Case study for Bhopal Gas Tragedy

Introduction

As a result of an explosion at the Union Carbide pesticide plant on December 3, 1984, a

poisonous plume of methylisocyanate (MIC) vapour spread around the city of Bhopal. Over
2,000 of Bhopal's 800,000 residents perished instantly, and another 300,000 were hurt (Stix,
1999). Union Carbide's Bhopal factory used MIC heavily in the manufacturing of the
pesticide Sevin. The now-famous Bhopal Gas Disaster ranks among the worst suitable for
commercial disasters ever. It's a high-stakes accident with a slim chance of happening. The
accident's chaotic aftermath can be traced back to the combination of the seven factors listed
below (Bowonder, 1987; 32).

1. Significant quantities of chemical exuded from plant.

2. Leakage of the very poisonous yet odourless MIC.
3. a densely populated region bordering the facility.
4. The weather has been rather calm, allowing the vapour cloud to descend.
5. The leak happens at night, when everyone is sound asleep.
6. Defeat or inadequate warnings
7. Workers in the factory who are neither qualified nor informed.

The Bhopal crisis has been studied by the media as an example of how to improve industrial
safety due to its shocking scale. Among the biggest commercial industrial disasters ever, this
event has been dubbed the "Hiroshima of the Chemical Industry" (Common Dreams, 2009).
Throughout the subsequent years, several investigations were carried out, various hypotheses
were tested, and blame was levelled at all levels. In this study, we'll look into Union Carbide
Corporation's response to the issue and the numerous theories that have been put out to
explain what happened.

Early warnings

Before the catastrophe, the factory had a history of accidents. Everyone who spoke up
expressed concern about the company's management, infrastructure, personnel, and general
disregard for safety protocols. Two labour organisations filed formal complaints about the
plant's air quality in 1976. (Wikipedia ). Phosgene poisoning claimed the life of a worker in
1981. (Peterson.M.J, 2009). A team of American specialists visited the factory in 1981 and
cautioned UCC about the potential for a rear - end collision in the MIC water tanks. A similar
warning was issued by Indian officials to UCIC in 1979, but UCIC did little to address the
issue (Peterson.M.J, 2009) Twenty-four employees were hospitalised after being exposed to
phosgene in January 1982. No one was required to use respirators due to the lack of gas.
Within a month of MIC leakage exposure, 18 personnel (Peterson.M.J, 2009). A chemical
engineer was exposed to MIC in August 1982, and the resulting burns covered 30% of his
body. In the same year, another MIC leakage severely burned the supervisor who was tasked
with stopping it. The years 1983 and 1984 saw additional leaks. The chlorine, mustard gas,
carbon tetrachloride, and monomethyl amine concentrations were all within the MIC range.

In fact, the catastrophe was accompanied by warning events dating back to 1976, however
neither the incidents were treated nor were any measures taken to lessen the potential impact
of the eventual disaster. No one was held accountable for their carelessness, either.

Contributing factors

1) UCC persisted in employing the riskiest procedure even while a less hazardous
alternative existed.
2) Several circumstances, including storing MIC in excess of the recommended quantity
in massive tanks, contributed to this catastrophic event.
3) After MIC production ends in 1984, the factory is not maintained well.
4) In an effort to conserve funds, the safety systems were placed on standby. The
refrigeration equipment for the MIC storage tanks, which could avert this catastrophe,
is included. The system actually lacked Freon.
5) Poor neighbourhoods sprouting up around the plant amplify the impact of gas
emissions (nearest one was 1.5 mile away from the plant when it was installed).
6) The severity of the calamity was exacerbated by the weather conditions at the time.
The gas was not dispersed by a strong breeze, and it was not reacted to by any
precipitation. A calm breeze drove the gas in a tight front towards Bhopal. Most
importantly, the accident occurred at night, when the convection current was strongest
and could have carried the gas to higher altitudes.
 7) There are no emergency measures in place to provide medical care or evacuate people
in the event of a catastrophic gas spill.

Leak Timeline

The most widely accepted version of what transpired on December 2 and 3, 1984, at the
Bhopal Plant is outlined in the timeline below.

December 2, 1984:

Between the hours of 8 and 9, the MIC plant administrator was tasked with cleaning out the
phosgene system's pipes that connect to the scrubber via the MIC facility's storage tanks. The
slip bound (a solid disc) must be placed in the pipe just above the final rinse input, and this
task falls to the maintenance staff. Workers at the MIC unit did not install slip shades because
they were unaware that doing so was a mandatory safety measure. MIC in tanks was kept
between 15 and 20 degrees Celsius. According to (Peterson MJ, 2009)

The dishwashing starts at 9:30 tonight. A clog in one of the bypass valve valves (an overflow
device) prevented water from flowing normally. The piping system gathered it for later use.
The plant manager gave the go-ahead to continue washing until the water level rose 20 feet
above ground, past the leaky separator in the lines being cleaned, and into the control valves
pipe. As cited in (MJ Peterson, 2009)

At 11 o'clock, the control room operator saw that the pressure indicator for Tank E610 had
grown from 2 psi to 10 psi. As 10 psi is still well within the normal 2–25 psi range, the
operator wasn't too worried about the increase in pressure. Nevertheless, there was no way to
track the tank's temperature from the command centre. At around 11:30 p.m., the unit staff
smelled MIC and discovered a leak near the skimmer. On the downstream end of the safety
valve, far from the tank area, they discovered MIC and unclean water seeping out of one of
the pressure switch lines. After notifying those in the control tower of the issue, the personnel
deployed a spray bottle to neutralise the leaking MIC (MJ Peterson, 2009)

December 3, 1984:

12.15‐12:30 am: The operator in the control room has seen that the flow meter for Tank E610
is between 25 and 30 pounds per square inch. The operator in the control room discovered
that the pressure in the same tank had reached 55 psi at about 12.30 a.m. His investigation
revealed that a safety valve had failed, releasing deadly gas clouds from the plant's stack vent
extractor and into the air throughout Bhopal. According to (Peterson MJ, 2009)

12.40 am: The dangerous gas alarms both inside and outside the facility were activated by the
plant supervisor. The fire water cannon was also activated by the operators. The gas cloud at
the top of the extractor stack was too high for the water to reach. As a corollary, the Freon in
the refrigeration system was depleted, therefore tries to cool the tank were fruitless.
According to (Peterson MJ, 2009)

1 am: Workers failed to lower the water level in E610 by conveying any MIC to the spare
tank, E619. This was discovered by the plant supervisor. 9 Outside of the plant, the odour of
gas was very strong.

1.30 am: Though the Bhopal police commissioner was aware of the leak, no meaningful
police response was initiated.

8 am: The governor of Madhya Pradesh issued a directive to shut down the plant and
apprehend the building manager and five other workers.

Causes for Disaster:

There are two main lines of argument involving the disaster:

1. Corporate Negligence
2. Worker Sabotage

The "Corporate Negligence" workers' actions that unintentionally allowed water to breach
the MIC tanks in the paucity of properly functioning safeguards are blamed for the tragedy,
which is seen as the culmination of years of neglecting the facility, ignoring safety concerns,
and failing to adequately train employees. (Wikipedia)

 This argument adds that a hazardous workplace was permitted to exist because
management (and perhaps local government) disinvested in safety measures.
 Several factors have been identified as causes of the disaster's severity: filling the
MIC tanks beyond standard values, a lack of restoration after the plant stopped
producing MIC at the end of 1984, the ineffectiveness of several safety systems as a
result of a lack of maintenance, the decision to turn off safety systems in order to save
 money (among them, the refrigeration system for the MIC tanks), and the absence of a
catastrophe management plan.
 Inadequately scaled safety equipment and reliance on manual activities were also
cited as causes by investigators from several government agencies. Many gaps in
plant management were exposed, including a shortage of trained workers, a
weakening of safety measures, a lack of preventative maintenance, and a lack of
contingency plans. (Wikipedia)

The "Worker Sabotage" argument holds that water couldn't have gotten into the tank
without some kind of coordinated human labour, and that extensive witness statements and
engineering analysis point to the conclusion that water got into the tank when a disgruntled
employee hooked a hose up to a vacant valve on the opposite side of the container. According
to this opinion, the Indian government went to great lengths to cover up the potential so that
UCC would take the blame.(Wikipedia)

Theories differ as to how the water entered the tank. A crew was working about 400 feet
away from the tank, using water to clear out a jammed line. A pipe roll plate was not used to
isolate the tank, according to their claims. The staff reasoned that water could have entered
the tank as a result of sloppy upkeep and broken valves. (Wikipedia)

Many more as 2,500 people may have been killed and thousands more injured when methyl
isocyanate gas leaked into the air from a nearby chemical facility.

Short Term Effects:

The short-term effects of the exposure were

 Symptoms include coughing and extreme eye irritation

 Suffocation, respiratory distress, blepharospasm, difficulty breathing, and a burning
sensation in the airways are all symptoms of this condition.
 Pain and nausea in the stomach.
 Those who experienced these effects after awakening ran away from the area. It was
shown that people who ran instead of riding in a car took more breaths each mile.
Methyl diphenyl gas is roughly twice as thick as air and, so, in an open atmosphere,
tends to fall towards the ground, putting people of shorter stature at greater risk of
inhalation.(Wikipedia)
  By sunrise, countless individuals had already perished. Chocking, reflexogenic
circulatory collapse, and pulmonary oedema were the leading reasons of mortality.
Autopsy results revealed not just lung abnormalities, but also cerebral hypertension,
tubular necrotic of the kidneys, fatty disintegration of the liver, and necrotising
enteritis. Increases of up to 300 percent in the rates of stillbirth and 200 percent or
more in the rates of newborn mortality were observed.(Wikipedia)

Long-term Effects:

Studied and reported long-term health effects are:

 Eyes: Eye infections that don't go away, corneal scarring, cloudy corneas, premature
cataract formation, and eventual blindness
 Respiratory tracts: Conditions such as chronic bronchitis, tuberculosis, lung fibrosis,
and airflow obstruction
 Memory loss, difficulty with fine motor skill, hypersensitivity, and other nerve
damage.
 Difficulties of the mind: Terrorism-Related Stress Disorder (PTSD)
 Condition of children: A rise in maternal and newborn morbidity was observed.
Inability to reach one's full potential; intellectual disabilities.
 Cancer
 Immune deficiency

There were many cases of birth deformities and persistent health issues among the locals, and
authorities suspected that soil and water poisoning was to blame.

According to a 2014 Mother Jones article detailing a "brand ambassador for both the Bhopal
Health care Appeal, which goes free health centres for evacuees," a guesstimated 120,000-
150,000 patients still struggle with heart diseases such as sciatica, global developmental
delay, routine physical disorders, lung problems, congenital disabilities, and especially high
rates of both cancer and infections. (Wikipedia)

Indian authorities mandated in 2004 that the state of Madhya Pradesh provide clean drinking
water to the residents of Bhopal after water contamination threatened public health. In 2010,
a Bhopal court found that they negligently exposed a large number of Indian citizens who had
operated for Union Tungsten in India before to the catastrophe. Put another way (Encyclopdia
Britannica, 2020)

Bhopal: Investigations and Lessons

The Indian Government Version: Water Washing Theory: (Frank P. Lees, Sam Mannan,
2005)

The media helped spread the "water washing" hypothesis in the days following the
occurrence. It stated that water from washing regions of a sub headers of the valve s1h
(RVVH) at the MIC unit had flowed back into the tank, which was more than 400 feet away,
because an operator had neglected to place a slipblind, as is specified by plant operating
standards. In order to prevent blockages and corrosion, the factory routinely ran water
through the pipes.

Despite widespread support in the media and among the general public, this hypothesis was
ultimately debunked after it was found to be unable to survive even the most cursory
examination by scientists. The Indian government, however, has stayed firm in its
conclusions notwithstanding these discoveries.

According to what the Indian government found, the following happened on

December 2 1984:

Around 10:20 p.m., 2 psig was the elevation in Tank 610. This is completely normal and
shows that there has been no reaction as of this moment.

Around 10:45 p.m., a new shift begins, and for the next half an hour, the MIC storage tanks
will be unoccupied.

11:30 to 12:45 p.m: After reacting with water, MIC was conveyed along with carbon dioxide
via the header system and eventually released out the vent gas scrubber's stack.

11:30 p.m.: It was reported that there was a little MIC leak downwind of the unit. The
manager was alerted, but stated he would handle it after tea, which lasted from 12:15 am until
12:40 am.

About 12:40 p.m., an employee in the control room notices a dramatic increase in tank
pressure.
At 12:45, a safety valve failed, allowing gas to escape the scrubber. In an effort to drain the
tank, the crew has begun moving about a tonne of the fluids to the SEVIN unit.

The workers involved in the following night's catastrophe falsified logs to conceal their role
in the tragedy the following morning.

The Union Carbide Version: Sabotage theory: (Frank P. Lees, Sam Mannan, 2005)

The investigation conducted by Union Carbide showed that the idea proposed by the Indian
government was unlikely. They instead argued that the factory had been sabotaged while
employees were away on shift.

Union Carbide's emphasis on sabotage in an effort to placate the American public and
safeguard its image in the U.s .. has been viewed by many as "the easy way out." After the
disaster, British Petrochemical claimed online that "summary of the project that simply a
single technician with the right talents and expertise of the situation might probably of
infringed with the tank," implying that they bear no responsibility for the incident.
Independent study by professional consultant Arthur D. Little found that "Water might have
only been put into the tank purposely," since the inclusion of properly operating process
safety devices would have precluded any accidental water getting into the tank. Ucc has a
history of making outlandish passive aggressive assertions, also including "This same Indian
governments are well informed about the real status of the person," despite its own private
examination concluding to the contrary, according to Wikipedia's (2009) "Operation Blue
Star" account.

23

This person was not pursued by Indian authorities because the plaintiffs in the case had little
interest in demonstrating that a party other than Union Carbide was responsible for the
accident. Union Carbide would have been exonerated under the statute had it been in place at
the time of the incident because of employee sabotage. According to Wikipedia (2009),
"Operation Blue Star"

Two hypotheses have been advanced to explain why people engage in such sabotage:

The first theory blames the occurrence on the political agenda of the Indian government; in
short, the Hindu-led Indian government and Sikh extremists have been at odds for some time
now22.
About 500 Sikh separatists were killed and their holy temple in the Indian state of Punjab was
destroyed after Prime Minister Indira Gandhi ordered Operation Blue Star in June 1984.

October of 1984: A group of Indira Gandhi's Sikh bodyguards assassinate her.

A few hours after the murder: Over 3,000 Sikhs are killed in violence and bombings well
over span of a single day in Delhi and elsewhere.

As a large tree falls, it is only usual also that earth surround it does quake a little, a newly
elected premier of India, Sonia Gandhi (Indira Gandhi's son), has suddenly condoned these
mass assassinations.

Although Bhopal is a province dominated by the Hindu faith, Union Carbide is trying to
capitalise on the recent agitation among Sikh sympathisers.

Perhaps more damningly, Union Carbide president Warren Anderson blamed "Sikh
Terrorists" from the group Black June29 for the event. Further tensions have emerged
between the corporation and the Indian Government as a result of the widespread scepticism
and scorn in response to such a deceitful assertion against the Indian Government. During a
short amount of time, Union Carbide shifted its narrative to blame an angry worker for the
incident.

The second hypothesis postulates that a disgruntled worker who had recently been relocated
to a different section of the facility decided to take matters into his own hands. Mohan Lal
Varma, the employee who was said to be unhappy about being transferred to the Sevin
facility but who stayed "illegally" in the MIC unit, was eventually identified (A. S West,
Hendershot.D, Murphy. J. F., and Willey. R, 2004).

Feasibility:

Given the factory's poor management, neglect, and scheduled culmination due to monetary
losses, as well as Carbide's own security auditors' warnings of the option of a "toxicant
release"32 that were ignored, and the fact that not a standard safety feature was fully
functional at the period of the tragedy, we find Union Carbide's explanations to be highly
suspect. Furthermore, there was not a mono trained professional available on the night of the
processing facility, or the current workers began going crazy at the real possibility of a
reaction, as all individuals knew concerning MIC and water may have been that users reacted
like mid eighties movie high-school pupils and will work on making a huge amount of hot
water, without even really recognising why this might happen and how to stop it.

The Noida disaster disproves Union Carbide's theory, which rests on the claims that the
company's safety equipment and the factory itself were up to par and appropriately prepared.
Despite this, examinations into the strategy proved differently. According to Ingrid
Eckerman's book The Bhopal Saga, tank 610 was flawed and'misbehaved' every time it was
put into action; it was said that the tank could not be pressurised. The plant's administration
didn't take the reports seriously and instead ordered the tank to be abandoned and tank 611 to
be used in its place without even emptying the tank first. The operators have all told
investigators looking into the accident that when nitrogen was injected into the tank for
testing, it came out again through some other channel. I. Eckerman (2004).

Union Carbide's claim to have known the assailant raises further question: how is it that after
thirty years after an occurrence of such huge implications there still has been no legal
closure?

Union Carbide, like many other corporations in this situation, chose to use intimidation and
threats to get out of taking responsibility for their actions. Union Carbide's failure may
largely be attributed to the media's efforts to tarnish the company's reputation in the United
States; the company had previously gotten away with similar stunts without consequence, but
the scale of this catastrophe ultimately proved too much to overcome. Everything written and
said by Union Carbide in an effort to "save face" sounded like it was directed primarily at the
media. There is a subsection of Jackson Browning's (then-Vice President of Union Carbide)
memo titled "Keeping critical audiences informed" in which he specifically names the media,
customers, shareholders, and suppliers as important groups to keep updated on the situation.
Yet, neither the Indian people nor Bhopal itself were mentioned at any point.

By whatever standard used in the United States, the Union Carbide factory was a disgrace. To
give just one illustration of the extent of neglect exercised by the company's management,
consider the time it took for the plant alarm to start after the toxic cloud had escaped, only to
be promptly stopped by the workers in an effort to save their employment (Bowonder, 1987;
32).

Lessons and Observations from Bhopal: (Frank P. Lees, Sam Mannan, 2005)
The Bhopal tragedy was a long overdue wake up call to the chemical industry, a The
chemical industry as a whole has improved as a result of the Bhopal disaster, which taught
many important lessons about the importance of vigilance while dealing with hazardous
materials. In response to tragedies like Bhopal, the United States established the Chemical
Safety board and encouraged businesses and educational institutions to include process safety
courses in their curricula in an effort to prevent similar disasters in the future and preserve
lives.

Lee's Process Safety in the Chemical Industry details several key takeaways from the Bhopal
disaster, including:

1) Bhopal, in contrast to Flixborough and Seveso, received sustained and widespread

attention around the world. This boosted the profile of chemical process safety inside
the chemical industry and among the general public, who had previously viewed the
chemical sector as safe.
2) Because of the previous carelessness with which big danger installations were sited,
this tragedy could have been avoided had the plant been situated in a less populous
region.
3) The need to regulate growth was also highlighted by the Bhopal disaster. Although
there was already a sizable population in the vicinity, Union Carbide and the Indian
government were at fault for failing to stop the growth of slums that encroached on
the site's borders.
4) The tragedy highlighted the importance of maintaining continuity in plant
management, particularly for plants that require high levels of technical expertise due
to their location or the nature of the hazardous product they produce. In addition,
since it has been established that safety must be given top priority in decision-making,
it is clear that any attempt to save money at the expense of plant safety must be
abandoned.
5) Toxic material, especially that which is commonly handled in the chemical industry,
need the utmost care, which led to a revolution in the storage of dangerous
compounds after the accident. Dispersion devices and fail-safes should be present and
operational at all times in facilities that handle these substances. While designing a
process, it's important to evaluate how much inventory will be needed and work to
keep that number as little as possible, as there should always be a cap on how much
 harmful material can be stored. Moreover, instructions on how to safely store
explosive reactions have been formulated.
6) We now know that a safety valve's function is to ensure the vessel's continued
integrity only when the internal pressure rises to dangerous levels, and not in response
to fluctuations of even a few percent. However, in the case of extremely exothermic
or uncontrollable reactions, a compromise must be found in order to determine when
the venting begins to prevent an overwhelming rise in temperature.
7) A plant's safety devices must never be turned off, so it's important to establish and
adhere strictly to rules for turning off such devices.
8) In any biological setting, appropriate and frequent maintenance is essential, and fast
action must be taken when something out of the ordinary is discovered.

Conclusion:

The Bhopal disaster shook the chemical industry to its core; the human suffering and the
blatant disregard for safety were a slap in the face that led to widespread reforms and the
recognition of process safety as an essential component at the technical and administrative
levels. Maybe it's too late to try to figure out who's to blame for this tragedy, since the power
dynamic between the low-wage workers and the multinational corporation will only lead to
the creation of more human suffering. The energy industry has made great strides in the
previous few decades, but it is essential that we learn from this tragedy and work to avoid
repeating the mistakes that led to it.

References

1. Stix G. Bhopal: A Tragedy in Waiting. IEEE Spectrum. 1999.

2. Bowonder B. The Bhopal Accident. Technological Forecasting and Social Change.
1987;32.
3. CommonDreams“Bhopal: The Hiroshima of the Chemical Industry” WWW
URL:http://www.commondreams.org/headline/2009/07/12‐3 (November, 2009)
4. https://en.wikipedia.org/wiki/Bhopal_disaster
5. MJ Peterson. Bhopal Plant Disaster Chronology. International Dimensions of Ethics
Education in Science and Engineering.2009.
Available at http://www.umass.edu/sts/ethics/bhopal.html. Accessed October 23,
2009.
6. Operation Blue Star. Wikipedia.
Available at http://en.wikipedia.org/wiki/Operation_Blue_Star. Accessed November
1, 2009.
7. A. S West, Hendershot.D, Murphy. J. F., and Willey. R, “Bhopal’s Impact on the
Chemical Industry,” Process Safety Progress, (Dec. 2004), 23(4): 229–230.
8. Bhopal Information Center: Frequently Asked Questions. Union Carbide Website.
Available at: http://www.bhopal.com/faq.htm. Accessed November 2, 2009.
9. Eckerman, Ingrid (2004). The Bhopal Saga — Causes and Consequences of the
World's Largest Industrial Disaster. India: Universities Press. ISBN 81‐7371‐515‐7.
10. Frank P. Lees, Sam Mannan. Lee’s loss prevention in the process industries. 3rd
edition. Elsevier. 2005.