March 18, 2018

Ghosts of Bhopal?

In a CSB investigation report about a Nitrous oxide explosion in 2016 that killed an employee, the following causes were listed in the report. Many of the causes identified by the CSB are identical to the causes of the Bhopal gas disaster in 1984. Can you identify some of them?
 1.    XXXXXX did not evaluate inherently safer design options that could have eliminated the need for the pump;
 2.    XXXXXX never evaluated its process to identify and control process safety hazards;
3.    XXXXXX did not effectively apply the hierarchy of controls to the safeguards that the company used to prevent a possible nitrous oxide explosion;
4.    XXXXXX installed equipment that increased the likelihood of an explosion without performing a management of change safety review;
5.    XXXXXX did not apply an essential industry safety instrumentation standard, or key elements of a voluntary safe storage and handling standard, both of which are intended to prevent nitrous oxide explosions;
6.    XXXXXX safeguards that failed to prevent the explosion include an automatic shutdown safety control and an explosion prevention device;
 7.    The automatic shutdown safety control XXXXXX relied on required the XXXXXX worker to be physically present – and located immediately adjacent to the trailer truck – in order to bypass the shutdown at a time when an explosion was most likely to occur; and
8.    The XXXXXX explosion prevention device – a flame arrestor – was never tested or inspected to ensure it could protect workers from an explosion.
 9.    XXXXXX failed to apply lessons from previous nitrous oxide explosions; and
10. XXXXXX did not provide its Cantonment facility with an appropriate level of technical staffing support.

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