EF1RedPlease note if you choose to use the Excel table to fill in your analysis you will need to copy it into Word or use some other method (e.g. a pdf writer) to combine this into the one document that you need to submit. Turnitin will only accept one documentGreenBlueColour codeMORT Reference CodeKeywords - description of relevance toExplanationSA1AccidentWater and contaminants are injected into tank E610SA1 SB1Potentially Harmful Energy Flow or Environmental ConditionWater and contaminants are injected into tank E610RedSA1 SB1 a1Non-functional EnergyWater was not intended to flow through the MIC unit linesRedSA1 SB1 a1 b1Control of Non-functional EnergyA slip blind was not inserted to block water used for cleaning pipes to flow into the tankBlueSA1 SB1 a1 b2Control ImpracticableThe slip blind is a practicable solution, at the time of the accident there was no maintenance responsable to assure that the slip blind was inserted and operators did not know or gave the importance to the control.ARRedSA1 SB1 a2Functional EnergyLarge amounts of MIC were contained in tank E610 eventhough the tank was not working properlyRedSA1 SB1 a2 b3Control of Use LTAAt the time of the accident:Control and safety valves were leaking, nitrogen positive pressure could not be maintained, some lines of the MIC unit were not made with the appropiate materials, large amounts of MIC were stored, procedures were not followedRedSA1 SB1 a2 b4Diversion LTAThe only method to minimize MIC contamination was by storing small amounts of MICRedSA1 SB1 a2 b4 c1Control of Functional Energy LTALarge amounts of MIC were contained in tank E610 eventhough the tank was not working properlyBlueSA1 SB1 a2 b4 c1Diversion of functional Energy LTADiversion was practicable, it is possible that in an attempt to reduce production costs, MIC was produced in large batches; a manager had to give the order to store large amounts of MIC regardless of the risk associatedARRedSA1 SB2Vulnerable People or ObjectsThis branch takes in concern the MIC stored as a vulnerable object due to the consequences concerned to the reaction to water and rust related contaminantsSA1 SB2 a1Non-functional People or ObjectsSA1 SB2 a1 b1Control LTASA1 SB2 a1 b2Control ImpracticableRedSA1 SB2 a2Functional People or ObjectsThis branch takes in concern the MIC stored as a vulnerable object due to the consequences concerned to the reaction to water and rust related contaminantsBlueSA1 SB2 a2 b3Control of Exposure LTAMIC was intended to be stored in the MIC tanks, but it is certain that there was too much MIC in Bhopal at the time of the accident. The cleaning process using water should be analyzed if it was first intended by the designers or it was planned afterwards. The slip blind was not inserted in the line while the cleaning process took place. A jumper line was installed between the process line and the safety relief lineRedSA1 SB2 a2 b4Evasive Action LTAThis branch takes in concern the evation of water and contaminants to enter the tankRedSA1 sb2 a2 b4 c1Means of Evasion LTABesides the valves, slip blind and possitive tank pressure there was no other evasion actions.BlueSA1 SB2 a2 b4 c2Evasion ImpracticableThe slip blind and the possitive tank pressure were controls that could be proved. At the time of the accident nboth systems were not working properly and no one knew or cared about the risk associated to their failure stateARSA1 SB3Barriers and Controls LTASA1 SB3 SC1Control of work and process LTARedSA1 SB3 SC1 SD1Technical Information Systems LTAThis branch considers the information flow between the maintenance and operation personnel and managementRedSA1 SB3 SC1 SD1 a1Technical Information LTAThis branch considers the communication between staff and supervisorRedSA1 SB3 SC1 SD1 a1 b1Knowledge LTAAs an example of inappropiate communication and the lack of available technical guidance, when water did not came out through the drain valves and the operator cut the water supply, the supervisor ordered to restart the water flowRedSA1 SB3 SC1 SD1 a1 b1 c1Based on Existing KnowledgeSafety audits performed in Bhopal and Institute plant included recommendations in which actions where neede to avoid a run away reaction5-JulRedSA1 SB3 SC1 SD1 a1 b1 c1 d1Application of Codes and Manuals, LTADuring the design and construction of the MIC unit, many safety issues were not taken into concern because of a budget deficit. Afterwards during operation, some modifications were made to facilities and to the way that the plant was operated. First, a jumper line was installed between the process line and safety relief line. During the oplant operation, water was injected to te lines and all the safety devics were not working properly at the time of the accident.0.00162425/6/15RedSA1 SB3 SC1 SD1 a1 b1 c1 d2List of Experts LTAThere was no list of experts to be called. Supervisor was not experienced enough, he order to continue supplying water to a closed system615.687723186860SA1 SB3 SC1 SD1 a1 b1 c1 d3Local Knowledge LTASA1 SB3 SC1 SD1 a1 b1 c1 d4Solution Research LTARedSA1 SB3 SC1 SD1 a1 b1 c2If there was no knownprecedentLeakage to the environment were not unusual. Workers knew that tank E610 was not working properly due to a leak in the systemRedSA1 SB3 SC1 SD1 a1 b1 c2 d5Previous investigationand analysis LTAA safety audit in Institute plant discovered that MIC contamination was possible and that a run away reaction was possible. The recommendations were not passed to Bhopal managementRedSA1 SB3 SC1 SD1 a1 b1 c2 d6Research LTAThe use of water to flush pipes could had been considered as a solution to another problem. The use of unappropiate materials in pipes could had developed the need for flushing. It was an activity less than adequate due to the reactivity of MIC wit water and contaminantsRedSA1 SB3 SC1 SD1 a1 b2Communication of Knowledge LTAThis section refers to the communication among UCC, UCIL and the government of India regarding safety concernsRedSA1 SB3 SC1 SD1 a1 b2 c3Internal Communication LTASafety concerns were not properly communicated inside the plants premises and UCCRedSA1 SB3 SC1 SD1 a1 b2 c3 d7Internal Network Structure LTAThere was no infrastructure for internal communicationRedSA1 SB3 SC1 SD1 a1 b2 c3 d8Operation of Internal Network LTAInternal communication network was not properly managed, messages were sent from area to area using messengers.RedSA1 SB3 SC1 SD1 a1 b2 c4Was the external communication LTA?The government of India did not acted as a regulatory body, it justified Bhopals plant previous accidentsRedSA1 SB3 SC1 SD1 a1 b2 c4 d9External Network Definition LTAThe government was well identified as a external agentRedSA1 SB3 SC1 SD1 a1 b2 c4 d10External Network Operation LTAThere was no evidence of environmental protection control, no safety audits. Government knew MIC process was dangerous but they did not do anything to control itRedSA1 SB3 SC1 SD1 a2Data Collection LTAIt considers the data collection and use of proceduresRedSA1 SB3 SC1 SD1 a2 b3Monitoring Plan LTAThe monitoring plan was less than adequate during the cleaning process. An excesive amount of water was injected into the system, if there had been an adequate monitor plan, 500 kg of water should not had entered the tankBlueSA1 SB3 SC1 SD1 a2 b4Independent Review LTAAn independent view could had been the safety audits performed by the safety department of UCC, in which recommendations were made but not implementedARRedSA1 SB3 SC1 SD1 a2 b5Use of Previous Accident/Incident Information LTAIn previous accidents, people had been exposed to the deadly chemical, but a MIC tank contamination have not happened. No improvements were made from previohs accidents. When workers started strikes, UCIL and the government state that it was an important investment and it could not be movedRedSA1 SB3 SC1 SD1 a2 b6Learning from employee/contractor's personnel experience LTAWhen water did not came out through the drain valves, the operator cut the water supply. Regardless of the recommendation, the supervisor who lack experience, ordered to resume the water supplyRedSA1 SB3 SC1 SD1 a2 b7Were routine inspections of the work/process LTAThere was no routine inspections, there was no hazard analysis that could consider any observation from routine inspectionRedSA1 SB3 SC1 SD1 a2 b8Upstream Audits LTANo audits were taken in place, in fact working process ando conditions were unappropiate, profit was the number 1 prioritySA1 SB3 SC1 SD1 a2 b9Health Monitoring LTARedSA1 SB3 SC1 SD1 a3Data Analysis LTAThis section refers to the data available regarding the contamination of the MIC tankRedSA1 SB3 SC1 SD1 a3 b10Priority Problem List LTANo evidence of a list of priorities, management was too focused in profitSA1 SB3 SC1 SD1 a3 b11Statistics and Risk projection LTARedSA1 SB3 SC1 SD1 a3 b12Status Display LTAThere was no display that indicated the amount of water introduced, the state of pipe system, the position of valves and the insertion of the slip blindRedSA1 SB3 SC1 SD1 a4Triggers to Risk Analysis LTAThis branch considers changes occured in Bhopal plant before the occurrance of the accidentRedSA1 SB3 SC1 SD1 a4 b13Sensitivity LTAThere was no technical information system to detect the problem, when the operator shut the water supply there was awareness of a problem. A risk analysis did not started, in stead the water supply was restartedRedSA1 SB3 SC1 SD1 a4 b14Priority Problem Fixes LTAThis problem was not recognized by the supervisor as a major hazard. Instead of performing a hazard analysis, water supply was restartedRedSA1 SB3 SC1 SD1 a4 b15Planned Change Controls LTAThe installation of the jumper line betwen the process system and the pressure relief system could be considered as a planned change that did not had a proper hazard analysis.RedSA1 SB3 SC1 SD1 a4 b16Unplanned Change Controls LTAAn example is the lack of slip blind in the line, no risk analysis was ever intended. Awareness of a risk could be define by the action performed by the operator with the water flow, but no further analysis took place. The soe trigger for assuring that the slip blind was inserted had been laid off previously, which in deed is another example of an unplanned change performed without controlsRedSA1 SB3 SC1 SD1 a4 b17New Information use LTANo risk analysis was performed based on the recommendations made after the safety audit performed in the plantRedSA1 SB3 SC1 SD1 a5Independent Audit and Appraisal LTAThe technical information system was less than adequate, safety audits were performed but no issue related to technical information was mentionedRedSA1 SB3 SC1 SD2Operational Readiness LTAThis branch considers all actions related to assuring a safe pipe cleaning processRedSA1 SB3 SC1 SD2 a1Verification of Operational Readiness LTAThis branch considers every verification needed to clean the pipesRedSA1 SB3 SC1 SD2 a1 b1Did not Specify CheckPrevious performing the activity no checks for adequate working conditions were made, no responsibles were adequately identified. An adequate verification would had point out the need to use the slip blind, even the requirement to pospone the activity due to valve leaking conditionsRedSA1 SB3 SC1 SD2 a1 b2Readiness Criteria LTAThe only criteria to check readiness involve the responsability of the maintenance supervisor to check if the slip blind was inserted; when the supervisor was laid off no one was assigned this dutyRedSA1 SB3 SC1 SD2 a1 b3Verification Procedure LTANo evidence of a check list or operational procedure that considers the cleaning activityRedSA1 SB3 SC1 SD2 a1 b4Competence LTAThe MIC unit supervisor had not the experience to make a appropiate decision. This is seen when he ordered to restart the water supplyRedSA1 SB3 SC1 SD2 a1 b5Follow-up LTANo follow up, no maintenance responsable at the timeRedSA1 SB3 SC1 SD2 a2Technical Support LTAThis branch refers to the technical support provided to the operator during the pipe cleaning processRedSA1 SB3 SC1 SD2 a3Interface between Operations and Maintenance or Testing Activities LTAThe communication between each area is less than adequate. The responsable of inserting the slip blind was not present and the operation crew continued to perform the job. The use of a checklist with clear identification of responsability could had stopped the job from being doneBlueSA1 SB3 SC1 SD2 a4Configuration LTAIt is possible that modifications to the plant were made after procedures were established. For example the jumper line that was constructed mmay have not been contemplated in any procedureSA1 SB3 SC1 SD3Inspection LTASA1 SB3 SC1 SD3 a1Planning Process LTASA1 SB3 SC1 SD3 a1 b1Specification of Plan LTASA1 SB3 SC1 SD3 a1 b1 c1Maintainability (Inspectability) LTASA1 SB3 SC1 SD3 a1 b1 c2Completeness of the Plan LTASA1 SB3 SC1 SD3 a1 b1 c3Schedule LTASA1 SB3 SC1 SD3 a1 b1 c4Coordination LTASA1 SB3 SC1 SD3 a1 b1 c5Competence LTASA1 SB3 SC1 SD3 a1 b2Analysis of Failures LTASA1 SB3 SC1 SD3 a2Execution LTASA1 SB3 SC1 SD3 a2 b3"Point of Operation" Log LTASA1 SB3 SC1 SD3 a2 b4Failure caused by maintenance (inspection) activitySA1 SB3 SC1 SD3 a2 b5Time LTASA1 SB3 SC1 SD3 a2 b6Task Performance ErrorsRedSA1 SB3 SC1 SD4Maintenance LTAThis branch considers the les than adequate conditions at which Bhopal plant worked due to poor maintenanceRedSA1 SB3 SC1 SD4 a1Planning Process LTAThis branch considers the inadequacy of the maintenance plan for Bhopal facilitiesRedSA1 SB3 SC1 SD4 a1 b1Specification of Plan LTAThis branch considers details of maintenance plans at Bhopal plantRedSA1 SB3 SC1 SD4 a1 b1 c1Maintainability (Inspectability) LTAThe contamination of the MIC tank is produced because several barriers were not working properly due to unadequate maintenance. For example the possitive nitrogen pressure in the tank was not maintain because of a leakage in the systemRedSA1 SB3 SC1 SD4 a1 b1 c2Completeness of the Plan LTANo information of an adequate inventory is known, but the lack of maintenance personnel made it imposible to finish the activities that were needed to be performed in each equipmentRedSA1 SB3 SC1 SD4 a1 b1 c3Schedule LTAThe frequency of maintenance activities could had been adequate, but the lack of personnel did not assure that the activities were fully completedRedSA1 SB3 SC1 SD4 a1 b1 c4Coordination LTAThere was never a proper coordination while performing the pipe cleaning activity. It was an order of the superintendent that was executed by the operations personnel. All areas may had never been notifiedRedSA1 SB3 SC1 SD4 a1 b1 c5Competence LTAThe competence of personnel was limited because after water did not came out of the pipes, a risk analysis was never performed in order to detect possible causes and consequencesRedSA1 SB3 SC1 SD4 a1 b2Analysis of Failures LTAThe nitrogen pressure system was not working properly and it had been informed previously. Any additional failure analysis would had determined that the problem was a leakage that could let water and contaminants enter the tankRedSA1 SB3 SC1 SD4 a2Execution LTAThis branch considers the maintenance activities when performedRedSA1 SB3 SC1 SD4 a2 b3"Point of Operation" Log LTANo point of operation logSA1 SB3 SC1 SD4 a2 b4Failure caused by maintenance (inspection) activityRedSA1 SB3 SC1 SD4 a2 b5Time LTAThe personnel required to perform all the maintenance tasks in Bhopal plant was limited, the time to perform each activity was less than adequateRedSA1 SB3 SC1 SD4 a2 b6Task Performance ErrorsThe slip blind was not inserted by the maintenance personnelRedSA1 SB3 SC1 SD5Supervision & Staff Performance LTAThis branch considers the role of the MIC supervisorRedSA1 SB3 SC1 SD5 a1Time LTAThe MIC supervisor had time to analyze the problem during the cleaning process, but he did not consider it importantRedSA1 SB3 SC1 SD5 a2Continuity of Supervision LTAThe pipe cleaning task was done during the night shift hand over, the water supply may had been left unattendent for a whileRedSA1 SB3 SC1 SD5 a3DetectionCorrection of Hazards LTAThis section considers the performance of the MIC supervisor related to a risk identification processRedSA1 SB3 SC1 SD5 a3 b1Detection of Hazards LTAThis section the causes of the event related to preexisting hazard conditionsRedSA1 SB3 SC1 SD5 a3 b1 c1Checklists LTAIf a checklist was used, activities needed to be done before the pipe cleaning process could be identify.RedSA1 SB3 SC1 SD5 a3 b1 c2Detection Plan LTAThis branch considers whether there was a systematic approach touncovering hazardous conditions in Bhopal plantRedSA1 SB3 SC1 SD5 a3 b1 c2 d1Logs and Diagrams LTANo evidence of any permit to work or another method to identify hazards for the pipe cleaning activityRedSA1 SB3 SC1 SD5 a3 b1 c2 d2Supervisor's Monitor Plan LTAThe supervisor did not used a systematic approach to identify risks, which could be caused by the lack of experience of the supervisorRedSA1 SB3 SC1 SD5 a3 b1 c2 d3Review of Changes LTAIt is possible that changes were reviewed by the supervisor and other manager of UCIL, but importance was not gave to safety concernsRedSA1 SB3 SC1 SD5 a3 b1 c2 d4Did not Relate to Prior EventsLeaks were common in Bhopal plant, but they were all related to realeasing MIC in to the environment. In a safety audit the possibility of MIC contamination was exposed. No recommendations were implementedGreenSA1 SB3 SC1 SD5 a3 b1 c3Time LTATime was adequateRedSA1 SB3 SC1 SD5 a3 b1 c4Workforce Input LTAThe operator knew there was a problem in the system when he decided to cut the water supply, but he obey to restart the water supplyRedSA1 SB3 SC1 SD5 a3 b2Correction of Hazards LTAHazards were not identifyRedSA1 SB3 SC1 SD5 a3 b2 c5Inter-departmental Co-ordination LTAThe coordination of the job was unadequate, maintenance personnel never was communicated to insert the slip blind. The operator continued with his task even when the maintenance personnel have not authorized the interventionBlueSA1 SB3 SC1 SD5 a3 b2 c6PostponedDuring the pipe cleaning activity the operator was aware that water could contaminate the MIC tank when no water came out through the drain valves. The supervisor payed no attention to this action an restarted the water supply. More detail is needed to determine if the supervisor was aware of the safety issues related to MIC contaminationARRedSA1 SB3 SC1 SD5 a3 b2 c7Did not Correct in TimeThis branch considers the leaking valves and the failure in the tanks possitive pressure systemRedSA1 SB3 SC1 SD5 a3 b2 c7 d5Authority LTAAs a budget related issue, supervisor had no authority and upper management was cutting expensesRedSA1 SB3 SC1 SD5 a3 b2 c7 d6Budget LTAUpper management was cutting expensesRedSA1 SB3 SC1 SD5 a3 b2 c7 d7Time LTARedSA1 SB3 SC1 SD5 a3 b2 c8Housekeeping LTAHousekeeping was les than adequate, if the facilities would had been more organized, clean and with a better look, workers could detect hazards more easilyRedSA1 SB3 SC1 SD5 a3 b2 c9Supervisor Judgment LTARisks related to the valves leakage and failure of the possitive pressure system were underestimated due to the cutting of expenses in UCILRedSA1 SB3 SC1 SD5 a4Performance ErrorsThis branch considers the activities performed by the operator during the cleaning processRedSA1 SB3 SC1 SD5 a4 b3Task Performance ErrorsThis branch considers errors during the cleaning processRedSA1 SB3 SC1 SD5 a4 b3 c10Task Assignment LTAThe task assignment was adequate, the supervisor was there during the activityRedSA1 SB3 SC1 SD5 a4 b3 c11Task-specific Risk Assessment not performedIt is evident that before the execution of the cleaning task, no risk assessment related to the task was done. The line that was going to be injected with water was not sealedRedSA1 SB3 SC1 SD5 a4 b3 c11 d8High Potential not IdentifiedThis branch considers the hazards related to not installing the slip blind in lineBlueSA1 SB3 SC1 SD5 a4 b3 c11 d8 e1Task Analysis not RequiredIt is not clear if the hazard assessment was a requirement from management, procedures and checklists should be verifiedRedSA1 SB3 SC1 SD5 a4 b3 c11 d8 e2Task Analysis LTARedSA1 SB3 SC1 SD5 a4 b3 c11 d8 e3Task Analysis not madeThis branch considers the lack of hazard assessment before the pipe cleaning taskRedSA1 SB3 SC1 SD5 a4 b3 c11 d8 e3 f1Authority LTAIt is possible that the procedure would had indicated that the supervisor or the operator were responsable of performing pre job analysis, but they were not madeRedSA1 SB3 SC1 SD5 a4 b3 c11 d8 e3 f2Budget LTARedSA1 SB3 SC1 SD5 a4 b3 c11 d8 e3 f3Time LTATime could had been an issue because the shift was ending and the personnel could had been rushing the activity to go homeRedSA1 SB3 SC1 SD5 a4 b3 c11 d8 e3 f4Supervisor Judgment LTAThe supervisor did not had the experience or the knowledge related to the risk of MIC contaminationBlueSA1 SB3 SC1 SD5 a4 b3 c11 d9Low PotentialA further research into safety management systems needs to be done, it is not clear if the risk was identified and treated as a low potential risk. A written procedure of the insertion of the slip blind will help clearify if the procedures were not followed or there was a decision needed to be mad and risks were underestimatedARBlueSA1 SB3 SC1 SD5 a4 b3 c12Task-specific Risk Assessment LTAThis branch considers the possibility that a risk assessment was doneBlueSA1 SB3 SC1 SD5 a4 b3 c12 d10Task-specific Risk Analysis LTAThis section considers the quality of the risk analysis before the pipe cleaning taskBlueSA1 SB3 SC1 SD5 a4 b3 c12 d10 e4Knowledge LTAThis branch considers the available knowledge in the time of the accidentBlueSA1 SB3 SC1 SD5 a4 b3 c12 d10 e4 f5Use of Workers'Suggestions and Inputs LTAWorker suggestion was not taken in concern. When the operator cut the water supply, it was evident that the risk of MIC contamination was idntified, but no further action was taken.BlueSA1 SB3 SC1 SD5 a4 b3 c12 d10 e4 f6Technical Information Systems LTATechnical information systems were not appropiate, risk may had been underestimated and the use of diagrams omitted, which led to a poorer understanding of the hazards related to the jobBlueSA1 SB3 SC1 SD5 a4 b3 c12 d10 e5Execution LTAThis branch considers the performance of the risk assessment if it had been madeGreenSA1 SB3 SC1 SD5 a4 b3 c12 d10 e5 f7Time LTATime was adequate, but the people involved were underestimating the risk assessmentGreenSA1 SB3 SC1 SD5 a4 b3 c12 d10 e5 f8Budget LTABudget was limited, but it was no excuse for not performing an adequate risk assessmentBlueSA1 SB3 SC1 SD5 a4 b3 c12 d10 e5 f9Scope LTAThe scope of the analysis could had been limited and the possibility of MIC contamination may not have been identified at firstBlueSA1 SB3 SC1 SD5 a4 b3 c12 d10 e5 f10Analytical Skill LTAIt may have not been adequate because the supervisor did not recognize the MIC contamination risk when the operator closed the water supply. The operator also limited himself to follw instructions even though he knew what was happeningBlueSA1 SB3 SC1 SD5 a4 b3 c12 d10 e5 f11Hazard Selection LTAThis section considers that the risk assessment was not adequate because the MIC contamination risk was not properly addressedBlueSA1 SB3 SC1 SD5 a4 b3 c12 d10 e5 f11 g1Hazard Identification LTAFurther information is needed to consider if all hazards were identifyBlueSA1 SB3 SC1 SD5 a4 b3 c12 d10 e5 f11 g2Hazard Prioritization LTAFurther information is needed to consider if the hazards were given the correct weightBlueSA1 SB3 SC1 SD5 a4 b3 c12 d11Recommended Risk Controls LTAThis section considers the relationship of risk controls to the contamination of MICBlueSA1 SB3 SC1 SD5 a4 b3 c12 d11 e6Clarity LTAThe use of the slip blind should had been a clear recommendation, further information is needed to determine why it was not usedGreenSA1 SB3 SC1 SD5 a4 b3 c12 d11 e7Compatibility LTAThe use of the slip blind is compatible with the pipe that had to be blockedBlueSA1 SB3 SC1 SD5 a4 b3 c12 d11 e8Testing of control LTAThe pipe blockage was never testedBlueSA1 SB3 SC1 SD5 a4 b3 c12 d11 e9Directive to Use LTAThe directive to use controls may had been less than adequate, more information is needed to proof that even though the controls were known, the instructions from management could be confusing when they priorized makin profit.BlueSA1 SB3 SC1 SD5 a4 b3 c12 d11 e10Availability LTAThe availability of the slip blind needs to be analized, maybe there was no maitenance worker to perform the activityBlueSA1 SB3 SC1 SD5 a4 b3 c12 d11 e11Adaptability LTAThe slip blind was a control well fitted for the taskBlueSA1 SB3 SC1 SD5 a4 b3 c12 d11 e12Use not MandatoryMore information is needed to determine if the use of slipblind was mandatory. In both cases the slip blind was not usedARBlueSA1 SB3 SC1 SD5 a4 b3 c13Pre-task Briefing LTAThe pre task briefing was less than adequate, maybe the task was done frequently, so the supervisor underestimated risk analysis. The condition of some components like valves and possitive pressure system were not working properly, these conditions were not taken in concernGreenSA1 SB3 SC1 SD5 a4 b3 c14Fit between Task Procedures and actual Situation LTAthe task was simple and the operator followed all the instructionsRedSA1 SB3 SC1 SD5 a4 b3 c15Personnel Performance DiscrepancyThis branch considers the performance of the operator and MIC supervisor during the pipe cleaning taskRedSA1 SB3 SC1 SD5 a4 b3 c15 d12Personnel Selection LTAThis branch considers facts related to personell selection for operator and MIC supervisorBlueSA1 SB3 SC1 SD5 a4 b3 c15 d12 e13Criteria LTAFurther information is needed, but it is possible that job description was too general and it did not included knowlege in chemistry. The seletion of the supervisor could had been based in other criterias different from the ones related for the jobBlueSA1 SB3 SC1 SD5 a4 b3 c15 d12 e14Testing LTAFurther information is needed to determine if employees were continuously testedRedSA1 SB3 SC1 SD5 a4 b3 c15 d13Training LTAThis branch considers if training was aprropiate for the employeesRedSA1 SB3 SC1 SD5 a4 b3 c15 d13 e15No trainingNo evidence of training was presentBlueSA1 SB3 SC1 SD5 a4 b3 c15 d13 e16Criteria Training LTAA lack of safety criteria for performing the job may had been related to not using the slipblind when requiredRedSA1 SB3 SC1 SD5 a4 b3 c15 d13 e17Methods LTABased on results the method used was not adequate because the slip blind was not used, the superisor did not realice all safety concernsSA1 SB3 SC1 SD5 a4 b3 c15 d13 e18Trainer Skills LTABlueSA1 SB3 SC1 SD5 a4 b3 c15 d13 e19Verification LTAFurther information is needed to establish if there was retraining for operators and supervisorsRedSA1 SB3 SC1 SD5 a4 b3 c15 d14Consideration of Deviations LTAThis branch considers posible signs of deviations on the operators performanceBlueSA1 SB3 SC1 SD5 a4 b3 c15 d14 e20Normal VariabilityThere is no record of anormality, the operator could had been rushing to finish the shiftSA1 SB3 SC1 SD5 a4 b3 c15 d14 e21ChangesSA1 SB3 SC1 SD5 a4 b3 c15 d14 e22Supervisor Observation LTASA1 SB3 SC1 SD5 a4 b3 c15 d14 e23Supervisor Correction LTASA1 SB3 SC1 SD5 a4 b3 c15 d14 e23 f12Re-instruction LTASA1 SB3 SC1 SD5 a4 b3 c15 d14 e23 f13Enforcement LTARedSA1 SB3 SC1 SD5 a4 b3 c15 d15Employee Motivation LTAThis branch considers the motivation that the employee had to finish his jobBlueSA1 SB3 SC1 SD5 a4 b3 c15 d15 e24Leadership & Examples LTAThe order to restart the water supply could meant that there was no leadership, it could be assumed that the supervisor and the operator just wanted to finish his job and leaveSA1 SB3 SC1 SD5 a4 b3 c15 d15 e25Time PressureBlueSA1 SB3 SC1 SD5 a4 b3 c15 d15 e26Correct Performance is PunishedFurther information is needed for establishing this point, it could be assume that the water supply cut off was a correct action performed by the operator but misinterpreted by the supervisorRedSA1 SB3 SC1 SD5 a4 b3 c15 d15 e27Incorrect Performance is RewardedIncorrect performance could had been encouraged by the supervisor in order the operator perform the activity faster. The practive of not wearing protective equipment in previous incidents could had been encouraged. Management knew about the exposure of workers to contamination and they took corrective actions to assure they were better feedBlueSA1 SB3 SC1 SD5 a4 b3 c15 d15 e28Job Interest Building LTAIt is possible that the task was too simple and frequent that the operator and the supervisor did not put much attention to the missing slip blindRedSA1 SB3 SC1 SD5 a4 b3 c15 d15 e29Group Norms ConflictAn evident lack of agreement was seen previously in Bhopal. Strikes had been organize previously because of the safety conditions under which people workRedSA1 SB3 SC1 SD5 a4 b3 c15 d15 e30Obstacles Prevent PerformanceThe main obstacle could had been that there was no responsable of the maintenance areaRedSA1 SB3 SC1 SD5 a4 b3 c15 d15 e31Personal ConflictThis branch consider conflicts between management and workersRedSA1 SB3 SC1 SD5 a4 b3 c15 d15 e31 f15[Conflict] with SupervisorWorkers at Bhopal were concerned about their safety and they felt that management was not listening to their requests. Strikes were organizedRedSA1 SB3 SC1 SD5 a4 b3 c15 d15 e31 f16[Conflict] with OthersStrikes caused government concern but in favor of UCIL interestBlueSA1 SB3 SC1 SD5 a4 b3 c15 d15 e31 f17Deviant TraitsThe conditions of agriculture in Bhopal made the company less profitable every year. Management put a side safety concerns for profit, which previously had caused accidents to workers. Workers felt they were disposable, less qualified workers were hired and they were not treated appropiatelyARSA1 SB3 SC1 SD5 a4 b3 c15 d15 e32General Motivation Program LTASA1 SB3 SC1 SD5 a4 b4Performance Errors in unrelated tasksSA1 SB3 SC1 SD5 a4 b4 c16Allowed ActivitiesSA1 SB3 SC1 SD5 a4 b4 c17Prohibited ActivitiesSA1 SB3 SC1 SD5 a4 b5Emergency Shut-off Performance ErrorsSA1 SB3 SC1 SD5 a4 b5 c18Task Performance ErrorsSA1 SB3 SC1 SD5 a4 b5 c19Unrelated Task ErrorsRedSA1 SB3 SC1 SD6Support of Supervisors LTAThis branch considers the support of upper management to the MIC supervisorRedSA1 SB3 SC1 SD6 a1Help and Training LTAThe supervisor was not well trained in safety and operation issues of an agreggate products factory, his experience came from a battery factory; management did not assure proper training to perform his dutySA1 SB3 SC1 SD6 a2Research and Fact-Finding LTABlueSA1 SB3 SC1 SD6 a3Information Exchange LTAIt seems that the communication is only in one direction, supervisors and operator could only follow orders that were made to maintain the companys profitsBlueSA1 SB3 SC1 SD6 a4Standards and Directives LTAMore information is needed to determine if there were internal codes and standards that requested certain maintenance activities, procedures, building standard or risk assessment that could had prevented failure. External standards were not followed since the construction of the plant, where safety devices were not used beause of the limited budget. Afterwards, modifications were made that were not comply in any standard (jumper line)RedSA1 SB3 SC1 SD6 a5Resources LTAThis branch considers the resources provided to the supervisorSA1 SB3 SC1 SD6 a5 b1Training LTARedSA1 SB3 SC1 SD6 a5 b2Access to Expertise LTATechnical support may had been adequate, operator knew there was a problem when water did not came through the drain valves. The supervisor did not take into account the operator expertiseBlueSA1 SB3 SC1 SD6 a5 b3Access to Equipment & Materials LTAFurther information is needed in order to determine if the slip blind was available. Even if it was not, the task should had been suspendedRedSA1 SB3 SC1 SD6 a5 b4Coordination of Resources LTAAdequate coordination was not done with the maintenance crewSA1 SB3 SC1 SD6 a6Deployment of Resources LTARedSA1 SB3 SC1 SD6 a7Referred Risk Response LTARecommendations from safety audits, requirements from employees and other issues were not taken in concern by managementSA1 SB3 SC2Barriers LTARedSA1 SB3 SC2 a1On the Energy SourceUse of water to clean pipe may have not been adequate. The slip blind was not installed to block water from going into the MIC tankSA1 SB3 SC2 a1 b1Barriers None PossibleSA1 SB3 SC2 a1 b2Barrier FailedRedSA1 SB3 SC2 a1 b3Did not UseThe slip blind was not usedSA1 SB3 SC2 a1 b3 c1Did not ProvideIt is possible that without a maintenance supervisor, there was no responsabie to assure safe conditions to the pipe cleaning process, management may have not evaluate the consequences of not hiring a new maintenance supervisorARRedSA1 SB3 SC2 a1 b3 c2Task Performance ErrorThe supervisor and the operator were not aware if all barriers were in juseRedSA1 SB3 SC2 a2Between energy source and targetValves were leaking and a jumper line was constructed between the process line and the safety relief line.RedSA1 SB3 SC2 a3On Persons or ObjectsThe possitive ressure system was not working properly to block possible contaminationSA1 SB3 SC2 a4Separate Time and distanceRedSA1 SB4Events and Energy Flows Leading to Accident/IncidentThe contamination of the MIC tank leads to a run away reactionRedSA1 SB4 SC3Barriers and Controls LTATank E619 had to be used for containing an emergency run away, during the disaster it had MIC insideThe refrigeration system was shutdown and dismantled to save operation and maintenance costsUnreliable safety and measurement devicesUnderstanding of MIC reaction and safety issues was limited in all levels of the companyA leak was identified in tank E610, nitrogen pressure could not be maintainAutomatic shutdown devices were not used Early detection equipments were not usedLarge amounts of MIC was stored in plantManagement budget reduction had no hazard analysisContaminants in tank accelerated the runaway reactionSA1 SB4 SC4Energy TransfersWater and contaminants were conducted through pipes to the MIC tank, a run away reaction started; which lead to a gas leakageSA2Stabilization & Restoration LTASA2 a1Prevention of Follow-up AccidentsSA2 a1 b1Plan LTASA2 a1 b2Execution of Plan LTASA2 a1 b2 c1Notification LTA (Trigger)SA2 a1 b2 c2Training and Experience LTASA2 a1 b2 c3Personnel and/or Equipment ChangesSA2 a1 b2 c4Logistics LTASA2 a1 b2 c5Task Performance ErrorsSA2 a1 b2 c6Response DelaySA2 a2Emergency Action (Firefighters, etc.) LTASA2 a3Rescue and Salvage LTASA2 a4Medical Services LTASA2 a5Dissemination of Information LTASA2 a6Restoration and Rehabilitation LTASA2 a6 b3Operational Continuity LTASA2 a6 b4Rehabilitation LTASA2 a6 b5Restoration LTASA2 a6 b6Absorb LossMManagement System Factors LTAMA1Policy LTAMA2Implementation of Policy LTAMA2 a1Planning Process LTAMA2 a1 b1Specification of Plan LTAMA2 a1 b1 c1Methods, Criteria, Analyses LTAMA2 a1 b1 c2Specification of Responsibilities LTAMA2 a1 b1 c2 d1Definition of Line-responsibility LTAMA2 a1 b1 c2 d2Staff Responsibility LTAMA2 a1 b1 c2 d3Task Assignment LTAMA2 a1 b1 c3Schedule LTAMA2 a1 b1 c4Budgets LTAMA2 a1 b1 c5Communication Plan LTAMA2 a1 b1 c5 d4Information Flow LTAMA2 a1 b1 c5 d5Guidance and Directives LTAMA2 a1 b2Use of Feedback LTAMA2 a2Execution of Policy Implementation Plan LTAMA2 a2 b3Leadership LTAMA2 a2 b4Capability LTAMA2 a2 b4 c6Authority LTAMA2 a2 b4 c7Accountability LTAMA2 a2 b4 c8Task Performance ErrorsMA2 a2 b5Practical Support LTAMA2 a2 b6Time and Budget LTAMA2 a2 b7DelaysMA2 a2 b8Caused FailureMA2 a3Monitoring LTAMA3Risk Management System LTAMA3 MB1Risk Management Policy LTAMA3 MB2Implementation of Risk Management Policy LTAMA3 MB3Risk Analysis Process LTAMA3 MB3 a1Concepts and Requirements LTAMA3 MB3 a1 b1Technical Information System LTAMA3 MB3 a1 b2Definition of Goals and tolerance Risks LTAMA3 MB3 a1 b2 c1ES&H Goals and Risks not definedMA3 MB3 a1 b2 c2Performance Goals and Risks not definedMA3 MB3 a1 b3Risk Analysis Criteria LTAMA3 MB3 a1 b3 c3Plan LTAMA3 MB3 a1 b3 c4Change Analysis LTAMA3 MB3 a1 b3 c5Other Analytical Methods LTAMA3 MB3 a1 b3 c6Scaling Mechanism LTAMA3 MB3 a1 b3 c7Required Alternatives LTAMA3 MB3 a1 b3 c8Solution Precedence Sequence LTAMA3 MB3 a1 b4Criteria for Procedures LTAMA3 MB3 a1 b5Specification of Requirements LTAMA3 MB3 a1 b3 c9Stakeholder/customer requirementsMA3 MB3 a1 b3 c10Statutory codes and regulationsMA3 MB3 a1 b3 c11Requirements of other National and International codes and standardsMA3 MB3 a1 b3 c12Local Codes and BylawsMA3 MB3 a1 b3 c13Internal StandardsMA3 MB3 a1 b6Information Search LTAMA3 MB3 a1 b7Life Cycle Analysis LTAMA3 MB3 a1 b7 c14Scope LTAMA3 MB3 a1 b7 c15Analysis of Environmental Impact LTAMA3 MB3 a1 b7 c16Requirement for Life Cycle Analysis LTAMA3 MB3 a1 b7 c17Extended Use Analysis LTAMA3 MB3 a2Design and Development LTAMA3 MB3 a2 b8Energy Control LTAMA3 MB3 a2 b8 c18Safer EnergyMA3 MB3 a2 b8 c19Limitation of Energy LTAMA3 MB3 a2 b8 c20Automatic Controls LTAMA3 MB3 a2 b8 c21Warnings LTAMA3 MB3 a2 b8 c22Manual Controls LTAMA3 MB3 a2 b8 c23Safe Energy Release LTAMA3 MB3 a2 b8 c24Controls and Barriers LTAMA3 MB3 a2 b9Human Factors (Ergonomics) Review LTAMA3 MB3 a2 b9 c25Professional HF Skills LTAMA3 MB3 a2 b9 c26Task Analysis LTAMA3 MB3 a2 b9 c27Allocation Human/Machine Tasks LTAMA3 MB3 a2 b9 c28Did not Establish Human Task RequirementsMA3 MB3 a2 b9 c28 d1Did not Define UsersMA3 MB3 a2 b9 c28 d2Design of Displays LTAMA3 MB3 a2 b9 c28 d3Interpretation LTAMA3 MB3 a2 b9 c28 d4Design of Controls LTAMA3 MB3 a2 b9 c29Did not Predict ErrorsMA3 MB3 a2 b10Inspection Plan LTAMA3 MB3 a2 b11Maintenance Plan LTAMA3 MB3 a2 b12Arrangement LTAMA3 MB3 a2 b13Environment LTAMA3 MB3 a2 b14Specification of Operational Readiness LTAMA3 MB3 a2 b14 c30Test and Qualification LTAMA3 MB3 a2 b14 c31[Specification of] Supervision LTAMA3 MB3 a2 b14 c32Task Procedures LTAMA3 MB3 a2 b14 c32 d5Match to Hardware Change LTAMA3 MB3 a2 b14 c32 d6Match to Users LTAMA3 MB3 a2 b14 c32 d7Match to Task and Equipment LTAMA3 MB3 a2 b14 c32 d8Emergency Provisions LTAMA3 MB3 a2 b14 c32 d9Cautions and Warnings LTAMA3 MB3 a2 b14 c32 d10Task Sequence LTAMA3 MB3 a2 b14 c32 d11Lockouts LTAMA3 MB3 a2 b14 c32 d12Communications Interfaces LTAMA3 MB3 a2 b14 c32 d13Specification of Work Conditioning LTAMA3 MB3 a2 b14 c33Personnel Selection LTAMA3 MB3 a2 b14 c34Personnel Training and Qualification LTAMA3 MB3 a2 b14 c35Personnel Motivation LTAMA3 MB3 a2 b14 c36Monitor Points LTAMA3 MB3 a2 b15Emergency Shutdown Provision LTAMA3 MB3 a2 b16Contingency Planning LTAMA3 MB3 a2 b17Disposal Planning LTAMA3 MB3 a2 b18Independent ReviewMA3 MB3 a2 b19Configuration Control LTAMA3 MB3 a2 b20Documentation Control LTAMA3 MB3 a2 b21Fast Action Cycle LTAMA3 MB3 a2 b22Design Acceptance and Change Control Processes LTAMA3 MB3 a2 b22 c37Code Compliance Verification LTAMA3 MB3 a2 b22 c38Engineering Studies LTAMA3 MB3 a2 b22 c39Standardization of Parts LTAMA3 MB3 a2 b22 c40Design Description LTAMA3 MB3 a2 b22 c41Acceptance Criteria LTAMA3 MB3 a2 b22 c42Development and Qualification Testing LTAMA3 MB3 a2 b22 c43Change Review Procedure LTAMA3 MB3 a2 b22 c44Reliability and Quality Assurance LTAMA3 MB4Risk Management Assurance Programme LTAMA3 MB4 a1Definition of Aims and Policy LTAMA3 MB4 a2Programme Scope LTAMA3 MB4 a3Documentation LTAMA3 MB4 a4Assurance Programme Organization LTAMA3 MB4 a4 b1Risk Management Assurance Staff Performance LTAMA3 MB4 a4 b2Management Committees LTAMA3 MB4 a4 b3Organisation for Improvement LTAMA3 MB4 a5Assurance Programme Services LTAMA3 MB4 a6Activities LTAMA3 MB5Review of Risk Management System LTARAssumed Risks

EF2RedPlease note if you choose to use the Excel table to fill in your analysis you will need to copy it into Word or use some other method (e.g. a pdf writer) to combine this into the one document that you need to submit. Turnitin will only accept one documentGreenBlueColour codeMORT Reference CodeKeywords - description of relevance toExplanationSA1AccidentRun away reaction in the E610 tank4000SA1 SB1Potentially Harmful Energy Flow or Environmental ConditionRun away reaction in the E610 tank42000RedSA1 SB1 a1Non-functional EnergyThe run away reaction was not a funcional energy flow10%RedSA1 SB1 a1 b1Control of Non-functional EnergyControls were implemented but they were out of service at the time of the accidentRedSA1 SB1 a1 b2Control ImpracticableAt the time of the accident the control was impracticle because several barriers were not working properlyARSA1 SB1 a2Functional EnergySA1 SB1 a2 b3Control of Use LTASA1 SB1 a2 b4Diversion LTASA1 SB1 a2 b4 c1Control of Functional Energy LTASA1 SB1 a2 b4 c1Diversion of functional Energy LTARedSA1 SB2Vulnerable People or ObjectsThis branch takes in concern the MIC stored as a vulnerable object due to the consequences concerned to the reaction to water and rust related contaminantsXXXXSA1 SB2 a1Non-functional People or ObjectsSA1 SB2 a1 b1Control LTASA1 SB2 a1 b2Control ImpracticableRedSA1 SB2 a2Functional People or ObjectsThis branch takes in concern the MIC stored as a vulnerable object due to the consequences concerned to the reaction to water and rust related contaminantsBlueSA1 SB2 a2 b3Control of Exposure LTAMIC was intended to be stored in the MIC tanks, but it is certain that there was too much MIC in Bhopal at the time of the accident. The cleaning process using water should be analyzed if it was first intended by the designers or it was planned afterwards. The slip blind was not inserted in the line while the cleaning process took place. A jumper line was installed between the process line and the safety relief lineRedSA1 SB2 a2 b4Evasive Action LTAThis branch takes in concern the evation of water and contaminants to enter the tankRedSA1 sb2 a2 b4 c1Means of Evasion LTABesides the valves, slip blind and possitive tank pressure there was no other evasion actions.BlueSA1 SB2 a2 b4 c2Evasion ImpracticableThe slip blind and the possitive tank pressure were controls that could be proved. At the time of the accident nboth systems were not working properly and no one knew or cared about the risk associated to their failure stateARSA1 SB3Barriers and Controls LTASA1 SB3 SC1Control of work and process LTARedSA1 SB3 SC1 SD1Technical Information Systems LTAThis branch considers the information flow between the maintenance and operation personnel and managementRedSA1 SB3 SC1 SD1 a1Technical Information LTAThis branch considers the communication between staff and supervisorRedSA1 SB3 SC1 SD1 a1 b1Knowledge LTAAs an example of inappropiate communication and the lack of available technical guidance, when water did not came out through the drain valves and the operator cut the water supply, the supervisor ordered to restart the water flowRedSA1 SB3 SC1 SD1 a1 b1 c1Based on Existing KnowledgeSafety audits performed in Bhopal and Institute plant included recommendations in which actions where neede to avoid a run away reaction5-JulRedSA1 SB3 SC1 SD1 a1 b1 c1 d1Application of Codes and Manuals, LTADuring the design and construction of the MIC unit, many safety issues were not taken into concern because of a budget deficit. Afterwards during operation, some modifications were made to facilities and to the way that the plant was operated. First, a jumper line was installed between the process line and safety relief line. During the oplant operation, water was injected to te lines and all the safety devics were not working properly at the time of the accident.0.00162425/6/15RedSA1 SB3 SC1 SD1 a1 b1 c1 d2List of Experts LTAThere was no list of experts to be called. Supervisor was not experienced enough, he order to continue supplying water to a closed system615.687723186860SA1 SB3 SC1 SD1 a1 b1 c1 d3Local Knowledge LTASA1 SB3 SC1 SD1 a1 b1 c1 d4Solution Research LTARedSA1 SB3 SC1 SD1 a1 b1 c2If there was no knownprecedentLeakage to the environment were not unusual. Workers knew that tank E610 was not working properly due to a leak in the systemRedSA1 SB3 SC1 SD1 a1 b1 c2 d5Previous investigationand analysis LTAA safety audit in Institute plant discovered that MIC contamination was possible and that a run away reaction was possible. The recommendations were not passed to Bhopal managementRedSA1 SB3 SC1 SD1 a1 b1 c2 d6Research LTAThe use of water to flush pipes could had been considered as a solution to another problem. The use of unappropiate materials in pipes could had developed the need for flushing. It was an activity less than adequate due to the reactivity of MIC wit water and contaminantsRedSA1 SB3 SC1 SD1 a1 b2Communication of Knowledge LTAThis section refers to the communication among UCC, UCIL and the government of India regarding safety concernsRedSA1 SB3 SC1 SD1 a1 b2 c3Internal Communication LTASafety concerns were not properly communicated inside the plants premises and UCCRedSA1 SB3 SC1 SD1 a1 b2 c3 d7Internal Network Structure LTAThere was no infrastructure for internal communicationRedSA1 SB3 SC1 SD1 a1 b2 c3 d8Operation of Internal Network LTAInternal communication network was not properly managed, messages were sent from area to area using messengers.RedSA1 SB3 SC1 SD1 a1 b2 c4Was the external communication LTA?The government of India did not acted as a regulatory body, it justified Bhopals plant previous accidentsRedSA1 SB3 SC1 SD1 a1 b2 c4 d9External Network Definition LTAThe government was well identified as a external agentRedSA1 SB3 SC1 SD1 a1 b2 c4 d10External Network Operation LTAThere was no evidence of environmental protection control, no safety audits. Government knew MIC process was dangerous but they did not do anything to control itRedSA1 SB3 SC1 SD1 a2Data Collection LTAIt considers the data collection and use of proceduresRedSA1 SB3 SC1 SD1 a2 b3Monitoring Plan LTAThe monitoring plan was less than adequate during the cleaning process. An excesive amount of water was injected into the system, if there had been an adequate monitor plan, 500 kg of water should not had entered the tankBlueSA1 SB3 SC1 SD1 a2 b4Independent Review LTAAn independent view could had been the safety audits performed by the safety department of UCC, in which recommendations were made but not implementedARRedSA1 SB3 SC1 SD1 a2 b5Use of Previous Accident/Incident Information LTAIn previous accidents, people had been exposed to the deadly chemical, but a MIC tank contamination have not happened. No improvements were made from previohs accidents. When workers started strikes, UCIL and the government state that it was an important investment and it could not be movedRedSA1 SB3 SC1 SD1 a2 b6Learning from employee/contractor's personnel experience LTAWhen water did not came out through the drain valves, the operator cut the water supply. Regardless of the recommendation, the supervisor who lack experience, ordered to resume the water supplyRedSA1 SB3 SC1 SD1 a2 b7Were routine inspections of the work/process LTAThere was no routine inspections, there was no hazard analysis that could consider any observation from routine inspectionRedSA1 SB3 SC1 SD1 a2 b8Upstream Audits LTANo audits were taken in place, in fact working process ando conditions were unappropiate, profit was the number 1 prioritySA1 SB3 SC1 SD1 a2 b9Health Monitoring LTARedSA1 SB3 SC1 SD1 a3Data Analysis LTAThis section refers to the data available regarding the contamination of the MIC tankRedSA1 SB3 SC1 SD1 a3 b10Priority Problem List LTANo evidence of a list of priorities, management was too focused in profitSA1 SB3 SC1 SD1 a3 b11Statistics and Risk projection LTARedSA1 SB3 SC1 SD1 a3 b12Status Display LTAThere was no display that indicated the amount of water introduced, the state of pipe system, the position of valves and the insertion of the slip blindRedSA1 SB3 SC1 SD1 a4Triggers to Risk Analysis LTAThis branch considers changes occured in Bhopal plant before the occurrance of the accidentRedSA1 SB3 SC1 SD1 a4 b13Sensitivity LTAThere was no technical information system to detect the problem, when the operator shut the water supply there was awareness of a problem. A risk analysis did not started, in stead the water supply was restartedRedSA1 SB3 SC1 SD1 a4 b14Priority Problem Fixes LTAThis problem was not recognized by the supervisor as a major hazard. Instead of performing a hazard analysis, water supply was restartedRedSA1 SB3 SC1 SD1 a4 b15Planned Change Controls LTAThe installation of the jumper line betwen the process system and the pressure relief system could be considered as a planned change that did not had a proper hazard analysis.RedSA1 SB3 SC1 SD1 a4 b16Unplanned Change Controls LTAAn example is the lack of slip blind in the line, no risk analysis was ever intended. Awareness of a risk could be define by the action performed by the operator with the water flow, but no further analysis took place. The soe trigger for assuring that the slip blind was inserted had been laid off previously, which in deed is another example of an unplanned change performed without controlsRedSA1 SB3 SC1 SD1 a4 b17New Information use LTANo risk analysis was performed based on the recommendations made after the safety audit performed in the plantRedSA1 SB3 SC1 SD1 a5Independent Audit and Appraisal LTAThe technical information system was less than adequate, safety audits were performed but no issue related to technical information was mentionedRedSA1 SB3 SC1 SD2Operational Readiness LTAThis branch considers all actions related to assuring a safe pipe cleaning processRedSA1 SB3 SC1 SD2 a1Verification of Operational Readiness LTAThis branch considers every verification needed to clean the pipesRedSA1 SB3 SC1 SD2 a1 b1Did not Specify CheckPrevious performing the activity no checks for adequate working conditions were made, no responsibles were adequately identified. An adequate verification would had point out the need to use the slip blind, even the requirement to pospone the activity due to valve leaking conditionsRedSA1 SB3 SC1 SD2 a1 b2Readiness Criteria LTAThe only criteria to check readiness involve the responsability of the maintenance supervisor to check if the slip blind was inserted; when the supervisor was laid off no one was assigned this dutyRedSA1 SB3 SC1 SD2 a1 b3Verification Procedure LTANo evidence of a check list or operational procedure that considers the cleaning activityRedSA1 SB3 SC1 SD2 a1 b4Competence LTAThe MIC unit supervisor had not the experience to make a appropiate decision. This is seen when he ordered to restart the water supplyRedSA1 SB3 SC1 SD2 a1 b5Follow-up LTANo follow up, no maintenance responsable at the timeRedSA1 SB3 SC1 SD2 a2Technical Support LTAThis branch refers to the technical support provided to the operator during the pipe cleaning processRedSA1 SB3 SC1 SD2 a3Interface between Operations and Maintenance or Testing Activities LTAThe communication between each area is less than adequate. The responsable of inserting the slip blind was not present and the operation crew continued to perform the job. The use of a checklist with clear identification of responsability could had stopped the job from being doneBlueSA1 SB3 SC1 SD2 a4Configuration LTAIt is possible that modifications to the plant were made after procedures were established. For example the jumper line that was constructed mmay have not been contemplated in any procedureSA1 SB3 SC1 SD3Inspection LTASA1 SB3 SC1 SD3 a1Planning Process LTASA1 SB3 SC1 SD3 a1 b1Specification of Plan LTASA1 SB3 SC1 SD3 a1 b1 c1Maintainability (Inspectability) LTASA1 SB3 SC1 SD3 a1 b1 c2Completeness of the Plan LTASA1 SB3 SC1 SD3 a1 b1 c3Schedule LTASA1 SB3 SC1 SD3 a1 b1 c4Coordination LTASA1 SB3 SC1 SD3 a1 b1 c5Competence LTASA1 SB3 SC1 SD3 a1 b2Analysis of Failures LTASA1 SB3 SC1 SD3 a2Execution LTASA1 SB3 SC1 SD3 a2 b3"Point of Operation" Log LTASA1 SB3 SC1 SD3 a2 b4Failure caused by maintenance (inspection) activitySA1 SB3 SC1 SD3 a2 b5Time LTASA1 SB3 SC1 SD3 a2 b6Task Performance ErrorsRedSA1 SB3 SC1 SD4Maintenance LTAThis branch considers the les than adequate conditions at which Bhopal plant worked due to poor maintenanceRedSA1 SB3 SC1 SD4 a1Planning Process LTAThis branch considers the inadequacy of the maintenance plan for Bhopal facilitiesRedSA1 SB3 SC1 SD4 a1 b1Specification of Plan LTAThis branch considers details of maintenance plans at Bhopal plantRedSA1 SB3 SC1 SD4 a1 b1 c1Maintainability (Inspectability) LTAThe contamination of the MIC tank is produced because several barriers were not working properly due to unadequate maintenance. For example the possitive nitrogen pressure in the tank was not maintain because of a leakage in the systemRedSA1 SB3 SC1 SD4 a1 b1 c2Completeness of the Plan LTANo information of an adequate inventory is known, but the lack of maintenance personnel made it imposible to finish the activities that were needed to be performed in each equipmentRedSA1 SB3 SC1 SD4 a1 b1 c3Schedule LTAThe frequency of maintenance activities could had been adequate, but the lack of personnel did not assure that the activities were fully completedRedSA1 SB3 SC1 SD4 a1 b1 c4Coordination LTAThere was never a proper coordination while performing the pipe cleaning activity. It was an order of the superintendent that was executed by the operations personnel. All areas may had never been notifiedRedSA1 SB3 SC1 SD4 a1 b1 c5Competence LTAThe competence of personnel was limited because after water did not came out of the pipes, a risk analysis was never performed in order to detect possible causes and consequencesRedSA1 SB3 SC1 SD4 a1 b2Analysis of Failures LTAThe nitrogen pressure system was not working properly and it had been informed previously. Any additional failure analysis would had determined that the problem was a leakage that could let water and contaminants enter the tankRedSA1 SB3 SC1 SD4 a2Execution LTAThis branch considers the maintenance activities when performedRedSA1 SB3 SC1 SD4 a2 b3"Point of Operation" Log LTANo point of operation logSA1 SB3 SC1 SD4 a2 b4Failure caused by maintenance (inspection) activityRedSA1 SB3 SC1 SD4 a2 b5Time LTAThe personnel required to perform all the maintenance tasks in Bhopal plant was limited, the time to perform each activity was less than adequateRedSA1 SB3 SC1 SD4 a2 b6Task Performance ErrorsThe slip blind was not inserted by the maintenance personnelRedSA1 SB3 SC1 SD5Supervision & Staff Performance LTAThis branch considers the role of the MIC supervisorRedSA1 SB3 SC1 SD5 a1Time LTAThe MIC supervisor had time to analyze the problem during the cleaning process, but he did not consider it importantRedSA1 SB3 SC1 SD5 a2Continuity of Supervision LTAThe pipe cleaning task was done during the night shift hand over, the water supply may had been left unattendent for a whileRedSA1 SB3 SC1 SD5 a3DetectionCorrection of Hazards LTAThis section considers the performance of the MIC supervisor related to a risk identification processRedSA1 SB3 SC1 SD5 a3 b1Detection of Hazards LTAThis section the causes of the event related to preexisting hazard conditionsRedSA1 SB3 SC1 SD5 a3 b1 c1Checklists LTAIf a checklist was used, activities needed to be done before the pipe cleaning process could be identify.RedSA1 SB3 SC1 SD5 a3 b1 c2Detection Plan LTAThis branch considers whether there was a systematic approach touncovering hazardous conditions in Bhopal plantRedSA1 SB3 SC1 SD5 a3 b1 c2 d1Logs and Diagrams LTANo evidence of any permit to work or another method to identify hazards for the pipe cleaning activityRedSA1 SB3 SC1 SD5 a3 b1 c2 d2Supervisor's Monitor Plan LTAThe supervisor did not used a systematic approach to identify risks, which could be caused by the lack of experience of the supervisorRedSA1 SB3 SC1 SD5 a3 b1 c2 d3Review of Changes LTAIt is possible that changes were reviewed by the supervisor and other manager of UCIL, but importance was not gave to safety concernsRedSA1 SB3 SC1 SD5 a3 b1 c2 d4Did not Relate to Prior EventsLeaks were common in Bhopal plant, but they were all related to realeasing MIC in to the environment. In a safety audit the possibility of MIC contamination was exposed. No recommendations were implementedGreenSA1 SB3 SC1 SD5 a3 b1 c3Time LTATime was adequateRedSA1 SB3 SC1 SD5 a3 b1 c4Workforce Input LTAThe operator knew there was a problem in the system when he decided to cut the water supply, but he obey to restart the water supplyRedSA1 SB3 SC1 SD5 a3 b2Correction of Hazards LTAHazards were not identifyRedSA1 SB3 SC1 SD5 a3 b2 c5Inter-departmental Co-ordination LTAThe coordination of the job was unadequate, maintenance personnel never was communicated to insert the slip blind. The operator continued with his task even when the maintenance personnel have not authorized the interventionBlueSA1 SB3 SC1 SD5 a3 b2 c6PostponedDuring the pipe cleaning activity the operator was aware that water could contaminate the MIC tank when no water came out through the drain valves. The supervisor payed no attention to this action an restarted the water supply. More detail is needed to determine if the supervisor was aware of the safety issues related to MIC contaminationARRedSA1 SB3 SC1 SD5 a3 b2 c7Did not Correct in TimeThis branch considers the leaking valves and the failure in the tanks possitive pressure systemRedSA1 SB3 SC1 SD5 a3 b2 c7 d5Authority LTAAs a budget related issue, supervisor had no authority and upper management was cutting expensesRedSA1 SB3 SC1 SD5 a3 b2 c7 d6Budget LTAUpper management was cutting expensesRedSA1 SB3 SC1 SD5 a3 b2 c7 d7Time LTARedSA1 SB3 SC1 SD5 a3 b2 c8Housekeeping LTAHousekeeping was les than adequate, if the facilities would had been more organized, clean and with a better look, workers could detect hazards more easilyRedSA1 SB3 SC1 SD5 a3 b2 c9Supervisor Judgment LTARisks related to the valves leakage and failure of the possitive pressure system were underestimated due to the cutting of expenses in UCILRedSA1 SB3 SC1 SD5 a4Performance ErrorsThis branch considers the activities performed by the operator during the cleaning processRedSA1 SB3 SC1 SD5 a4 b3Task Performance ErrorsThis branch considers errors during the cleaning processRedSA1 SB3 SC1 SD5 a4 b3 c10Task Assignment LTAThe task assignment was adequate, the supervisor was there during the activityRedSA1 SB3 SC1 SD5 a4 b3 c11Task-specific Risk Assessment not performedIt is evident that before the execution of the cleaning task, no risk assessment related to the task was done. The line that was going to be injected with water was not sealedRedSA1 SB3 SC1 SD5 a4 b3 c11 d8High Potential not IdentifiedThis branch considers the hazards related to not installing the slip blind in lineBlueSA1 SB3 SC1 SD5 a4 b3 c11 d8 e1Task Analysis not RequiredIt is not clear if the hazard assessment was a requirement from management, procedures and checklists should be verifiedRedSA1 SB3 SC1 SD5 a4 b3 c11 d8 e2Task Analysis LTARedSA1 SB3 SC1 SD5 a4 b3 c11 d8 e3Task Analysis not madeThis branch considers the lack of hazard assessment before the pipe cleaning taskRedSA1 SB3 SC1 SD5 a4 b3 c11 d8 e3 f1Authority LTAIt is possible that the procedure would had indicated that the supervisor or the operator were responsable of performing pre job analysis, but they were not madeRedSA1 SB3 SC1 SD5 a4 b3 c11 d8 e3 f2Budget LTARedSA1 SB3 SC1 SD5 a4 b3 c11 d8 e3 f3Time LTATime could had been an issue because the shift was ending and the personnel could had been rushing the activity to go homeRedSA1 SB3 SC1 SD5 a4 b3 c11 d8 e3 f4Supervisor Judgment LTAThe supervisor did not had the experience or the knowledge related to the risk of MIC contaminationBlueSA1 SB3 SC1 SD5 a4 b3 c11 d9Low PotentialA further research into safety management systems needs to be done, it is not clear if the risk was identified and treated as a low potential risk. A written procedure of the insertion of the slip blind will help clearify if the procedures were not followed or there was a decision needed to be mad and risks were underestimatedARBlueSA1 SB3 SC1 SD5 a4 b3 c12Task-specific Risk Assessment LTAThis branch considers the possibility that a risk assessment was doneBlueSA1 SB3 SC1 SD5 a4 b3 c12 d10Task-specific Risk Analysis LTAThis section considers the quality of the risk analysis before the pipe cleaning taskBlueSA1 SB3 SC1 SD5 a4 b3 c12 d10 e4Knowledge LTAThis branch considers the available knowledge in the time of the accidentBlueSA1 SB3 SC1 SD5 a4 b3 c12 d10 e4 f5Use of Workers'Suggestions and Inputs LTAWorker suggestion was not taken in concern. When the operator cut the water supply, it was evident that the risk of MIC contamination was idntified, but no further action was taken.BlueSA1 SB3 SC1 SD5 a4 b3 c12 d10 e4 f6Technical Information Systems LTATechnical information systems were not appropiate, risk may had been underestimated and the use of diagrams omitted, which led to a poorer understanding of the hazards related to the jobBlueSA1 SB3 SC1 SD5 a4 b3 c12 d10 e5Execution LTAThis branch considers the performance of the risk assessment if it had been madeGreenSA1 SB3 SC1 SD5 a4 b3 c12 d10 e5 f7Time LTATime was adequate, but the people involved were underestimating the risk assessmentGreenSA1 SB3 SC1 SD5 a4 b3 c12 d10 e5 f8Budget LTABudget was limited, but it was no excuse for not performing an adequate risk assessmentBlueSA1 SB3 SC1 SD5 a4 b3 c12 d10 e5 f9Scope LTAThe scope of the analysis could had been limited and the possibility of MIC contamination may not have been identified at firstBlueSA1 SB3 SC1 SD5 a4 b3 c12 d10 e5 f10Analytical Skill LTAIt may have not been adequate because the supervisor did not recognize the MIC contamination risk when the operator closed the water supply. The operator also limited himself to follw instructions even though he knew what was happeningBlueSA1 SB3 SC1 SD5 a4 b3 c12 d10 e5 f11Hazard Selection LTAThis section considers that the risk assessment was not adequate because the MIC contamination risk was not properly addressedBlueSA1 SB3 SC1 SD5 a4 b3 c12 d10 e5 f11 g1Hazard Identification LTAFurther information is needed to consider if all hazards were identifyBlueSA1 SB3 SC1 SD5 a4 b3 c12 d10 e5 f11 g2Hazard Prioritization LTAFurther information is needed to consider if the hazards were given the correct weightBlueSA1 SB3 SC1 SD5 a4 b3 c12 d11Recommended Risk Controls LTAThis section considers the relationship of risk controls to the contamination of MICBlueSA1 SB3 SC1 SD5 a4 b3 c12 d11 e6Clarity LTAThe use of the slip blind should had been a clear recommendation, further information is needed to determine why it was not usedGreenSA1 SB3 SC1 SD5 a4 b3 c12 d11 e7Compatibility LTAThe use of the slip blind is compatible with the pipe that had to be blockedBlueSA1 SB3 SC1 SD5 a4 b3 c12 d11 e8Testing of control LTAThe pipe blockage was never testedBlueSA1 SB3 SC1 SD5 a4 b3 c12 d11 e9Directive to Use LTAThe directive to use controls may had been less than adequate, more information is needed to proof that even though the controls were known, the instructions from management could be confusing when they priorized makin profit.BlueSA1 SB3 SC1 SD5 a4 b3 c12 d11 e10Availability LTAThe availability of the slip blind needs to be analized, maybe there was no maitenance worker to perform the activityBlueSA1 SB3 SC1 SD5 a4 b3 c12 d11 e11Adaptability LTAThe slip blind was a control well fitted for the taskBlueSA1 SB3 SC1 SD5 a4 b3 c12 d11 e12Use not MandatoryMore information is needed to determine if the use of slipblind was mandatory. In both cases the slip blind was not usedARBlueSA1 SB3 SC1 SD5 a4 b3 c13Pre-task Briefing LTAThe pre task briefing was less than adequate, maybe the task was done frequently, so the supervisor underestimated risk analysis. The condition of some components like valves and possitive pressure system were not working properly, these conditions were not taken in concernGreenSA1 SB3 SC1 SD5 a4 b3 c14Fit between Task Procedures and actual Situation LTAthe task was simple and the operator followed all the instructionsRedSA1 SB3 SC1 SD5 a4 b3 c15Personnel Performance DiscrepancyThis branch considers the performance of the operator and MIC supervisor during the pipe cleaning taskRedSA1 SB3 SC1 SD5 a4 b3 c15 d12Personnel Selection LTAThis branch considers facts related to personell selection for operator and MIC supervisorBlueSA1 SB3 SC1 SD5 a4 b3 c15 d12 e13Criteria LTAFurther information is needed, but it is possible that job description was too general and it did not included knowlege in chemistry. The seletion of the supervisor could had been based in other criterias different from the ones related for the jobBlueSA1 SB3 SC1 SD5 a4 b3 c15 d12 e14Testing LTAFurther information is needed to determine if employees were continuously testedRedSA1 SB3 SC1 SD5 a4 b3 c15 d13Training LTAThis branch considers if training was aprropiate for the employeesRedSA1 SB3 SC1 SD5 a4 b3 c15 d13 e15No trainingNo evidence of training was presentBlueSA1 SB3 SC1 SD5 a4 b3 c15 d13 e16Criteria Training LTAA lack of safety criteria for performing the job may had been related to not using the slipblind when requiredRedSA1 SB3 SC1 SD5 a4 b3 c15 d13 e17Methods LTABased on results the method used was not adequate because the slip blind was not used, the superisor did not realice all safety concernsSA1 SB3 SC1 SD5 a4 b3 c15 d13 e18Trainer Skills LTABlueSA1 SB3 SC1 SD5 a4 b3 c15 d13 e19Verification LTAFurther information is needed to establish if there was retraining for operators and supervisorsRedSA1 SB3 SC1 SD5 a4 b3 c15 d14Consideration of Deviations LTAThis branch considers posible signs of deviations on the operators performanceBlueSA1 SB3 SC1 SD5 a4 b3 c15 d14 e20Normal VariabilityThere is no record of anormality, the operator could had been rushing to finish the shiftSA1 SB3 SC1 SD5 a4 b3 c15 d14 e21ChangesSA1 SB3 SC1 SD5 a4 b3 c15 d14 e22Supervisor Observation LTASA1 SB3 SC1 SD5 a4 b3 c15 d14 e23Supervisor Correction LTASA1 SB3 SC1 SD5 a4 b3 c15 d14 e23 f12Re-instruction LTASA1 SB3 SC1 SD5 a4 b3 c15 d14 e23 f13Enforcement LTARedSA1 SB3 SC1 SD5 a4 b3 c15 d15Employee Motivation LTAThis branch considers the motivation that the employee had to finish his jobBlueSA1 SB3 SC1 SD5 a4 b3 c15 d15 e24Leadership & Examples LTAThe order to restart the water supply could meant that there was no leadership, it could be assumed that the supervisor and the operator just wanted to finish his job and leaveSA1 SB3 SC1 SD5 a4 b3 c15 d15 e25Time PressureBlueSA1 SB3 SC1 SD5 a4 b3 c15 d15 e26Correct Performance is PunishedFurther information is needed for establishing this point, it could be assume that the water supply cut off was a correct action performed by the operator but misinterpreted by the supervisorRedSA1 SB3 SC1 SD5 a4 b3 c15 d15 e27Incorrect Performance is RewardedIncorrect performance could had been encouraged by the supervisor in order the operator perform the activity faster. The practive of not wearing protective equipment in previous incidents could had been encouraged. Management knew about the exposure of workers to contamination and they took corrective actions to assure they were better feedBlueSA1 SB3 SC1 SD5 a4 b3 c15 d15 e28Job Interest Building LTAIt is possible that the task was too simple and frequent that the operator and the supervisor did not put much attention to the missing slip blindRedSA1 SB3 SC1 SD5 a4 b3 c15 d15 e29Group Norms ConflictAn evident lack of agreement was seen previously in Bhopal. Strikes had been organize previously because of the safety conditions under which people workRedSA1 SB3 SC1 SD5 a4 b3 c15 d15 e30Obstacles Prevent PerformanceThe main obstacle could had been that there was no responsable of the maintenance areaRedSA1 SB3 SC1 SD5 a4 b3 c15 d15 e31Personal ConflictThis branch consider conflicts between management and workersRedSA1 SB3 SC1 SD5 a4 b3 c15 d15 e31 f15[Conflict] with SupervisorWorkers at Bhopal were concerned about their safety and they felt that management was not listening to their requests. Strikes were organizedRedSA1 SB3 SC1 SD5 a4 b3 c15 d15 e31 f16[Conflict] with OthersStrikes caused government concern but in favor of UCIL interestBlueSA1 SB3 SC1 SD5 a4 b3 c15 d15 e31 f17Deviant TraitsThe conditions of agriculture in Bhopal made the company less profitable every year. Management put a side safety concerns for profit, which previously had caused accidents to workers. Workers felt they were disposable, less qualified workers were hired and they were not treated appropiatelyARSA1 SB3 SC1 SD5 a4 b3 c15 d15 e32General Motivation Program LTASA1 SB3 SC1 SD5 a4 b4Performance Errors in unrelated tasksSA1 SB3 SC1 SD5 a4 b4 c16Allowed ActivitiesSA1 SB3 SC1 SD5 a4 b4 c17Prohibited ActivitiesSA1 SB3 SC1 SD5 a4 b5Emergency Shut-off Performance ErrorsSA1 SB3 SC1 SD5 a4 b5 c18Task Performance ErrorsSA1 SB3 SC1 SD5 a4 b5 c19Unrelated Task ErrorsRedSA1 SB3 SC1 SD6Support of Supervisors LTAThis branch considers the support of upper management to the MIC supervisorRedSA1 SB3 SC1 SD6 a1Help and Training LTAThe supervisor was not well trained in safety and operation issues of an agreggate products factory, his experience came from a battery factory; management did not assure proper training to perform his dutySA1 SB3 SC1 SD6 a2Research and Fact-Finding LTABlueSA1 SB3 SC1 SD6 a3Information Exchange LTAIt seems that the communication is only in one direction, supervisors and operator could only follow orders that were made to maintain the companys profitsBlueSA1 SB3 SC1 SD6 a4Standards and Directives LTAMore information is needed to determine if there were internal codes and standards that requested certain maintenance activities, procedures, building standard or risk assessment that could had prevented failure. External standards were not followed since the construction of the plant, where safety devices were not used beause of the limited budget. Afterwards, modifications were made that were not comply in any standard (jumper line)RedSA1 SB3 SC1 SD6 a5Resources LTAThis branch considers the resources provided to the supervisorSA1 SB3 SC1 SD6 a5 b1Training LTARedSA1 SB3 SC1 SD6 a5 b2Access to Expertise LTATechnical support may had been adequate, operator knew there was a problem when water did not came through the drain valves. The supervisor did not take into account the operator expertiseBlueSA1 SB3 SC1 SD6 a5 b3Access to Equipment & Materials LTAFurther information is needed in order to determine if the slip blind was available. Even if it was not, the task should had been suspendedRedSA1 SB3 SC1 SD6 a5 b4Coordination of Resources LTAAdequate coordination was not done with the maintenance crewSA1 SB3 SC1 SD6 a6Deployment of Resources LTARedSA1 SB3 SC1 SD6 a7Referred Risk Response LTARecommendations from safety audits, requirements from employees and other issues were not taken in concern by managementSA1 SB3 SC2Barriers LTARedSA1 SB3 SC2 a1On the Energy SourceUse of water to clean pipe may have not been adequate. The slip blind was not installed to block water from going into the MIC tankSA1 SB3 SC2 a1 b1Barriers None PossibleSA1 SB3 SC2 a1 b2Barrier FailedRedSA1 SB3 SC2 a1 b3Did not UseThe slip blind was not usedSA1 SB3 SC2 a1 b3 c1Did not ProvideIt is possible that without a maintenance supervisor, there was no responsabie to assure safe conditions to the pipe cleaning process, management may have not evaluate the consequences of not hiring a new maintenance supervisorARRedSA1 SB3 SC2 a1 b3 c2Task Performance ErrorThe supervisor and the operator were not aware if all barriers were in juseRedSA1 SB3 SC2 a2Between energy source and targetValves were leaking and a jumper line was constructed between the process line and the safety relief line.RedSA1 SB3 SC2 a3On Persons or ObjectsThe possitive ressure system was not working properly to block possible contaminationSA1 SB3 SC2 a4Separate Time and distanceRedSA1 SB4Events and Energy Flows Leading to Accident/IncidentThe contamination of the MIC tank leads to a run away reactionRedSA1 SB4 SC3Barriers and Controls LTATank E619 had to be used for containing an emergency run away, during the disaster it had MIC insideThe refrigeration system was shutdown and dismantled to save operation and maintenance costsUnreliable safety and measurement devicesUnderstanding of MIC reaction and safety issues was limited in all levels of the companyA leak was identified in tank E610, nitrogen pressure could not be maintainAutomatic shutdown devices were not used Early detection equipments were not usedLarge amounts of MIC was stored in plantManagement budget reduction had no hazard analysisContaminants in tank accelerated the runaway reactionSA1 SB4 SC4Energy TransfersWater and contaminants were conducted through pipes to the MIC tank, a run away reaction started; which lead to a gas leakageSA2Stabilization & Restoration LTASA2 a1Prevention of Follow-up AccidentsSA2 a1 b1Plan LTASA2 a1 b2Execution of Plan LTASA2 a1 b2 c1Notification LTA (Trigger)SA2 a1 b2 c2Training and Experience LTASA2 a1 b2 c3Personnel and/or Equipment ChangesSA2 a1 b2 c4Logistics LTASA2 a1 b2 c5Task Performance ErrorsSA2 a1 b2 c6Response DelaySA2 a2Emergency Action (Firefighters, etc.) LTASA2 a3Rescue and Salvage LTASA2 a4Medical Services LTASA2 a5Dissemination of Information LTASA2 a6Restoration and Rehabilitation LTASA2 a6 b3Operational Continuity LTASA2 a6 b4Rehabilitation LTASA2 a6 b5Restoration LTASA2 a6 b6Absorb LossMManagement System Factors LTAMA1Policy LTAMA2Implementation of Policy LTAMA2 a1Planning Process LTAMA2 a1 b1Specification of Plan LTAMA2 a1 b1 c1Methods, Criteria, Analyses LTAMA2 a1 b1 c2Specification of Responsibilities LTAMA2 a1 b1 c2 d1Definition of Line-responsibility LTAMA2 a1 b1 c2 d2Staff Responsibility LTAMA2 a1 b1 c2 d3Task Assignment LTAMA2 a1 b1 c3Schedule LTAMA2 a1 b1 c4Budgets LTAMA2 a1 b1 c5Communication Plan LTAMA2 a1 b1 c5 d4Information Flow LTAMA2 a1 b1 c5 d5Guidance and Directives LTAMA2 a1 b2Use of Feedback LTAMA2 a2Execution of Policy Implementation Plan LTAMA2 a2 b3Leadership LTAMA2 a2 b4Capability LTAMA2 a2 b4 c6Authority LTAMA2 a2 b4 c7Accountability LTAMA2 a2 b4 c8Task Performance ErrorsMA2 a2 b5Practical Support LTAMA2 a2 b6Time and Budget LTAMA2 a2 b7DelaysMA2 a2 b8Caused FailureMA2 a3Monitoring LTAMA3Risk Management System LTAMA3 MB1Risk Management Policy LTAMA3 MB2Implementation of Risk Management Policy LTAMA3 MB3Risk Analysis Process LTAMA3 MB3 a1Concepts and Requirements LTAMA3 MB3 a1 b1Technical Information System LTAMA3 MB3 a1 b2Definition of Goals and tolerance Risks LTAMA3 MB3 a1 b2 c1ES&H Goals and Risks not definedMA3 MB3 a1 b2 c2Performance Goals and Risks not definedMA3 MB3 a1 b3Risk Analysis Criteria LTAMA3 MB3 a1 b3 c3Plan LTAMA3 MB3 a1 b3 c4Change Analysis LTAMA3 MB3 a1 b3 c5Other Analytical Methods LTAMA3 MB3 a1 b3 c6Scaling Mechanism LTAMA3 MB3 a1 b3 c7Required Alternatives LTAMA3 MB3 a1 b3 c8Solution Precedence Sequence LTAMA3 MB3 a1 b4Criteria for Procedures LTAMA3 MB3 a1 b5Specification of Requirements LTAMA3 MB3 a1 b3 c9Stakeholder/customer requirementsMA3 MB3 a1 b3 c10Statutory codes and regulationsMA3 MB3 a1 b3 c11Requirements of other National and International codes and standardsMA3 MB3 a1 b3 c12Local Codes and BylawsMA3 MB3 a1 b3 c13Internal StandardsMA3 MB3 a1 b6Information Search LTAMA3 MB3 a1 b7Life Cycle Analysis LTAMA3 MB3 a1 b7 c14Scope LTAMA3 MB3 a1 b7 c15Analysis of Environmental Impact LTAMA3 MB3 a1 b7 c16Requirement for Life Cycle Analysis LTAMA3 MB3 a1 b7 c17Extended Use Analysis LTAMA3 MB3 a2Design and Development LTAMA3 MB3 a2 b8Energy Control LTAMA3 MB3 a2 b8 c18Safer EnergyMA3 MB3 a2 b8 c19Limitation of Energy LTAMA3 MB3 a2 b8 c20Automatic Controls LTAMA3 MB3 a2 b8 c21Warnings LTAMA3 MB3 a2 b8 c22Manual Controls LTAMA3 MB3 a2 b8 c23Safe Energy Release LTAMA3 MB3 a2 b8 c24Controls and Barriers LTAMA3 MB3 a2 b9Human Factors (Ergonomics) Review LTAMA3 MB3 a2 b9 c25Professional HF Skills LTAMA3 MB3 a2 b9 c26Task Analysis LTAMA3 MB3 a2 b9 c27Allocation Human/Machine Tasks LTAMA3 MB3 a2 b9 c28Did not Establish Human Task RequirementsMA3 MB3 a2 b9 c28 d1Did not Define UsersMA3 MB3 a2 b9 c28 d2Design of Displays LTAMA3 MB3 a2 b9 c28 d3Interpretation LTAMA3 MB3 a2 b9 c28 d4Design of Controls LTAMA3 MB3 a2 b9 c29Did not Predict ErrorsMA3 MB3 a2 b10Inspection Plan LTAMA3 MB3 a2 b11Maintenance Plan LTAMA3 MB3 a2 b12Arrangement LTAMA3 MB3 a2 b13Environment LTAMA3 MB3 a2 b14Specification of Operational Readiness LTAMA3 MB3 a2 b14 c30Test and Qualification LTAMA3 MB3 a2 b14 c31[Specification of] Supervision LTAMA3 MB3 a2 b14 c32Task Procedures LTAMA3 MB3 a2 b14 c32 d5Match to Hardware Change LTAMA3 MB3 a2 b14 c32 d6Match to Users LTAMA3 MB3 a2 b14 c32 d7Match to Task and Equipment LTAMA3 MB3 a2 b14 c32 d8Emergency Provisions LTAMA3 MB3 a2 b14 c32 d9Cautions and Warnings LTAMA3 MB3 a2 b14 c32 d10Task Sequence LTAMA3 MB3 a2 b14 c32 d11Lockouts LTAMA3 MB3 a2 b14 c32 d12Communications Interfaces LTAMA3 MB3 a2 b14 c32 d13Specification of Work Conditioning LTAMA3 MB3 a2 b14 c33Personnel Selection LTAMA3 MB3 a2 b14 c34Personnel Training and Qualification LTAMA3 MB3 a2 b14 c35Personnel Motivation LTAMA3 MB3 a2 b14 c36Monitor Points LTAMA3 MB3 a2 b15Emergency Shutdown Provision LTAMA3 MB3 a2 b16Contingency Planning LTAMA3 MB3 a2 b17Disposal Planning LTAMA3 MB3 a2 b18Independent ReviewMA3 MB3 a2 b19Configuration Control LTAMA3 MB3 a2 b20Documentation Control LTAMA3 MB3 a2 b21Fast Action Cycle LTAMA3 MB3 a2 b22Design Acceptance and Change Control Processes LTAMA3 MB3 a2 b22 c37Code Compliance Verification LTAMA3 MB3 a2 b22 c38Engineering Studies LTAMA3 MB3 a2 b22 c39Standardization of Parts LTAMA3 MB3 a2 b22 c40Design Description LTAMA3 MB3 a2 b22 c41Acceptance Criteria LTAMA3 MB3 a2 b22 c42Development and Qualification Testing LTAMA3 MB3 a2 b22 c43Change Review Procedure LTAMA3 MB3 a2 b22 c44Reliability and Quality Assurance LTAMA3 MB4Risk Management Assurance Programme LTAMA3 MB4 a1Definition of Aims and Policy LTAMA3 MB4 a2Programme Scope LTAMA3 MB4 a3Documentation LTAMA3 MB4 a4Assurance Programme Organization LTAMA3 MB4 a4 b1Risk Management Assurance Staff Performance LTAMA3 MB4 a4 b2Management Committees LTAMA3 MB4 a4 b3Organisation for Improvement LTAMA3 MB4 a5Assurance Programme Services LTAMA3 MB4 a6Activities LTAMA3 MB5Review of Risk Management System LTARAssumed Risks

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