Bhopal management systems

AIChE created the Center for Chemical Process Safety (CCPS) in 1985 after the chemical disasters in Mexico City, Mexico, and Bhopal, India. The CCPS is chartered to develop and disseminate technical information for use in the prevention of major chemical accidents. The center is supported by more than 100 chemical process industry sponsors that provide the necessary funding and professional guidance to its technical committees. The major product of CCPS activities has been a series of guidelines to assist those implementing various elements of a process safety and risk management system. This book is part of that series. 

Other examples of organization contributions to accidents include the degradation of the safety management system in the Bhopal chemical accident in 1984 (Gupta, 2002), poor equipment and job design in the Herald of Free Enterprise... 

Unfortunately, this appears to be precisely what happened in the Bhopal case an assumed match or compatibility of the two pairs of cultural systems as regards elements related to the safe operation of the transferred MIC plant technology apparently blocked recognition by managers and engineers of a profound mismatch and incompatibility between the safety-related elements of the respective cultural subsystems of donor and recipient. 

The several bullets above indicate that the risk management process failed to minimize or manage the risks. Indeed, extremely hazardous processes usually do have several layers of protection and Bhopal personnel took active steps to override many safety systems. They took many known risks. Most disasters are the result of multiple failures to take known safety precautions. Often we are protected by multiple layers of safety, but when these layers are continually removed, we are put in jeopardy. As each layer is removed and nothing happens (but the risk increases), the operators become more comfortable in time, then seek to remove more... 

As with almost aU incidents, in hindsight it is easy to identify the cause(s) of the event and the procedures that could have easily prevented this from occurring. It is probably inaccurate to characterize the Bhopal disaster as an accident since this implies a certain statistical randomness to the event. In this incident, people took overt actions that caused the event to occur, removed safety systems that could have minimized the effects of the initial mistake, and failed to adequately prepare for the disaster. A recent video produced by the Chemical Safety Board reviews this incident 30 years afterwards and commends improved state and federal regulations regarding process safety management (See Section 7.3.7.)... 

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