HAZARD AND OPERABILITY REVIEW ON BHOPAL TRAGEDY

Item

1A

Study
Node

Process
Parameter

Deviation

N2 flow

Flow

No

1B
1C
1D
2A

Gas Stream

Possible Causes

Possible Consequences

Action Required

(Guide
Words)
1.Control valve fails closed
1. 2. Controller fails& closed valve

High

1.Control valve fails open

Temperature

Low
High

1.Low water supply

1.High water supply

Flow

No

1.May be fatal
2. Flammable liquid

1. MIC tank could not

pressurised & slow initial
reaction
1. None-controller handles
1. cooling system capacity
limited

1. Select valve to fail to

open
2. Place controller on
critical instrumentation
list
1. Instruct operators and
update procedures
1. None
1. Install high flow
alarm/cooling water high
temperature alarm
1. Check and repair
control valve
Select valve to fail
open

1. Control valve fails closed

1. Clogging of gas in
pipeline cause
explosion occur in MIC
storage tank

2. Controller fails and closes

valve

2. As above

2. Place controller on
critical
instrumentation list

3. Air pressure fails lead to

closing valve due to small
amount of MIC in storage
tank (less gas produced)

3. As above

3. Clean the clogging

Install filter with
maintenance
procedure
Install gas flow meter

and low flow alarm

2B

High

1. Control valve fails open

1. possible runaway on
heating and lead to
explosion

1. Instruct operators and

update procedures.
2. See 1A.2

2C

Low

2. Controller fails and opens

valve

2. The rupture disk is

stimulated to burst

1. Partially plugged gas flow

route

1. Diminished cooling,
possible runaway and
can lead to explosion
due overheating

2. Control valve fails to respond

2. See 1A.2
2.

2D

As well
as

1. Backflow of water to MIC

storage tank

2E

Part of

1. Covered under 1C

2F

Reverse

1. Backflow of gas due to high

back pressure

2G

Other
than

1. Not considered possible

2H

Sooner
than

1. Cooling normally started

early

1. See 1A.3

As above

1. Possible runaway
reaction with the MIC
component

1. Install water indicator

2. Do schedule checking
and monitoring

1. Loss of cooling,
possible runaway of
heating
2. Contamination of MIC
component

1. Install check valve

1. None

1. Carry out
inspection
frequently.

2I

Later than

2J

Temperature

2K

2L

Pressure

2M
3A

Cooling
Stream

1. Operator error

1. Temperature rises,
possible runaway

Low

1. Low MIC temperature

1. None

High

1. High MIC temperature

1. Temperature rise and

boiling process occurs
which can lead to
explosion if
temperature too high

High

1.Cover under 1B

Low

1.Cover under 1C

Flow
No

1.Circulation of pump failed to

operate

1. Interlocking between
gas flow and reactor
feed (MIC)
1. None
1. Install high flow
alarm or MIC high
temperature alarm

1. Loss of cooling, possible

runaway

1. Reinstall pump with

consistent maintenance
procedure.

2. Refrigerant service failure

3B

High

1.Controller fails and valve open

1.Loss of cooling, possible

runaway

1. Check and monitor the

reliability of refrigerant

Low

1. control valve fails to respond

1. Liquid MIC cannot be

cooled as usual

1.Instruct the operator and

update the procedure for
the control valve

3C

3D

As well
as

4. Contamination of Freon
supply

4. Possible chemical
reaction with MIC
component

1.Do schedule checking

and monitoring

3E

Reverse

3. Backflow due to high back

pressure

3. Loss of cooling,
possible runaway

1. Install check valve

3F

Other
than

3. Not considered possible.

3G

Part of

3H

Sooner
than

1. Covered under deviation on

low
1. Cooling normally started early

3I

Later than

3J

Where
else

3K

Temperature

3L

4A

Storage
Tank

Pressure

1. Operator error

1. Temperature may
increases
2. Route of water,
possible runaway

Not considered possible

High

High pressure, increases the water

supply temperature

1. Cooling system
become limited,
temperature
increases

1.Install alarm high

flow alarm/cooling
water high
temperature alarm

Low

No flow, lower the water supply

temperature

1. None-controller
handle the situation

1. None

High

1. Drain line filter blocked

Valve leak

1. Water pass through

header

1.Unblock filter at drain

line
Change controller

4B

4C

Temperature

Low

1. Insufficient Pressure to make

water flow

High

1. Overheated

1. MIC tank could not

be pressurised
causes tank PVC
failed to open
1. Water leak into tank that

1.Control tank pressure

(Tank was designed for
only 70psig(4bar)
1. Supervise temperature

contains E610 gases

causing runaway heat and
producing reaction
4D

2. Turn on the
refrigeration system
(Freon refrigeration
system was shutdown to
save money)

Low

5A

Agitation

No

sensor

1. Power Breakdown

Mixing
Eductor

No mixing, possible
accumulation of
unreacted product.

Feed valve must fail

closed on power
breakdown.

2. Motor malfunction
2

5B

More

Motor controller fails, motor

turn at higher speed

5C

Less

1. Power supply low

5D
5E

Reverse
Faster
/slower

1. Not considerable possible

1. Not considerable possible

Higher reaction rate,

causing higher
temperature and
pressure, possible
runaway.

Lower reaction rate,

accumulation of
unreacted material.

Install agitation speed

indicator and
agitation speed alarm.
Schedule preventive
maintenance of
motor.
1. See 2A. 2

1. See 2A.2