Bhopal Gas Tragedy
Bhopal as a Case Study - Union Carbide Corp.
INVESTIGATION OF LARGE-MAGNITUDE INCIDENTS:
BHOPAL AS A CASE STUDY
Ashok S. Kalelkar
Arthur D. Little, Inc.
Cambridge, Massachusetts, USA
Presented At
The Institution of Chemical Engineers Conference On
Preventing Major Chemical Accidents
London, England
May 1988
ABSTRACT
The investigation of large-magnitude incidents is fraught with difficulties and the process of establishing the primary cause of an incident often requires an understanding of human nature in addition to the necessary technical and engineering skills. The salient non-technical features that are common to the investigation of large-magnitude events are discussed in general. The investigation of the Bhopal disaster is discussed as a specific case study in light of these salient features. The results of the overall investigation are discussed and it is demonstrated that the commonly-held view that water-washing of a certain header caused the disaster is physically impossible. Evidence is presented which indicates that direct water entry into the methyl isocyanate storage tank was the likely initiating cause of the Bhopal disaster.
I. INTRODUCTION
In the aftermath of a major accident or incident in the chemical industry, it is common practice to ascertain the cause of the event through an investigation. If the magnitude of the incident is very large in terms of its impact on people, property, or the environment, it is not uncommon to assemble several teams of investigators to seek the cause of the incident independently. In the
United States, a large-magnitude event may be investigated by the company that owns the facility, the insurance group that provides the liability coverage, federal investigators (e.g., OSHA, EPA), and state and local regulatory agencies. When several investigations are being conducted concurrently, in spite of the differing interests that are represented by each investigating team, cooperation and
INVESTIGATION OF LARGE-MAGNITUDE INCIDENTS:
BHOPAL AS A CASE STUDY
Ashok S. Kalelkar
Arthur D. Little, Inc.
Cambridge, Massachusetts, USA
Presented At
The Institution of Chemical Engineers Conference On
Preventing Major Chemical Accidents
London, England
May 1988
ABSTRACT
The investigation of large-magnitude incidents is fraught with difficulties and the process of establishing the primary cause of an incident often requires an understanding of human nature in addition to the necessary technical and engineering skills. The salient non-technical features that are common to the investigation of large-magnitude events are discussed in general. The investigation of the Bhopal disaster is discussed as a specific case study in light of these salient features. The results of the overall investigation are discussed and it is demonstrated that the commonly-held view that water-washing of a certain header caused the disaster is physically impossible. Evidence is presented which indicates that direct water entry into the methyl isocyanate storage tank was the likely initiating cause of the Bhopal disaster.
I. INTRODUCTION
In the aftermath of a major accident or incident in the chemical industry, it is common practice to ascertain the cause of the event through an investigation. If the magnitude of the incident is very large in terms of its impact on people, property, or the environment, it is not uncommon to assemble several teams of investigators to seek the cause of the incident independently. In the
United States, a large-magnitude event may be investigated by the company that owns the facility, the insurance group that provides the liability coverage, federal investigators (e.g., OSHA, EPA), and state and local regulatory agencies. When several investigations are being conducted concurrently, in spite of the differing interests that are represented by each investigating team, cooperation and
References: 1. Pietersen, J.M., "Analysis of the LPG Incident in San Juan Ixtahuapec, Mexico City, 19 November 1984", TNO Report 85-0222, 1985. MDL Docket No. 626, U.S. District Court, Southern District of New York, Ordered November 8, 1985.