbols:

OR gate

AND gate

Event Symbols:

Undeveloped event

External or house

event

Top event/Intermediate event

Transfer Symbols:

Transfer IN-OUT
10

Basic event

Advantages and Weaknesses of Fault Tree Analysis (FTA)

Advantages

Weaknesses

- We can get meaningful data about the

overall reliability of the system

Uncertainties in covering all failure

modes, inaccuracy in human error in
investigation of complex man-made
systems

Prioritize the contributors leading to

thetop event Creating the critical

Inefficiency of the tool in case of scarce

or insufficient data

equipment/ parts/ event lists for

different importance measures.

Minimize and optimize resources

Require some revision study to find

research to find the research questions
in detail

Served as a design tool that helps to

Complete understanding required

Very large trees developed

Trees not unique

create (output/lower level)

requirements.
-

Function as a diagnostic tool to identify

and correct cause of the top event. It
can help with the creation of diagnostic
manuals/processes.

We can understand the logic leading to

the top event/ undesired state

It shows compliance with the (input)

system safety/ reliability requirements

Systematic

Minimal Cut Sets

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Procedure of Fault Tree Analysis

Steps in Fault Tree Analysis involve:
1. Define the top event
In defining the top event, the type of failure to be investigated must be identified. This could
be any form of end results of the accidents happened.
2. Determine all the undesired events in operating a system
Separate the events which have common characteristics into groups. Several FTAs may be
needed to study a system completely. One event should be established representing all
events within each group and this event will become the undesired event to study.
3. Know the system
All available information about the system and its environment should be studied. A job
analysis may prove helpful in determining the necessary information.
4. Construct the fault tree
The tree must be constructed using the event symbols and it should be kept simple. Maintain
a logical, uniform, and consistent format from tier to tier. Use clear, concise titles when
writing in the event symbols. The logic gates used should be restricted to the AND gate and
OR gate with constraint symbols used only when necessary. An example would be
represented by the OVAL constraint symbol to illustrate a necessary order of events that
must happen to have an event occur. The transfer triangle should be used sparingly if at all.
The more the transfer triangle is used, the more complicated the tree becomes. The purpose
of the tree is to keep the procedure as simple as possible.
5. Validate the tree
This requires a knowledgeable person in the process to review the tree for completeness
and accuracy.
6. Evaluate the fault tree
The tree should then be scrutinized for those areas where improvements in the analysis can
be made or where there may be an opportunity to utilize alternative procedures or materials
to decrease the hazard.

12

7. Study trade-offs
Any alternative methods that are implemented should be further evaluated. This allows the
evaluators to see any problems that may be related with the new procedure prior to
implementation.
8. Consider alternatives and recommend action
This is the last step in the process where corrective action or alternative measures are
recommended.

Fault Tree Diagrams

Figure 1: Overall Fault Tree Analysis of the disaster

13

Figure 2: Fault Tree of a failure due to diminished design specifications

Figure 3: Fault Tree of incorrect management decisions

14

Figure 4: Fault Tree of poor maintenance

15

Possible Risk Associated with the Hazards

Bhopal tragedy is one of the worst accident occurred in which drew the attention of
investigators to study the causes of disaster in order to find solution and prevent the accident
from happen in future.
One of them is the plant safety systems were not designed to meet extreme cases. MIC
plants should be constructed of materials as well as those used on the West Virginia plant.
However, the Indian facility underwent cost-cutting programmes in design and construction
which were not mirrored in comparable Western plants. For example, carbon steel piping
which is more corrosive replaced stainless steel piping. The number and quality of safety
devices was reduced which is a $3-6 million saving.
The installed safety devices were manually controlled and there were not even any
emergency planning measures. In addition, only one vent gas scrubber (VGS) and one flare
tower were installed. To make it worse, no unit storage tank between MIC manufacture and
the main storage tank was installed to check for purity. None of the six man safety features
of the plant were efficient due to design but also on the night of the incident, none were
operational due to an under pressure maintenance schedule (due to under staffing).
Second is about the cheap engineering solution to a known maintenance problem. There are
defects and lapses n standard operating procedures which cause the incidents. MC storage
tank number 610 was filled beyond recommended capacity. Functional contents gauges
should have provided warning of this and the process halted until rectified. A storage tank
which supposed to be held in reserve for excess MIC already contained MIC. The reserve
storage tank should have been empty and any production should have been halted until this
requirement had been established. The blow-down valve of the MIC 610 tank was known to
be malfunctioning; consequentially it was permanently open. This valve should have been
repaired or the tank should have been removed from service until repaired. Besides, the
danger alarm sirens used for warning the adjacent residential communities were switched
off.
Not only that, the plant superintendent did not notify external agencies of the accident and
initially denied the accident had occurred. This was clear negligence on behalf of the
management. There is lack communications on site. The civic authorities did not know what
actions to take in light of there being no emergency procedures in place and were uninformed of the hazardous materials stored within the plant. Gauges measuring
temperatures and pressure in the various parts of the facility, including the crucial MIC

16

storage tanks, were so notoriously unreliable that workers ignored early signs. Besides, the
refrigeration unit for keeping MC at low temperatures and therefore making it less likely to
undergo overheating and expansion should contamination enter the tank, had been shut off
some time.
Lastly, the reductions in design. The gas scrubber designed to neutralize any escaping MIC
had been shut off for maintenance. Even it had been operative post disaster inquiries
revealed that the maximum pressure it could handle was only one quarter of that which was
actually reached in the accident. The flare tower which is designed to burn off MIC escaping
from the scrubber was also turned off, waiting for the replacement of a corroded piece of
pipe. The tower, however, was inadequately designed for its task as it was capable of
handling only a quarter of the volume of the gas released. Besides, the water curtain that is
used to neutralize any remaining gas was too short to reach the top of the flare tower where
the MIC billowed out. There was also a lack of effective warning systems where the alarm on
the storage tank failed to signal the increase in temperature on the night of the disaster.

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Consequences If Accident Occurs

In the aftermath of the poisonous cloud on December 7th 1984 a multi-billion dollar lawsuit
was filed. The American attorney who had filed the case in U.S. Court was the first beginning
of decades of legal fractions. Ultimately the legal fractions were moved from the U.S. Courts
and placed under Indian Jurisdiction to compensate those affected and injured. The Indian
Supreme Court arbitrated a settlement with UCC for a lump sum of $470 Million which was
to be distributed to the claimants as a full and final settlement. According to the BBC, the
average amount paid to the families of the dead was only $2,200. In preceding cases, UCC
made every effort to manipulate and withhold of scientific data to deter those affected. Today
the company still has not made public of the exact composition of the poisonous plume
cloud. In 1984, UCC was worth $10 billion dollars more than what it is worth today and
currently operates under DOW Chemical.
Also as a further insult to Bhopal, India, UCC discontinued investment operations following
the tragedy and has also failed to clean up the industrial site completely. The production
operations center continues to leak poisonous chemicals and heavy metals. The simplistic of
all necessities, water, has to be shipped because these poisonous chemicals have found
their way into local water aquifers. One of the principal legacys that has been added to this
Bhopal incident is that the water is so dangerously contaminated and has been left by the
company for the people of Madhya Pradesh to clean up.
The exothermic reaction triggered numerous short term health and long term health effects
for the people of Bhopal. The poisonous plume cloud was principally composed of materials
that were denser than the surrounding air consequently stayed close the ground, affecting
children that went running though some of the densest patches. Pregnant women amidst the
devastations suffered convolutions and extreme stomach pains. Many women ended up
miscarrying. As the gas cloud continued to set in individuals struggled for air, vomiting
violently, and their eyes burning. MIC breaks the walls of the lungs causing people to ooze
white foam from their mouth causing many to drown in their own bodily fluids. Other deaths
were caused relexogenic circulatory collapse and pulmonary oedema. After autopsies were
performed, the tragedy revealed the changes to the lungs, cerebral oedema, tubular
necrosis of the kidneys, fatty degeneration of the liver and necrotising enteritis. Stillbirth rate
increased by 300% and neonatal mortality rate also increased by 200%, amidst the gas leak.

18

The Methods for Controlling the Risk

The 21st century brings new and complex technologies into the industrial world. More risks
are brought over alongside with it to developing countries, companies and they often lack the
infrastructure to support and maintain these new technologies safely. Economically,
developing countries cater multinational corporations a competitive advantage. Companies
based in countries such as India offer cheap labour and low operating costs. However
workplace ethics, environmental ethics as well as the safety procedures are not stressed on
thus the very little practice on these important ways of doing work. Firms typically find it more
economically advantageous to avoid it and pay penalties than to meet the safety
requirements.
This case has examined and determined the causes and the risks of the Bhopals tragedy
previously. To avoid the tragedy to ever happen again, some important steps, no matter how
small they are needs to be practiced and not neglected so that the risks can be controlled.
There are many ways and methods to control the risks. Each category which consists of the
plant designs and operation, the company and the employees all play important roles in
controlling the risk.
The design of a plant should be regarded as the basis of importance and be made following
the existing approved plants which have been proven good. Of course this plant can be
improved and adjusted according to the location, the operations and others. Each use of
materials and products in design should be initially analysed properly and its consequences
being determined. For example in the piping, stainless steel piping should be used as it is
less corrosive than carbon steel piping. To cater to a big operational plant, quality-confirmed
materials are expected and recommended to be used despite the cost as one mistake may
lead to another mistake if the materials used are of bad quality resulting in it not able to
withstand the prior mistakes.
The installed safety devices should be able to be automatically controlled so that any
emergency measures can be done fast and smoothly. The essential devices used to contain
or burns of or neutralise certain chemicals or gases must always be available and working.
These devices can make a good difference in case of accidents. Devices such as vent gas
scrubber (VGS) and the flare tower should be available to be used all the time and they
should be in enough number and ability to support if as such large scale of accident
happens. Furthermore, unit storages tank between MIC manufacture and the main storage
tank is also an essential device as it checks for purity of the materials used therefore, this

19

device must be installed. Use of large tanks instead of a large number of steel drums is also
better in storing the chemicals.
The safety system especially, plays a critical role in controlling the risk. It has been claimed
that one of the reason for the disaster in Bhopal is due to the failure of safety system. Safety
system should follow the standards and regulations and be maintained frequently. Shutting
down of any safety system, no matter for what reason should not ever be done as it results
in a huge risk. Instead, it should be made operational all the time. Other than that, the design
of the safety system itself is important for example, a water curtain which could neutralize
escaping gases. If it was designed improperly, such as it being not tall enough to reach the
top of a flare tower, it will be entirely useless as the initial function cannot even be done. A
good, working alarm or warning systems are also an effective way to control the risks. After
a breakdown or any potential emergencies are detected, it can warn the whole plant and the
people in it so that they can take any counter measures and reduce the casualties.
Another way to control the risk is by having trained employees. These employees must not
be only trained in doing their work, but also in emergency cases. It is important to have
emergency-readied employees as this can reduce panic and an effective counter measures
for any emergencies can be calmly conducted instead. Employees must also have a good
ethical working behaviour. They must know what should be done and what should not. They
should be aware that in a place like the plant with all the chemicals and gases, a simple
careless mistake can lead to a disastrous accident. Employees must do their job properly as
well as recheck and confirm that their work has been done completely to avoid mistakes.
External agencies should be quickly notified in case of any accident. Plants supervisors
should be responsible if as such happens, instead of denying or hiding the accident. The
negligence on behalf of the management is absolutely unacceptable. They must know that
their actions can affect the whole employees that are at the plant. Communication is vital in
this case. They should communicate between each other as well as the external agencies so
that a counter measures can be effectively formed if possible. If not, they should quickly
alarm all the employees regarding the situation and to take the essential safety measures.
Furthermore, the civic authorities should also be informed of the materials stored within the
plant, including the hazardous ones.

20

The Solution for Minimizing the Risk

One of the solutions for minimizing the risk is by enhancing the safety system. As already
mentioned previously, the safety system plays a vital role in minimizing the risk. Safety
system, like its name is designed for the safety of the users by providing different systems in
different parts and paths of works that can minimize the risk as well as offers certain
equipment or ways to take counter measure on a certain accident.
The implementation of safety systems cannot be done lightly, instead it should be done with
proper plan while taking into consideration on the layout of a plant, the materials used and
the activities of the plant. Following the layout of the plant, the safety systems should be
placed strategically for them to be used efficiently. For example, the vent gas scrubber
(VGS) should be placed close to the area where there is more gas than the others and it has
potential for having leakages. VGS then can be used to scrub them off.
The safety system should be of good quality in order to provide the best efficient service.
The system for instance, must be able to withstand the faults and hold it without affecting
other areas in case of any accidents. If a system cannot endure the errors in its area, the
situation will be get worse with other areas being contaminated as well. This is why, a good,
durable and quality safety systems are needed for the best safety measures.
Last but not least, the safety system must be operational at all times. It must be maintained
from time to time in order to make sure that the safety system is fully working and there are
no damages. Faulty safety system can lead to disastrous hazards, which could not even try
to be prevented, as the safety system is not working. Therefore, functioning safety system is
crucial for the safety of the whole place.

21

Conclusion
The incident at Bhopal and its continuing consequences seem to have created a race within
the chemical process industry. Especially concerning Union Carbide and the Indian
government, there seems to be movement to concentrate on the economic ramifications for
the company and the government, versus the victims and the activists that represent
them. Oppositely, there seems to be a realization within the chemical process industry that
technology-centred design can no longer operate at the level present business conditions
require for success due to the lesser abilities and comprehension displayed by the human
component in chemical process systems. These two scenarios create a conflict.
Union Carbide wishes to close the books on the Bhopal incident, still standing firm on its
platform of sabotage as the cause of the disaster. This would avoid laying the blame on the
design and construction of the system, allowing for the presence of blind technology
transfer. If these conclusions can be avoided, Union Carbide and the Indian government can
escape any further damages, punishment, or red tape from liability. At the same time, the
chemical process industry is realizing that the application of technology in concepts such as
process safety management, qualitative risk analysis, and quantitative risk analysis could
lead to a more efficient, more beneficial, safer, human-centred chemical processing system.
The newer system would limit human error not by eliminating the human component from
the system, but by designing the system to be user friendly and user active. Participants in
the human component would be less in number but greater in knowledge, ability, and
activity. The two aspects of the conflict oppose on the same plane of influence. Activity in
the chemical process industry for more human-centred design must prove worthiness of
investment, while opposed by the attempts to end discussion of liability in the Bhopal
incident that would show the need for a technology-centred to human-centred shift.
We believe that human-centred design is the answer to revealing the faults at Bhopal, and to
allowing technology to continue to grow while still considering safety and humanity in the
face of economic ramifications. If the technology or its design is never determined to be
faulty, then mechanization could continue to grow, quantifying all aspects of humanity and
eliminating the complement between creator and creation of technology.

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