Hkksiky nq?

kZVuk
IykaV dh fLFkfr
dk;Z fof/k
dk;Z iz.kkyh dk rkjrE;
nq?kZVuk
nq?kZVuk ds dkj.k
lh[kus yk;d ikB
1

;wfu;u dkckZbM bafM;k fy- Hkksiky

fLFkfr%& e/; izns'k dh jkt/kkuh Hkksiky] uxj dk mRrj
iwohZ fdukjk
jsyos LVs'ku o cl LVS.M 2 fd-eh- nwj
iwoZ esa >qXxh >ksifM+;ka
nf{k.k iwoZ es vU; fjgk;lh cfLr;ka
izksMDV%& dkcZfjy rFkk mlls cuus okyh vusd dhVuk'kd
nok;sa
2

feFkkby vkblks lkbusV

izkjEHk esa fe- vk- lk- rFkk vYQk uSIFkky ls dkcZfjy 1979 esa fe-vk-lk- cukus ds ykblsal dh vuqefr ekaxh uxj iz'kkld usa la;a=k uxj ds ckgj yxkus dh laLrqfr nh fdUrq
ljdkj us mls vekU; djds ekStwnk fLFkfr ij gh mRiknu djus dh
vuqefr iznku dh 1981 esa fe-vk-lk- dk mRiknu izkjEHk rhu Hkwfexr VSadksa esa ls nks esa ,e-vkbZ-lh- dk
HkaMkj.k] rhljs dks vkikr fFkfr esa iz;ksx djus ds fy;s j[kk dkj[kkus esa /kkVk & vusd deZpkfj;ksa dk iyk;u3

feFkkby vkblks lkbusV

,e-vlb-lh- QsQM+ksa es tyu iSnk djrh gSA

QsQM+ksa es lwtu ls lkal ysus esa dfBukbZA
lguh; lkanzrk& 0-02 ihih,e] [krjukd & 20 ihih,e
Cok;fyax IokbaV & 400 lsVsadksa esa jsQzhtjs'ku dh O;oLFkk rFkk lqj{kk eSuqvy esa
rkieku 00lsa j[kus rFkk 150lsa ls mij dHkh u tkus nsus dk
funsZ'kA

STORAGE OF MIC
Scrubber
Safety
Valve

Safety vent
header

From
the
plant

Tank

610

Nitrogen
line

Refriger
ation
Plant

Process vent
header
Toth
e
plan
t

Flare
stack
5

DEVIATIONS IN THE WORK PRACTICES

As Per Operating Manual

As Available

Vent Scrubber to be in
active mode
Refrigeration to be kept
running
Safety Vent and process
Vents to be kept separate
Flare vent to be kept
connected

Scrubber
closed.
Kept closed
Interconnect
ed
Flare vent
disconnected
7

Safety Lapses
One week back when attempt was done
to utilise 42 tons of MIC before closing
the plant for shut down, valve of
process vent header was found to be
leaking but nothing had been done to
repair the valve.
As per process manual only stainless
steel was to be used in all the pipelines
but vent headers had been made out of
only carbon steel
8

Sequence of events

When hose was connected to vent line of the

reactor to remove the bock on the day of
accident blind was not inserted in the line to
ensure that water may not flow to vent
header.
Safety Vent Header
Closed but leaking
Open
Closed

Hose
10

Reactor

Water entered into the vent header had passed on to

the process header. Valve connecting the MIC storage
tank was not holding as a result the water has entered
the tank and reacted with MIC to initiate self
polymerisation reaction which had heated up the MIC
tank.

Safety vent header

Jumper

Process vent Header

Valve not holding

11

The metallic salts present in the

headers had gone into the tank
which has acted as catalyst for
the polymerisation reaction.
Refrigeration plant was not
working

12

Scrubber was not working

The line of flare stack had been

removed for repairing
MIC was released from the vent
at the top of the scrubber

13

Hot vapour vent upwards but on

cooling it came back to the ground
in the form of due and fog
Vapour could not disperse properly in
air due to mist formation. This
resulted into very high
concentrations at the ground level.

14

le; c) fooj.k
9-15 ih,e & fcuk CykbaM fd;s fjyhQ okYo ykbuksa dh
lQkbZ izkjEHk A
9-30 ih,e & vkijsVj }kjk ykbu Cykd gksus dh lqijokbtj dks
fjiksVZ A
10-00 ih,e & lqijokbtj }kjk lQkbZ tkjh j[kus ds fy;s funsZ'k
A
10-20 ih,e & Vsad la- 610 esa izs'kj 2 ih,lvkbZ ls mij ugha
c<+ jgk Fkk A
15

 10-45 ih,e & f'kQ~V cnyh A

10-45 ih,e & lsQ~Vh osaV ls izklst osaV esa rFkk ogka ls Vsad es
ikuh dk izos'k A
11-00 ih,e & vkijsVj us ykxcqd esa 10 ih,lvkbZ izs'kj fy[kk A
11-30 ih,e & ,evkbZlh dk fjlko igyh ckj irk yxk A
11-45 ih,e & lqijokbtj dks fjlko rFkk Vsad esa izs'kj vf/kd gksus dh
lwpuk nh xbZ A
11-50 ih,e & vkijsVj us lsQ~Vh osaV gsMj ls ihys jax dk nzo Vidrs
ns[kk A
16

 12-00 ,,e & lqijokbtj us ikuh ls ykbu dh lQkbZ can djus dks dgk
A
12-15 ,,e & lqijokbtj dh pk; dh NqV~Vh A
12-20 ,,e & osaV xSl Ldzcj pkyw djus dk iz;kl A
12-25 ,,e & IykaV lqifjaVsaMsaV dk vkxeu A
12-30 ,,e & izlj xst dh jhfMax jat ls mij A VSad ds mij dadzhV
xje A
12-40 ,,e & osaV dh fpeuh ls xSl fudyus dh lwpuk A
1-00 ,,e & [krjs dk ,ykeZ ctk A iqfyl isV~jksy us daV~jky:e dks
dkj[kkus esa dqN xM+cM+h dh lwpuk nh A
17

izHkkfor yksxksa ds fooj.k

3-12-1984 izkr% & gehfn;k fpfdRlky; esa 12000 vk;sA
3@4-12-1984 jkr & dqN vkSj yksx izHkkfor gq;s A
4-12-84 dks fpfdRlky; dks 55000 yksxksa dk bykt djuk
iM+k] tc fd vLirky esa dqy 750 csM Fks A
ljdkjh vkad.ksa ds vuqlkj 2500 yksxksa dh e`R;q gqbZ fdUrq
Lo;a lsoh laLFkkvksa }kjk fd;s x;s ?kj&?kj losZ ds vk/kkj ij
vkbZ [kcjksa ds vk/kkj ij 5000 ls 8000 rd yksx ejsA
18

Ikkuh dSls x;k

fjyhQ okYo osaV gsMj
4

Izzkklst osV gsMj

1- vkblksys'ku okYo
2- jIpj fMLd

3- ukbV~jkstu okYo
4- tEij ykbu
5- lsQVh okYo

19

Nq?kZVuk ds eq[; dkj.k

1- vkblksys'ku okYo dk yhd gksuk A

2- fLyi IysV dk u yxk;k tkuk A
3- ,d fjeksV okYo dk can u fd;k tkuk A
4- fjyhQ okYo vkSj izklst osaV gsMjks dks vkil esa tksM+
fn;k tkuk A

20

xyfr;ka

1- gkMZos;j dh xyfr;ka
2- vkijsVj dh xyfr;ka
3- lwpuk dh deh
4- flLVe dh dfe;ka
5- ljdkjh ra=k dh xyfr;ka

21

gkMZos;j dh xyfr;ka

Ldzcj dh {kerk I;kZIr ugha FkhA mles eSuqvy fLop Fkk] ftls pkyw
djds ugha j[kk x;k FkkA
jsQzhtjsku IykaV dk;Z ugha dj jgk FkkA
rkieku c<+us dk ladsr nsus ds fy;s lsalj & ,ykeZ ugha FkkA
izslj vkSj VsEijspj baMhdsVj dk;Z ugha dj jgs FksA
I;kZIr la[;k esa xSl ekLd miyC/k ugha FksA
Q~ys;j LVSd tqM+h ugha FkhA
flLVe esa cnyko djrs gq;s izklst osaV gsMj rFkk fjyhQ okYo osaV
gsMj tksM+ fn;s x;s FksA
22

gkMZos;j dh xyfr;ka & dze'k%

,e vkbZ lh ds fy;s yksgs dh ikbi ykbu dk iz;ksx fd;k x;k FkkA

ikbiksa vkSj okYoksa dh lQkbZ le; ls ugha dh tkrh FkhA
,l-,l- ds ctk; yksgs ds ikbi dk iz;ksxA
Vsadksa es a,evkbZlh ds fy;s vkuykbu ekfuVj ugha FksA
okVj dVZsu dh mapkbZ I;kZIr ugha FkhA
izslj xst dh jsat vf/kdre laHkkfor iszlj ls de FkhA

23

vkijsVj ls LEcfU/kr xyfr;ka

vizfkf{kr lqijokbtj rFkk dkexkjksa dh la[;k esa ?kVkoA

VSd ds izljkbt u gksus ij dksbZ ,Dku u ysukA
ikbi dh /kqykbZ esa xyr rjhds dk iz;ksxA
iszlj c<+us ds ckjs esa rqjar lwpuk u nsukA
oDlZ eSustj dks xSl fjlko dh rqjUr lwpuk u nsukA
fjlko okys Vsad ds izslj dks [kkyh j[ks Vsad esa u ys tkukA

24

vkijsVj ls lEcfU/kr xyfr;ka & dze'k%

Iqfyl }kjk iwNs tkus ij fjlko dh lwpuk u nsukA
fjlko gksus ij rqjar lkbju u ctkukA
lkbju ctkus ds ckn rqjar can dj nsukA

25

lwpuk lEcU/kh xyfr;ka

dkj[kkus esa betSZUlh Iyku ugha Fkk A
dkexkjksa dks mfpr funsZ'k ugha fn;s x;s A
IykaV ekMhfQds'ku ds igys gStkMZ ,ukfyfll ugha dh x;h
Fkh A
osLV othZfu;k ds IykaV ds vkfMV esa ;g dgk x;k Fkk fd bl
izdkj dk fj;D'ku lEHko gS] fqQj Hkh ml ij /;ku ugha fn;k
x;k A
26

lwpuk lEcU/kh xyfr;ka & dze'k%

fdlh fpfdRld dks ,evklh ds fo"kSysiu rFkk ihfM+r O;fDr dh
fpfdRlk fof/k dh tkudkjh ugha Fkh A
tulkekU; dks lEHkkfor ?kVuk dh tkudkjh ugha FkhA
dkj[kkus esa cts ,ykeZ ds egRo ds ckjs esa fdlh dks tkudkjh
ugha FkhAQkLthu dks vf/kd fo"kSyh xSl le>us dh xyrgeh A

27