CASE STUDY

ON

1. BHOPAL GAS TRAGEDY

2. SPACE SHUTTLE CHALLENGER
3. NUCLEAR POWER PLANT DISASTERS
(i) The Three Mile Island Accident
(ii) The Chernobyl disaster
(iii) The Fukushima Daiichi nuclear
disaster
BHOPAL GAS TRAGEDY

The Bhopal gas tragedy is considered the worst industrial disaster in the Indian industry. The
leak of the methyl isocyanate gas from the Union Carbide India Limited (UCIL) plant at
Bhopal caused immense damage. It lead to the loss of several lives and long term health
effects to thousands of people. There is still no exact count of the number of dead and the
number of injured. Initial estimates put the number of deaths at 2259 but this was later
official modified to 3787 the local government. There are other higher estimates that put the
death toll at a much higher number of about 10000. The tragedy happened on the night of 3rd
December 1984. UCIL was the Indian subsidiary of Union Carbide USA. It was established
to produce a pesticide called Sevin using methyl isocyanate as an intermediate.

During the night of 3rd and 4th December 1984 water entered the tank containing 42 tons of
methyl isocyanide. This lead to an exothermic reaction, causing the temperature to rise to
about 200 degrees celsius and also increase the pressure. This high pressure caused the
release of the toxic gases into the atmosphere. The gas spread over parts of the city due to an
existing wind from the north westerly direction.

Effects
Thousands of children died and many others were disabled after the accident. Many children
born before the gas leak continue to suffer from respiratory diseases and defective eye sights.
Many women suffered miscarriages or gave birth to malformed babies after the accident.
More than half the children died when their mothers when exposed to the gas.Many others
suffered permanent disabilities.

Many people died after inhaling the deadly gas. The following morning witnessed mass
funerals and cremations. More than 1.5 Lakh people were treated at hospitals and temporary
dispensaries. Many animals also died upon inhaling the gas. The gas was so deadly that
leaves on trees changed colour. There was also shortage of food due to fear of the food
having been affected by the gas. Fishing was also not allowed due to fear of food poisoning.

The gas cloud essentially consisted of methyl isocyanate but according to many, it may also
have contained other deadly chemicals. The gas being denser than air, settled close to the
ground surface was dispersed by prevailing winds this affected a much larger area. People
initially complained of eye irritation, vomiting, throat congestion and suffocation. Those who
inhaled the gas immediately succumbed to the poisoning.

Lack of disaster preparedness

The tragedy exposed the complete lack of preparedness on the part of the company and this
civic administration. There was nothing in place to be called a disaster management system.
The Healthcare system was not adequately equipped to handle the thousands of casualties and
lakhs of affected people. There was no information available on how to treat people affected
by such a deadly gas. The patients were only prescribed cough medicines and eyedrops which
were highly inadequate as treatments for such effects. The company also the emptied contents
of the tanks within two weeks of the tragedy. This again led to further evacuation due to lack
of information. The company also did not inform the administration of the possible effects
and line of treatment to those affected. The administration was also not prepared with
contingency plans immediately. The slow reaction to the tragedy and the lack of information
further aggravated the situation.

Ethical concerns
1. The process used by the plant to produce the pesticides carbyl was potentially
dangerous as it involved production and storage of dangerous chemicals. This was
very dangerous as the plant was located in a densely populated area. The plant also
had a densely populated slum around it.
2. There was a fall in the demand for pesticides in early 1980 but the production was not
stopped, resulting in the storage of large quantities of the dangerous chemical methyl
isocyanate.
3. The plant was poorly maintained and the operations were mainly manual with the
potential danger of human error. Safety precautions and devices in the plant were also
not up to the mark. The alarm in the tank storing methyl isocyanate was not functional
for many years. The scrubber tower was also not functional and when the tank leaked,
the scrubber did not treat the gas as per requirement. According to investigations by
the company itself, most of the safety systems in the plant were not functional.
4. There were many management deficiencies that would identified including lack of
skilled operators lack of security management awareness and the complete lack of any
contingency in case of an emergency.
5. It was also reported that safety systems was switched off to save on expenses. The
refrigeration system of the tank was switched off. If this had been kept functional the
temperature rise wouldn’t have been so severe.
6. Even after the tragedy large quantities of dangerous chemicals were still stored in the
plant polluting the groundwater in the region, which continued to affect thousands of
residents who depended on this supply for their daily water requirements.
7. The company had neglected and turned a blind eye to earlier warnings about a
possible mishap. Workers had complained and agitated about high pollution levels in
the plant for long. Many an earlier incidence went uncared for and were not taken
seriously. In 1981, 1 worker died of exposure to phosgene gas. In 1982, 24 workers
were hospitalized due to a phosgene leak. There was also an earlier methyl isocyanate
leak affecting a number of workers. There were many similar minor incidents
resulting in injury to workers and supervisors. No significant steps were taken to
enhance safety measures in the plant.

Follow-up
Many rehabilitation measures of different dimensions were initiated after the tragedy struck
Bhopal. The disaster preparedness of cities like Bhopal was exposed after the tragedy. The
state government established number of Hospitals Health Care clinics and mobile health
centres for the treatment of patients affected by the tragedy. The central government opened
many hospitals in Bhopal for treating the people affected by the gas leak. In addition a lot of
medical facilities were created after the disaster by various agencies. UCIL closed its factory
during the period 1985 to 1986. Many items were cleaned up and sold. However hazardous
chemicals were dumped in and around the factory. The water from that tube wells and the
groundwater in general was found to be highly polluted. A separate water supply project was
planned to supply clean water to the area. On the orders of the Madhya Pradesh High Court,
the hazardous materials were to be incinerated. The plant site is yet to be cleaned of
hazardous materials. The Government of India passed the Bhopal gas leak Act 1985
appointing the government to act on behalf of the victims of the tragedy. Based upon a
suggestion from the Supreme Court of India an out of court settlement was reached. The
company was to pay USD 70 million dollars as damages for the Bhopal Gas tragedy. There is
public outcry to bring Warren Anderson to India to face criminal charges for this massive
tragedy. In addition, it is being demanded that the new owners of UCIL which is the Dow
Chemical Company provide adequate compensation to the victims of the tragedy.

SPACE SHUTTLE CHALLENGER

On January 28, 1986, the NASA shuttle orbiter mission STS-51-L and the tenth flight of
Space Shuttle Challenger (OV-99) broke apart 73 seconds into its flight, killing all seven
crew members, which consisted of five NASA astronauts and two Payload Specialists. The
spacecraft disintegrated over the Atlantic Ocean, off the coast of Cape Canaveral, Florida, at
11:39 EST. Disintegration of the vehicle began after an O-ring seal in its right solid rocket
booster (SRB) failed at liftoff. The O-ring was not designed to fly under unusually cold
conditions as in this launch. Its failure caused a breach in the SRB joint it sealed, allowing
pressurized burning gas from within the solid rocket motor to reach the outside and impinge
upon the adjacent SRB aft field joint attachment hardware and external fuel tank. This led to
the separation of the right-hand SRB's aft field joint attachment and the structural failure of
the external tank. Aerodynamic forces broke up the orbiter.

The crew compartment and many other vehicle fragments were eventually recovered from
the ocean floor after a lengthy search and recovery operation. The exact timing of the death
of the crew is unknown; several crew members are known to have survived the initial
breakup of the spacecraft. The shuttle had no escape system, and the impact of the crew
compartment with the ocean surface was too violent to be survivable.

Issues
Challenger was originally set to launch on January 22. Delays in the previous mission, STS-
61-C, due to bad weather and problems with the exterior access hatch caused the launch date
to be moved to January 28.

The temperature on the day of the launch was far lower than had been the case with previous
launches: below freezing at −2.2 to −1.7 °C (28.0 to 28.9 °F); previously, the coldest launch
had been at 12 °C (54 °F). Although the Ice Team had worked through the night removing
ice, engineers at Rockwell still expressed concern. Rockwell engineers watching the pad from
their headquarters in Downey, California, were horrified when they saw the amount of ice.
They feared that during launch, ice might be shaken loose and strike the shuttle's thermal
protection tiles, possibly due to the aspiration induced by the jet of exhaust gas from the
SRBs. Rocco Petrone, the head of Rockwell's space transportation division, and his
colleagues viewed this situation as a launch constraint, and told Rockwell's managers at the
Cape that Rockwell could not support a launch. Rockwell's managers at the Cape voiced their
concerns in a manner that led Houston-based mission manager Arnold Aldrich to go ahead
with the launch. Aldrich decided to postpone the shuttle launch by an hour to give the Ice
Team time to perform another inspection. After that last inspection, during which the ice
appeared to be melting, Challenger was cleared to launch at 11:38 am EST.

While extrusion was taking place, hot gases leaked past, damaging the O-rings until a seal
was made. Investigations by Morton-Thiokol engineers determined that the amount of
damage to the O-rings was directly related to the time it took for extrusion to occur, and that
cold weather, by causing the O-rings to harden, lengthened the time of extrusion.

On the morning of the disaster, the primary O-ring had become so hard due to the cold that it
could not seal in time. The secondary O-ring was not in its seated position due to the metal
bending. There was now no barrier to the gases, and both O-rings were vaporized across 70
degrees of arc. Aluminium oxides from the burned solid propellant sealed the damaged joint,
temporarily replacing the O-ring seal before flame passed through the joint.

Ethical Concerns
1. The NASA managers did not follow the rules for Criticality 1 Component. They
advanced with wrong subgenus to ensure that the launch was not delayed.
2. Due to the expenses involved and the reduction in payload capacity, NASA did not
consider the implementation of a safe exit for the crew in case of tragedy. Safety was
compromised for commercial reasons.
3. NASA's safety culture was under question. They were more concerned about
Launcher window being used because of the delays than safety of the launch. This
‘launch first safety second’ approach was against a primary responsibility to ensure
safety of the seven members.

Follow-up
The disaster resulted in a 32-month hiatus in the shuttle program and the formation of the
Rogers Commission, a special commission appointed by United States President Ronald
Reagan to investigate the accident. The Rogers Commission found NASA's organizational
culture and decision-making processes had been key contributing factors to the accident, with
the agency violating its own safety rules. NASA managers had known since 1977 that
contractor Morton Thiokol's design of the SRBs contained a potentially catastrophic flaw in
the O-rings, but they had failed to address this problem properly. NASA managers also
disregarded warnings from engineers about the dangers of launching posed by the low
temperatures of that morning, and failed to adequately report these technical concerns to their
superiors.

As a result of the disaster, the Air Force decided to cancel its plans to use the Shuttle for
classified military satellite launches from Vandenberg Air Force Base in California, deciding
to use the Titan IV instead.

NUCLEAR POWER PLANT DISASTERS

A nuclear and radiation accident is defined by the International Atomic Energy Agency
(IAEA) as "an event that has led to significant consequences to people, the environment or
the facility." Examples include lethal effects to individuals, large radioactivity release to the
environment, or reactor core melt." The prime example of a "major nuclear accident" is one
in which a reactor core is damaged and significant amounts of radioactivity are released, such
as in the Chernobyl disaster in 1986.

The impact of nuclear accidents has been a topic of debate since the first nuclear reactors
were constructed in 1954, and has been a key factor in public concern about nuclear
facilities.Technical measures to reduce the risk of accidents or to minimize the amount of
radioactivity released to the environment have been adopted, however human error remains,
and "there have been many accidents with varying impacts as well near misses and
incidents". As of 2014, there have been more than 100 serious nuclear accidents and incidents
from the use of nuclear power. Fifty-seven accidents have occurred since the Chernobyl
disaster, and about 60% of all nuclear-related accidents have occurred in the USA.

1. Three Mile Island Accident

The Three Mile Island accident was a partial nuclear meltdown that occurred on March 28,
1979, in reactor number 2 of Three Mile Island Nuclear Generating Station (TMI-2) in
Dauphin County, Pennsylvania, United States. It was the most significant accident in U.S.
commercial nuclear power plant history. The incident was rated a five on the seven-point
International Nuclear Event Scale: Accident With Wider Consequences.

The accident began with failures in the non-nuclear secondary system, followed by a stuck-
open pilot-operated relief valve in the primary system, which allowed large amounts of
nuclear reactor coolant to escape. The mechanical failures were compounded by the initial
failure of plant operators to recognize the situation as a loss-of-coolant accident due to
inadequate training and human factors, such as human-computer interaction design oversights
relating to ambiguous control room indicators in the power plant's user interface. In
particular, a hidden indicator light led to an operator manually overriding the automatic
emergency cooling system of the reactor because the operator mistakenly believed that there
was too much coolant water present in the reactor and causing the steam pressure release.
The accident crystallized anti-nuclear safety concerns among activists and the general public,
resulted in new regulations for the nuclear industry, and has been cited as a contributor to the
decline of a new reactor construction program that was already underway in the 1970s. The
partial meltdown resulted in the release of radioactive gases and radioactive iodine into the
environment. Worries were expressed by anti-nuclear movement activists; however,
epidemiological studies analyzing the rate of cancer in and around the area since the accident,
determined there was a small statistically non-significant increase in the rate and thus no
causal connection linking the accident with these cancers has been substantiated. Cleanup
started in August 1979, and officially ended in December 1993, with a total cleanup cost of
about $1 billion.

Effects
Approximately 2.5 megacuries (93 PBq) of radioactive gases, and approximately 15 curies
(560 GBq) of iodine-131 was released into the environment. According to the American
Nuclear Society, using the official radioactivity emission figures, "The average radiation dose
to people living within ten miles of the plant was eight millirem, and no more than 100
millirem to any single individual. Eight millirem is about equal to a chest X-ray, and 100
millirem is about a third of the average background level of radiation received by US
residents in a year."

Based on these emission figures, early scientific publications, according to Mangano, on the
health effects of the fallout estimated no additional cancer deaths in the 10 mi (16 km) area
around TMI. Disease rates in areas further than 10 miles from the plant were never examined.
Local activism in the 1980s, based on anecdotal reports of negative health effects, led to
scientific studies being commissioned. A variety of epidemiology studies have concluded that
the accident had no observable long term health effects.

Three Mile Island Unit 2 was too badly damaged and contaminated to resume operations; the
reactor was gradually deactivated and permanently closed. TMI-2 had been online only 13
months but now had a ruined reactor vessel and a containment building that was unsafe to
walk in. Cleanup started in August 1979 and officially ended in December 1993, with a total
cleanup cost of about $1 billion. Benjamin K. Sovacool, in his 2007 preliminary assessment
of major energy accidents, estimated that the TMI accident caused a total of $2.4 billion in
property damages.

Follow-up
1. Upgradation and strengthening of plant designs and equipment requirement, including
fire protection, piping systems, auxiliary feed water system, containment building
isolation, reliability of individual components and the ability of plants to shut down
automatically.
2. Identification of human performance as a critical part of plant safety, revamping
operator training and staffing requirements, followed by improved instrumentation
and controls for operating the plant, and establishment of fitness for duty programmes
for plant workers to guard against substance abuse.
 3. Improved instruction to avoid the confusing signals that played operations during the
accident.
4. Enhancement if emergency preparedness to include immediate NRC notification
requirements for plant events.
5. Expansion in NRC’s resident inspector programme.

2. The Chernobyl disaster

The Chernobyl disaster, also referred to as the Chernobyl accident, was a catastrophic nuclear
accident that occurred on 26 April 1986 in the No.4 light water graphite moderated reactor at
the Chernobyl Nuclear Power Plant near Pripyat, in what was then part of the Ukrainian
Soviet Socialist Republic of the Soviet Union (USSR).

During a hurried late night power-failure stress test, in which safety systems were
deliberately turned off, a combination of inherent reactor design flaws, together with the
reactor operators arranging the core in a manner contrary to the checklist for the stress test,
eventually resulted in uncontrolled reaction conditions that flashed water into steam
generating a destructive steam explosion and a subsequent open-air graphite "fire". This
"fire" produced considerable updrafts for about 9 days, that lofted plumes of fission products
into the atmosphere, with the estimated radioactive inventory that was released during this
very hot "fire" phase, approximately equal in magnitude to the airborne fission products
released in the initial destructive explosion. Practically all of this radioactive material would
then go on to fall-out/precipitate onto much of the surface of the western USSR and Europe.

It is one of only two nuclear energy accidents classified as a level 7 event (the maximum
classification) on the International Nuclear Event Scale, the other being the Fukushima
Daiichi nuclear disaster in Japan in 2011. The struggle to safeguard against scenarios which
were, at many times falsely perceived as having the potential for greater catastrophe and the
later decontamination efforts of the surroundings, ultimately involved over 500,000 workers
and cost an estimated 18 billion rubles. During the accident, blast effects caused 2 deaths
within the facility and later 29 firemen and employees died in the days-to-months afterward
from acute radiation syndrome, with the potential for long-term cancers still being
investigated.

The remains of the No.4 reactor building were enclosed in a large sarcophagus (radiation
shield) by December 1986, at a time when what was left of the reactor was entering the cold
shut-down phase; the enclosure was built quickly as occupational safety for the crews of the
other undamaged reactors at the power station, with No.3 continuing to produce electricity
into 2000.

Causes
1. The reactor had a dangerously large positive void coefficient of reactivity. The void
coefficient is a measurement of how a reactor responds to increased steam formation
 in the water coolant. Chernobyl's RBMK reactor, used solid graphite as a neutron
moderator to slow down the neutrons, and the water in it, on the contrary, acts like a
harmful neutron absorber. Thus neutrons are slowed down even if steam bubbles form
in the water. Furthermore, because steam absorbs neutrons much less readily than
water, increasing the intensity of vaporization means that more neutrons are able to
split uranium atoms, increasing the reactor's power output. This makes the RBMK
design very unstable at low power levels, and prone to suddenly increasing energy
production to a dangerous level. This behaviour is counter-intuitive, and this property
of the reactor was unknown to the crew.
2. A more significant flaw was in the design of the control rods that are inserted into the
reactor to slow down the reaction. In the RBMK reactor design, the lower part of each
control rod was made of graphite and was 1.3 metres shorter than necessary, and in
the space beneath the rods were hollow channels filled with water. The upper part of
the rod, the truly functional part that absorbs the neutrons and thereby halts the
reaction, was made of boron carbide. With this design, when the rods are inserted into
the reactor from the uppermost position, the graphite parts initially displace some
water (which absorbs neutrons, as mentioned above), effectively causing fewer
neutrons to be absorbed initially. Thus for the first few seconds of control rod
activation, reactor power output is increased, rather than reduced as desired. This
behaviour is counter-intuitive and was not known to the reactor operators.
3. Other deficiencies besides these were noted in the RBMK-1000 reactor design, as
were its non-compliance with accepted standards and with the requirements of nuclear
reactor safety.

Effects
Four hundred times more radioactive material was released from Chernobyl than by the
atomic bombing of Hiroshima. The disaster released 1/100 to 1/1000 of the total amount of
radioactivity released by nuclear weapons testing during the 1950s and 1960s.Approximately
100,000 km² of land was significantly contaminated with fallout, with the worst hit regions
being in Belarus, Ukraine and Russia. Slighter levels of contamination were detected over all
of Europe.
237 people suffered from acute radiation sickness (ARS), of whom 31 died within the first
three months. Most of the victims were fire and rescue workers trying to bring the accident
under control, who were not fully aware of how dangerous the exposure to radiation in the
smoke was. 28 emergency workers ("liquidators") died from acute radiation syndrome
including beta burns and 15 patients died from thyroid cancer in the following years, and it
roughly estimated that cancer deaths caused by Chernobyl may reach a total of about 4,000
among the 5 million persons residing in the contaminated areas.

Follow-up
1. All work on the unfinished reactors 5 and 6 was halted three years later.The damaged
reactor was sealed off and 200 cubic meters (260 cu yd) of concrete was placed
between the disaster site and the operational buildings. The Ukrainian government
continued to let the three remaining reactors operate because of an energy shortage in
 the country. The accident motivated safety upgrades on all remaining Soviet-designed
reactors in the RBMK (Chernobyl No.4) family, of which eleven continued to power
electric grids as of 2013.
2. Italy began phasing out its nuclear power plants in 1988, a decision that was
effectively reversed in 2008. A referendum in 2011 reiterated Italians' strong
objections to nuclear power, thus abrogating the government's decision of 2008.
3. In Germany, the Chernobyl accident led to the creation of a federal environment
ministry, after several states had already created such a post. The minister was given
the authority over reactor safety as well, which the current minister still holds as of
2015. The events are also credited with strengthening the anti-nuclear power
movement, which culminated in the decision to end the use of nuclear power that was
made by the 1998–2005 Schröder government.

3. Fukushima Daiichi nuclear disaster

The Fukushima Daiichi nuclear disaster was an energy accident at the Fukushima I Nuclear
Power Plant in Fukushima, initiated primarily by the tsunami following the Tōhoku
earthquake on 11 March 2011. Immediately after the earthquake, the active reactors
automatically shut down their sustained fission reactions. However, the tsunami disabled the
emergency generators that would have provided power to control and operate the pumps
necessary to cool the reactors. The insufficient cooling led to three nuclear meltdowns,
hydrogen-air chemical explosions, and the release of radioactive material in Units 1, 2 and 3
from 12 March to 15 March. Loss of cooling also caused the pool for storing spent fuel from
Reactor 4 to overheat on 15 March due to the decay heat from the fuel rods.

On 5 July 2012, the Fukushima Nuclear Accident Independent Investigation Commission

(NAIIC) found that the causes of the accident had been foreseeable, and that the plant
operator, Tokyo Electric Power Company (TEPCO), had failed to meet basic safety
requirements such as risk assessment, preparing for containing collateral damage, and
developing evacuation plans. On 12 October 2012, TEPCO admitted for the first time that it
had failed to take necessary measures for fear of inviting lawsuits or protests against its
nuclear plants.

The Fukushima disaster is the largest nuclear disaster since the 1986 Chernobyl disaster and
the second disaster to be given the Level 7 event classification of the International Nuclear
Event Scale. Though there have been no fatalities linked to radiation due to the accident, the
eventual number of cancer deaths that will be caused by the accident is expected to be around
130–640 people in the years and decades ahead.

Effects
No deaths followed short term radiation exposure, though there were a number of deaths in
the evacuation of the nearby population, while 15,884 died (as of 10 February 2014) due to
the earthquake and tsunami.
Very few cancers are expected as a result of accumulated radiation exposures, even though
people in the area worst affected by Japan's Fukushima nuclear accident have a slightly
higher risk of developing certain cancers such as leukemia, solid cancers, thyroid cancer and
breast cancer.Estimated effective doses from the accident outside Japan are considered to be
below (or far below) the dose levels regarded as very small by the international radiological
protection community.In 2013, WHO reported that area residents who were evacuated were
exposed to so little radiation that radiation induced health impacts were likely to be below
detectable levels.

The amount of compensation to be paid by TEPCO is expected to reach 7 trillion yen.

Costs to Japanese taxpayers are likely to exceed 12 trillion yen ($100 billion). In December
2016 the government estimated decontamination, compensation, decommissioning and
radioactive waste storage costs at 21.5 trillion yen ($187 billion), nearly double the 2013
estimate.

Follow-up
Government agencies and TEPCO were unprepared for the "cascading nuclear disaster". The
tsunami that "began the nuclear disaster could and should have been anticipated and that
ambiguity about the roles of public and private institutions in such a crisis was a factor in the
poor response at Fukushima". In March 2012, Prime Minister Yoshihiko Noda said that the
government shared the blame for the Fukushima disaster, saying that officials had been
blinded by a false belief in the country's "technological infallibility", and were taken in by a
"safety myth".

A number of nuclear reactor safety system lessons emerged from the incident. The most
obvious was that in tsunami-prone areas, a power station's sea wall must be adequately tall
and robust. At the Onagawa Nuclear Power Plant, closer to the epicenter of 11 March
earthquake and tsunami,the sea wall was 14 meters tall and successfully withstood the
tsunami, preventing serious damage and radioactivity releases.

Nuclear power station operators around the world began to install Passive Auto-catalytic
hydrogen Recombiners ("PARs"), which do not require electricity to operate. Had such
devices been positioned at the top of Fukushima I's reactor and containment buildings, where
hydrogen gas collected, the explosions would not have occurred and the releases of
radioactive isotopes would arguably have been much less.

In October 2013, the owners of Kashiwazaki-Kariwa nuclear power station began installing
wet filters and other safety systems, with completion anticipated in 2014.
For generation II reactors located in flood or tsunami prone areas, a 3+ day supply of back-up
batteries has become an informal industry standard. Another change is to harden the location
of back-up diesel generator rooms with water-tight, blast-resistant doors and heat sinks,
similar to those used by nuclear submarines.