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Bhopal Incident - Coggle Diagram
Bhopal Incident
Management
Training deficiencies
Due to budget many workers were not trained sufficiently in emergency procedures
Lack of safety management
Failure in emergency evacuation procedure
Emergency evacuation drills not preformed
When the leak occurred nobody knew what to do resulting in chaos
Failure in safety procedure management
Failure to maintain equipment
Multiple plant equipment items not in working order
Isolation valves leaking
Pressure monitor reading incorrectly
Failure to follow procedure
Did not keep the spare tank empty as required by procedure
It was found that the plant operators often left chemicals in the spare tank - even though they were not meant to . It was found to be a common practice for them to leave chemicals in there.
Failure to comply with company procedure
Failure in inspection
Failure in safety management
Failure to investigate
When a leak occurred they were rarely if not ever investigated
Poor health and safety management
People
Doctors
No knowledge of how to treat victims
Lack of information given to doctors
Poor emergency procedure management
Bhopal residents
Were not prepared for a gas leak emergency or the dangers involved
Lack of communication
Lack of emergency procedure
Bhopal Government
Fear of losing investors
Lack of compliance inspections in fear of losing investors and jobs for residents
Poor health and safety management
Workers
Under trained
Due to budget the quality of training provided was reduced
Poor safety management
Overworked
Due to budget - operators cut from 12 to 6 on shift
Lack of safety management
Lack of fatigue management
Workplace
Equipment
Lack of leak detection
Plant relied on workers to detect leaks
Once workers eyes started to water the leak is detected
Poor health and safety management
Leaking isolation valves
Safety systems
Lack of emergency procedures
Lack of communication between management and city
Lack of risk analysis
Absence of toxic information centre
Regular cleaning of pipes and valves did not occur
Lack of maintenance management
Poor safety management