Many of the precursors that led to the Bhopal disaster actually occur daily in minor forms throughout industry today. Preventing disasters — and the incidents of lesser consequence leading up to them — requires probing deeper beneath their seemingly superficial, distracting, and highly-visible exterior. Doing so shows how similar all industrial disasters actually are. Recognizing the patterns that led to the Bhopal disaster in many of the processes that we operate today indicates there is a weakness deserving our attention. This paper will summarize fundamentals of a portion of the Bhopal plant’s process design, changes that were made contrary to the original specifications, problems encountered, numerous design and operational changes that were made (with the best of intentions) that simply led to further problems, and how these issues came together to cause the worst industrial disaster in history. Relating these events to issues commonly encountered in other facilities around the world today creates many parallels. This awareness is needed to prevent major industrial disasters and the more frequent “minor” process safety events that precede them today.
Paul Gruhn is a Global Functional Safety Consultant with aeSolutions in Houston, Texas. Paul is an ISA Life Fellow, a 25+ year member and co-chair of the ISA 84 standard committee (on safety instrumented systems), the developer and instructor of ISA courses on safety systems, the author of two ISA textbooks, and the developer of the first commercial safety system software modeling program. Paul has a B.S. degree in Mechanical Engineering from Illinois Institute of Technology, is a licensed Professional Engineer (PE) in Texas, a member of the Control Systems Engineering PE exam committee, and both a Certified Functional Safety Expert (CFSE) and an ISA 84 Safety Instrumented Systems Expert. Paul is the 2018 ISA President-elect Secretary.