Adding multiple safeguards does not necessarily make a manufacturing operation safer. The Bhopal gas tragedy serves as an example of how the failure of a single pump can defeat multiple mitigative safety layers.
This is the second article in a three-part series that promotes a deeper understanding of the causes and lessons related to the Bhopal gas tragedy. The first article describes how incidents can occur when workers are conditioned to address chronic equipment or operating issues with workaround solutions (1). It also introduces how a common cause failure hid the initiating contamination event responsible for the toxic gas release.
This article dives further into this topic by demonstrating how a seemingly inconsequential equipment failure in one area can affect safety system performance in other locations. This point is illustrated by comparing the actual observed safeguard performance at the Bhopal factory with what was expected by design...
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