(133b) Three Decades after Bhopal: What We Have Learned about Effectively Managing Process Safety Risks

While no industrial chemical incident has had the magnitude for loss of life that occurred in 1984 at Bhopal, process safety incidents continue to occur today often resulting in serious injuries, fatalities, environmental harm, property damage and business interruption.  Over the last three decades since Bhopal, we have learned that these three inter-related foundations are essential for effective process safety programs: 1) process safety culture and leadership, 2) process safety systems, and 3) operational discipline.  If any one of these foundations is weak, the process safety programs will be weak, process safety incidents will occur and the organization’s process safety performance will be poor.  This paper explores how the process safety systems are essential barriers when protecting against incidents and presents a visual tool which can be used to help illustrate the gaps in the three foundations.  The visual tool shows these gaps using a novel combination of the Layer of Protection and Bow Tie barrier analysis models.  Bhopal is presented as the case study using this visual tool, showing which process safety system barriers failed (ultimately all of them) due to poor process safety leadership, poor safety culture, and poor operational discipline.