CHE 458

Chapter 1: Introduction

1
 SAFETY

System
Attitude
Fundamentals
Experience
Time
You

2
 Occupational VS Process Safety
Occupational Safety
Protect workers
Considers human level
Focuses on changing behavior
Less expensive to implement
Process Safety
Protects both workers and public
Takes humans, environment,
business into consideration
Focuses on changing systems
Expensive because of the large
scale of investment
3
 Process Safety
A disciplined framework for managing the integrity
of operating systems and processes handling
hazardous substances by applying good design
principles, engineering, and operating practices. It
deals with the prevention and control of incidents
that have the potential to release hazardous
materials or energy.

4
 Definitions
Safety: Strategy for accident prevention
- not very well defined.

Accident: An unplanned event or sequence of events that

results in an undesirable consequence.
Example: A leak in a pressurized vessel containing
ammonia.

Incident: The basic description of an event or series of

events, resulting in one or more undesirable
consequences, such as harm to people, damage to
the environment, or asset / business losses. For
chemical plants this includes fires / explosions and
releases of toxic or harmful substances.
Example: A leak of 10 kg/s caused by corrosion of
the storage vessel.

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 Definitions
Hazard: An inherent chemical or physical characteristic
that has the potential for causing damage to
people, property, or the environment.
Hazards are typically always present.
Example: A pressurized tank containing ammonia.

Consequence: A measure of the expected effects of a specific

incident outcome.
Example: A 10 kg/s ammonia release resulted in a
toxic cloud downwind.

Impact: A measure of the ultimate loss and harm of an

incident.
Example: A 10 kg/s ammonia leak prodused a
downwind toxic vapor cloud resulting in local
evacuations, emergency response, plant downtime
and loss of community support.
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 Definitions
Risk: A measure of human injury,
environmental damage, or economic loss
in terms of both the incident likelihood
and the magnitude of the loss or injury.
A function of two important things:
1. Probability 2. Consequence

Likelihood: A measure of the expected probability

or frequency of occurrence of an event.
For chemical plants the frequency is most
commonly used.

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Truths / Myths of Process Safety
“Process safety is a soft science with no more
than hardhats and safety glasses - not
engineering science.”
Myth!

Textbook: Chemical Process

Safety, Fundaments with
Applications, 3rd ed. by Crowl and
Louvar contains 427 equations,
comparable to any chemical
engineering text.

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Truths / Myths of Process Safety
“Process safety is the same as personal safety.”

Myth!
Process Safety addresses the
Consequence control and prevention of “high
Major Offsite consequence, low frequency
Incident events” (such as fires, explosions
Process Safety and accidental releases of
hazardous materials).
Serious Onsite
Incident

Personal Safety
Slips, Trips
and Falls

Frequency 9
Source: Enform.ca
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Truths / Myths of Process Safety

6. “Process safety costs lots of money and has

a negative effect on the company’s profits.”
Myth!
Process safety actually saves money. The
increased cost of the process safety
program is offset by savings due to fewer
accidents, less down time, increased
production, improved product quality … .
There may be extra costs to start-up the
safety program.

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 Typical Chemical Plant Hazards
Properties of Chemicals: Toxicity
Flammability
Reactivity
Bio hazards

Equipment / Process: High Pressure

High Temperature
Mechanical

Procedures: Normal process operation

Vessel entry
Hot work permit

Management: Performance monitoring

Safety culture
Hazard identification

Important point: Not possible to list all the potential hazards!

Hazards may be continuously present or may
change based on operations
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 Safety Culture

The common set of values, behaviors, and norms at

all levels in a facility or in the wider organization that
affect process safety.

The normal way things are done at a facility,

company, or organization, reflecting expected
organizational values, beliefs, and behaviors, that set
the priority, commitment and resource levels for
safety programs and performance.

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 Hazard Identification

It is a relatively easy to identify the hazards given a

specific physical situation.

It is a lot more difficult to identify the hazards for a

plant that is being designed and doesn’t exist yet.

We will rely on our risk based process safety

(RBPS) procedures to help us with this.

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Definitions

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 Voluntary and Involuntary Risk
Voluntary Risk – Risk that is consciously tolerated by
someone seeking to obtain the benefits of the activity that
poses the risk.
Examples: Riding a car,
Riding a motorcycle,
Mountain climbing,
Skiing

Involuntary Risk – Risk that is imposed on someone who does

not directly benefit from the activity that poses the risk.
Examples: Living in the vicinity of a chemical plant,
Riding a train,
Riding an airplane,
Visiting a mall.

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 Accident Pyramid

1-2 Fatalities

10 - 20 Serious Injuries

100 - 200 Minor Injuries

ity
ver

1,000 - 2,000 Near Misses

Se

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 Safety Metrics
Used to measure the effectiveness of a
safety program.

Lagging metrics: data collected after an

incident has occurred.

Leading metrics: data collected before an

incident has occurred.

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 Leading / Lagging Indicators
Leading Indicators:
Response time for process safety suggestions
Number of workers with overdue training
Number of operating procedures updated each year
Work order backlog

Lagging Indicators: Based on accidents that occurred.

First aid incidents
Loss of primary containment (LOPC) incidents
Property damage
Injuries
Fatalities

Lagging indicators are easier to define and tabulate.

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 Accident Statistics
All lagging indicators!

1. Total number of fatalities or injuries /

illnesses.
2. Deaths per 100,000 people.
3. Fatality rate, or deaths per person per
year.
4. Fatal injury rate based on total hours or
total workers.
5. Incidence rate.

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Glossary of Terms used by OSHA

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Glossary of Terms used by OSHA

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 Accident and Loss Statistics

Three main systems:

1. OSHA incidence rate (OIR)

2. Fatal accident rate (FAR)
3. Fatality rate, or deaths per person per year

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 Accident and Loss Statistics

OSHA incidence rate 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑖𝑛𝑗𝑢𝑟𝑖𝑒𝑠 𝑎𝑛𝑑 𝑖𝑙𝑙𝑛𝑒𝑠𝑠𝑒𝑠 x 200,000

=
(based on injuries and illness) 𝑇𝑜𝑡𝑎𝑙 ℎ𝑜𝑢𝑟𝑠 𝑤𝑜𝑟𝑘𝑒𝑑 𝑏𝑦 𝑎𝑙𝑙 𝑒𝑚𝑝𝑙𝑜𝑦𝑒𝑒𝑠 𝑑𝑢𝑟𝑖𝑛𝑔 𝑝𝑒𝑟𝑖𝑜𝑑 𝑐𝑜𝑣𝑒𝑟𝑒𝑑

OSHA incidence rate 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑙𝑜𝑠t workdays x 200,000

=
(based on lost workdays) 𝑇𝑜𝑡𝑎𝑙 ℎ𝑜𝑢𝑟𝑠 𝑤𝑜𝑟𝑘𝑒𝑑 𝑏𝑦 𝑎𝑙𝑙 𝑒𝑚𝑝𝑙𝑜𝑦𝑒𝑒𝑠 𝑑𝑢𝑟𝑖𝑛𝑔 𝑝𝑒𝑟𝑖𝑜𝑑 𝑐𝑜𝑣𝑒𝑟𝑒𝑑

𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑓𝑎𝑡𝑎𝑙𝑖𝑡𝑖𝑒𝑠 x 108

Fatal Accident Rate (FAR) =
𝑇𝑜𝑡𝑎𝑙 ℎ𝑜𝑢𝑟𝑠 𝑤𝑜𝑟𝑘𝑒𝑑 𝑏𝑦 𝑎𝑙𝑙 𝑒𝑚𝑝𝑙𝑜𝑦𝑒𝑒𝑠 𝑑𝑢𝑟𝑖𝑛𝑔 𝑝𝑒𝑟𝑖𝑜𝑑 𝑐𝑜𝑣𝑒𝑟𝑒𝑑

𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑓𝑎𝑡𝑎𝑙𝑖𝑡𝑖𝑒𝑠 𝑝𝑒𝑟 𝑦𝑒𝑎𝑟

Fatality rate =
𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑜𝑝𝑙𝑒 𝑖𝑛 𝑎𝑝𝑝𝑙𝑖𝑐𝑎𝑏𝑙𝑒 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛

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 Statistics for General
Population - 2014
Injury Class Total Deaths per
Fatalities 100,000 people
All deaths (occupational and non-occupational): 136,0531 42.7
Poisoning: 42,0321 13.2
Motor vehicle: 35,398 11.2
Falls: 31,959 10.0
Choking: 4,816 1.5
Drowning: 3,406 1.1
Fires, flames and smoke: 2,701 0.4
Exposure to excessive natural cold: 930
Firearm discharge: 270 0.2
Exposure to excessive natural heat: 244
Exposure to electric transmission lines: 58
Lightning: 25
Flood: 8

1Includes 38,718 fatalities due to drug overdose.

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 Industry
Hours Based
2015 Total
Fatalities
Fatal Injury
Rate1
All industries: 4836 3.4
Construction (overall): 937 10.1
Transportation and warehousing: 765 13.8
Agriculture, forestry, fishing and hunting: 570 22.8
Truck transportation: 546 25.2
Professional and business services: 477 3.0
Manufacturing: 353 2.3
Government (State and local): 338 2.2
Retail trade: 269 1.8
Leisure and hospitality: 225 2.0
Wholesale trade: 175 4.7
Government:, Federal 118 1.3
Restaurants and other food services: 100 1.4
Police and sheriff’s patrol officers: 85 11.7
Financial activities: 83 0.9
Carpenters: 83 6.7
Electricians: 83 10.7
Professional, scientific and technical services: 76 0.8
Roofers: 75 39.7
Taxi drivers and chauffeurs: 54 13.4
Information: 42 1.5
Fire fighters: 29 4.3
Mining (except oil and gas): 28 12.4
Chemical manufacturing: 28 2.0
Fishing, hunting and trapping: 23 54.8
Utilities: 22 2.2
Hospitals: 21 0.4
Colleges, universities and professional schools: 17
Plastics and rubber products manufacturing: 17 3.3
Oil and gas extraction: 6 26
Chemical and allied products merchant wholesalers: 3
 Chemical Industry Fatalities
2015 Gasoline Stations (Retail): 39

Chemical Manufacturing: 28
Fertilizer manufacturing: 6
Basic chemical manufacturing: 5
Soap, cleaning compound and
toilet prep manufacturing: 4
Pharmaceutical and medicine manufacturing: 3
Paint, coating and adhesive manufacturing: 2
Industrial gas manufacturing: 1
All other chemical manufacturing: 7

Plastics Manufacturing: 13

Petroleum and Coal Products Manufacturing: 12

Asphalt paving mixture and block manufacturing: 5
Petroleum refineries: 4
Asphalt shingle and coating materials manufacturing: 3

Petroleum and Petroleum Products Merchant Wholesalers: 9

Crude Petroleum and Natural Gas Extraction: 6

Rubber Product Manufacturing: 4

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Chemical and Allied Products Merchant Wholesalers: 3
2015 Chemical Industry Losses
Event Type Property Damage
($US Billions, adjusted to Dec. 2015 $)
Explosion: $21.19
Fire: $4.36
Blowout: $2.54
Storm: $2.00
Collision: $1.32
Earthquake: $1.23
Sinking: $0.61
Release: $0.23
Mechanical Damage: $0.27
TOTAL: $33.75
Property damage is only a fraction of the total losses!

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 Conclusions from Statistics

• Chemical industry has a low number of

fatalities / injuries.
• These fatalities / injuries are a lot less
than other activities that the public
considers less hazardous. Thus, the
chemical industry has to perform better
to convince the public.
• Financial losses from chemical plant
accidents are huge.

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 Workplace Fatalities

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Source: US Bureau of Labor Statistics
 Accident Sequence

Most accidents follow a three-step sequence:

1. Initiation (the event that starts the accident)

2. Propagation (the event or events that
maintain or expand the accident), and
3. Termination (the event or events that stop the
accident or diminish it in size)

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Defeating an Accident

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 Protecting Hazards: Safeguards

Hazard Incident Consequences

+ Enabling
Conditions + Conditional Modifiers

Enabling Conditions: Do not independently cause the incident, but must

be present or active for it to proceed. Examples: T or P at certain values,
process in particular state of operation (i.e. recycle mode), presence of
raw material in process, etc.

Conditional Modifiers: Conditions that occur after initiation and impact a

step in the sequence either before or after the incident has occurred.
Examples: weather conditions (wind speed in certain direction),
presence of people, probability of ignition, etc.

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 Preventive Safeguards
Preventive Safeguard: prevents an initiating event from
proceeding to a defined, undesirable incident. Also called a
protection layer. The preventive safeguard stops the
incident from proceeding.
• Basic process control system (BPCS)
• Alarm systems
• Operator response to an alarm or process conditions
• Pressure relief system with containment
• Maintenance
• Interlocks
• Emergency shutoff valves
• Emergency cooling systems
• Grounding and bonding to prevent static
accumulation
• Normal testing and inspection
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 Mitigative Safeguards
Mitigative Safeguards: reduces the consequences after an
incident has occurred. May already have consequences as
a result of the incident.
• Active fire protection, including sprinklers, sprays
• Emergency fire water system
• Passive fire protection including insulation
• Flammable vapor detectors
• Emergency response, including on-site and off-site
• Plant and equipment layout and spacing
• Diking around storage areas / process.
• Emergency power
• Blast walls
• Water curtains to disperse vapors
• Blast resistant control rooms
• Explosion blow-out panels on process vessels
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 Swiss Cheese Model

Safeguards
Preventive Mitigative

Consequences
Hazards

Incident

Defects in safeguards

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 Inherently Safer Design

Safeguards are used to prevent initiating events

from propagating into an incident with
consequences. These safeguards add considerable
cost to the process and also require testing and
maintenance – and the safeguards can still fail.

If we could design a process with fewer hazards,

then the process would be simplified, and the
safeguards reduced. This is the essence of
inherently safety design – to eliminate hazards
rather than to provide complex safeguard
hierarchies around the hazards.

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 Inherently Safer Design

An inherently safer plant uses the elimination of

hazards to prevent accidents, rather than depending
on control systems, interlocks, redundancy, special
management systems, complex operating
instructions or elaborate procedures. Inherently
safer plants are tolerant of errors and are often cost
effective. Inherently safer plants are simpler, easier
to operate, and more reliable.
Inherently safer designs permanently and
inseparably reduce or eliminate process hazards
that must be contained and controlled to avoid
accidents.
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 Inherently Safer Design

“The essence of the inherently safer

approach to plant design is the
avoidance of hazards rather than
their control by added-on protective
equipment.”
T. A. Kletz, Plant Design for Safety: A User-Friendly Approach (NY:
Hemisphere, 1991)

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Crowl’s Lion Farm

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 Crowl’s Lion Farm
Hazard: Lions

Incident: Driver loses control of pick-up truck.

Scenario: Truck drives thru Lion cage fence.

Lions walk thru hole in fence.
Lions prowl around community.
Incident Outcome: Local community is
alarmed, people are attacked, several dogs
disappear.
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 Crowl’s Lion Farm

Inherently Safer Design Approach: If we are

cultivating the lions only for meat, why not use
lambs instead? This way, the hazard is
eliminated, control is simplified, fences are
reduced in strength, and emergency response
is eliminated.

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Inherently Safer Design Strategies

• MINIMIZE

• SUBSTITUTE

• MODERATE

• SIMPLIFY

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Minimize

= Reduce hazardous
material/energy quantity
– Reduces energy
– Reduces potential accident severity

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Substitute

= Replace with a less hazardous

material
– Reduces/eliminates available
chemical energy
– Reduces/eliminates potential
accident severity

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Moderate
= Use under less hazardous
conditions
– Available energy may be the
same, but
– Passively reduces potential
loss event impacts
– For chemical processes, this
usually means lower
temperatures, pressures,
concentrations, etc.
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 Simplify

= Reduce unnecessary complexity

– Reduces likelihood of an accident

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 Inherent Safety Techniques

Type Typical techniques

• Change from large batch reactor to a smaller continuous reactor
• Reduce storage inventory of raw materials
Minimize • Improve control to reduce inventory of hazardous intermediate
chemicals
• Reduce process hold-up
• Use mechanical pump seals vs. packing
• Use welded pipe vs. flanged
• Use solvents that are less toxic
Substitute • Use mechanical gauges vs. mercury
• Use chemicals with higher flash points, boiling points, and other
less hazardous properties
• Use water as a heat transfer fluid instead of hot oil

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 Inherent Safety Techniques
Type Typical techniques
• Use vacuum to reduce boiling point
• Reduce process temperatures and pressures
• Refrigerate storage vessels
• Dissolve hazardous material in safe solvent
Moderate • Operate at conditions where reactor runaway is not possible
• Place control rooms away from operations
• Separate pump rooms from other rooms
• Acoustically insulate noisy lines and equipment
• Barricade control rooms and tanks
• Keep piping systems neat and visually easy to follow
• Design control panels that are easy to comprehend
• Design plants for easy and safe maintenance
• Pick equipment that requires less maintenance
• Pick equipment with low failure rates
Simplify • Add fire- and explosion-resistant barricades
• Separate systems and controls into blocks that are easy to comprehend and
understand
• Label pipes for easy "walking the line"
• Label vessels and controls to enhance understanding
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 Risk Tolerance – Risk Matrix
Risk Matrix Likelihood
1. Select the severity from the highest box in either of columns 1, 2 or 3. Read the 4 5 6 7
Category and Safety Severity Level from the same row. LIKELY UNLIKELY IMPROBABLE IMPROBABLE.
BUT NOT
2. Select the likelihood from columns 4 thru 7. IMPOSSIBLE
3. Read the Risk Level from the intersection of the severity row and the likelihood Expected to
column. Expected to happen Expected to Not expected to
happen possibly happen possibly happen anywhere
TMEF: Target mitigated event frequency several times once over once in the in the division
TQ: Threshold Quantity over the life of the life of the division over the over the life of the
the plant. plant. life of the plant. plant

1 2 3 Safety 0 to 9 10 to 99
Human Health Fire, Explosion Chemical Severity Severity ≥ 100 years > 1000 years
years years
Impact Direct Cost in $ Impact Category Level
Public fatality 4
possible, Greater than Risk Level Risk Level Risk Level Risk Level
$10 MM ≥ 20x TQ CATASTROPHIC TMEF =
employee A A B C
1×10-6
fatalities likely
Severity

Employee fatality From VERY 3

possible. Major $1 MM to < $10 MM 9x to < 20x TMEF = Risk Level Risk Level Risk Level Risk Level
SERIOUS A B C D
injury likely TQ 1×10-5
From 2
Lost time injury Risk Level Risk Level Risk Level Negligible
$100K to < $1 MM 3x to < 9x SERIOUS TMEF =
(LTI) likelya B C D Risk
TQ 1×10-4
Recordable From 1
$25K to < $100K MINOR TMEF = Risk Level Risk Level Negligible Negligible
Injuryb 1x to < 3x
TQ 1×10-3 C D Risk Risk

Risk Level A: Unacceptable risk, additional safeguards must be implemented immediately.

Risk Level B: Undesirable risk, additional safeguards must be implemented within 3 months.
Risk Level C: Acceptable risk, but only if existing safeguards reduces the risk to As Low as Reasonably Practicable (ALARP) levels.
Risk Level D: Acceptable risk, no additional safeguards required.

aLosttime injury (LTI): The injured worker is unable to perform regular job duties, takes time off for recovery, or is assigned modified work duties while
recovering.
bRecordable injury: Death, days away from work (DAW), restricted work or transfer to another job, medical treatment beyond first aid, or loss of

consciousness.

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Table 1-15: Risk matrix for semi-quantitative classification of incidents.
Table 1-16 Threshold quantities (TQ) for a variety of chemicals. Source: AICHE/CCPS
2,000 kg = 4,400 lbm Ethyl acetate 200 kg = 440 lbm
Acrylamide Ethyl benzene Ammonia, anhydrous
Ammonium nitrate fertilizer Ethylenediamine Carbon monoxide
Amyl acetate
Amyl nitrate
Formic acid
Heptane 100 kg = 220 lbm
Threshold Quantities (TQ)
Bromobenzene Hexane Hydrogen bromide, anhydrous
Calcium oxide Methacrylic acid Hydrogen chloride, anhydrous
Carbon dioxide Methyl acetate Hydrogen fluoride, anhydrous
Carbon, activated n-Heptene Methyl bromide
Chloroform Nitrobenzene Methyl mercaptan
Copper chloride Nitromethane Sulfur dioxide
Kerosene Octanes
Maleic anhydride Phenol, molten or solid
n-Decane Propylamine 25 kg = 55 lbm
Nitroethane Pyridine Chlorine
Nitrogen, compressed Silver nitrate Cyanogen
Nitrous oxide Sodium permanganate Germane
Nonanes Tetrahydrofuran Hydrogen sulfide
Oxygen, compressed Toluene Nitric acid, red fuming
Paraldehyde
Phosphoric acid
Triethylamine
Vinyl acetate
Sulfuric acid, fuming
Complete table and risk
Potassium fluoride
Potassium nitrate
Zinc peroxide 5 kg = 11 lbm
Acrolein
matrix provided in
Sulfur
Tetrachloroethylene
500 kg = 1,100 lbm
Acetaldehyde
Arsine
Diborane
Reference materials on
Undecane Acrylonitrile
Calcium cyanide
Dinitrogen tetroxide
Methyl isocyanate
course web page.
1,000 kg = 2,200 lbm Carbon disulfide Nitric oxide, compressed
Acetic anhydride Cyclobutane Nitrogen trioxide
Acetone
Acetonitrile
Diethyl ether or Ethyl ether
Ethane
Phosgene
Phosphine
Each company customizes
Aldol
Ammonium perchlorate
Ethylamine
Ethylene
Stibine
the risk matrix for their
Aniline
Arsenic
Furan
Hydrazine, anhydrous
operation.
Barium Hydrogen, compressed
Benzene Lithium
Benzidine Methylamine, anhydrous
Butyraldehyde Potassium
Carbon tetrachloride Potassium cyanide
Coper chlorate Propylene oxide
Copper cyanide Silane
Cycloheptane Sodium
Cycloheptene Sodium cyanide
Cyclohexene Sodium peroxide
Dioxane Trichlorosilane 51
Epichlorohydrin
 Example – Risk Matrix
A leak of 1,500 kg of acetone results in an explosion with a financial
loss of $1,500,000. The last incident of this type occurred 15 years
ago. Use the risk matrix to determine the Severity Category, the
Safety Severity Level and the Risk Level.

Solution: The Threshold Quantity (TQ) for acetone from the table is
1,000 kg. The release of 1,500 kg is 1.5 times the TQ. From Column 3
of the Risk Matrix – Chemical Impact - this is a MINOR severity
category. From the financial loss of $1,500,000, under column 2 of the
Risk Matrix – Fire, Explosion Direct Cost in $ - this is VERY SERIOUS.

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 Risk Tolerance – Risk Matrix
Risk Matrix Likelihood
1. Select the severity from the highest box in either of columns 1, 2 or 3. Read the 4 5 6 7
Category and Safety Severity Level from the same row. LIKELY UNLIKELY IMPROBABLE IMPROBABLE.
BUT NOT
2. Select the likelihood from columns 4 thru 7. IMPOSSIBLE
3. Read the Risk Level from the intersection of the severity row and the likelihood Expected to
column. Expected to happen Expected to Not expected to
happen possibly happen possibly happen anywhere
TMEF: Target mitigated event frequency several times once over once in the in the division
TQ: Threshold Quantity over the life of the life of the division over the over the life of the
the plant. plant. life of the plant. plant

1 2 3 Safety 0 to 9 10 to 99
Human Health Fire, Explosion Chemical Severity Severity ≥ 100 years > 1000 years
years years
Impact Direct Cost in $ Impact Category Level
Public fatality 4
possible, Greater than Risk Level Risk Level Risk Level Risk Level
$10 MM ≥ 20x TQ CATASTROPHIC TMEF =
employee A A B C
1×10-6
fatalities likely
Severity

Employee fatality From VERY 3

possible. Major $1 MM to < $10 MM 9x to < 20x TMEF = Risk Level Risk Level Risk Level Risk Level
SERIOUS A B C D
injury likely TQ 1×10-5
From 2
Lost time injury Risk Level Risk Level Risk Level Negligible
$100K to < $1 MM 3x to < 9x SERIOUS TMEF =
(LTI) likelya B C D Risk
TQ 1×10-4
Recordable From 1
$25K to < $100K MINOR TMEF = Risk Level Risk Level Negligible Negligible
Injuryb 1x to < 3x
TQ 1×10-3 C D Risk Risk

Risk Level A: Unacceptable risk, additional safeguards must be implemented immediately.

Risk Level B: Undesirable risk, additional safeguards must be implemented within 3 months.
Risk Level C: Acceptable risk, but only if existing safeguards reduces the risk to As Low as Reasonably Practicable (ALARP) levels.
Risk Level D: Acceptable risk, no additional safeguards required.

aLosttime injury (LTI): The injured worker is unable to perform regular job duties, takes time off for recovery, or is assigned modified work duties while
recovering.
bRecordable injury: Death, days away from work (DAW), restricted work or transfer to another job, medical treatment beyond first aid, or loss of

consciousness.

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Table 1-15: Risk matrix for semi-quantitative classification of incidents.
Bhopal, India Incident
December 3, 1984

Image by Daniel Willey from a photograph by Wil Lipkowski

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 Bhopal, India Incident - Background

• Plant was jointly owned by Union Carbide

(USA) and Union Carbide India Limited (UCIL).
• Pesticide production plant using methyl
isocyanate as an intermediate chemical.
• Plant was under extreme financial pressure and
could not sell all of its product line.
• Plant was originally in the open country, but a
shanty town grew around the plant against
zoning laws. Local officials looked the other
way.
• The plant had two large MIC storage tanks on
site containing over 16,000 gallons of material.
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Bhopal, India Incident - MIC

Boiling point: 39.1°C

Vapor pressure at 20°C: 348 mm HG
Molecular weight: 57
Vapor density (Rel to Air) 2
Flash point temperature: -7oC = 19oF
Reacts exothermically with water!
An extreme toxin: TLV-TWA or 0.02 ppm

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 Bhopal, India Incident - Safeguards

• Nitrogen padding for the storage tanks (15 psig) – this

reduces flammability hazard.
• Refrigeration for storage tanks to keep MIC from heating
to boiling point.
• Proper relief valve sizing to prevent high pressure in the
storage tanks.
• A NaOH scrubber system to handle small releases.
• A flare tower to burn releases.
Flare

Status of Safeguards at time of incident:

• Refrigeration: off to save money
• Scrubber: out of service to save money.
• Flare: not working due to corroded pipeline.

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 Bhopal, India Incident – Steps

1. Somehow the MIC storage tank became contaminated with

water. No definitive evidence has been provided for how this
occurred.
2. The MIC reacted with the water, heating the MIC to its boiling
point.
3. The pressure inside the storage tank increased until the relief
device opened, discharging MIC vapor into the atmosphere.
4. The atmospheric conditions were such that the wind speed was
low, causing little dispersion of the vapors.
5. It was nighttime so most folks in the shanty town were asleep.
6. No emergency response plan was in place, either at the plant or
the local community. Medical response was totally inadequate.

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Bhopal, India Incident – Consequences
• An estimated 2,500 people were killed. There is great uncertainty
in this number, with some estimates as high as 5,000 or more.
• As many as 20,000 suffered severe exposure effects – some still
suffer today.
• Prior to the accident Union Carbides annual sales were $9 billion,
with 116,000 employees and 500 sites. It was a “must interview”
company and a very desirable employer.
• It was the beginning of the end for Union Carbide. After the
accident the company took a big stock hit and was the target of a
hostile stock takeover.
• Union Carbide paid a settlement to India
of $470 million.
• Union Carbide continued its downward
spiral until it was purchased in 1999 by
Dow Chemical.
• The chemical industry and chemical
engineering were impacted negatively, forever. Many new
regulations originated from this incident.
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 Bhopal, India Incident – Current Site

• Union Carbide decided to remove the remaining MIC by operating

the plant to produce product.
• The site was never properly cleaned and remediated, and is
currently overgrown with weeds.

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