Journal of Loss Prevention in the Process Industries 15 (2002) 14

www.elsevier.com/locate/jlp

The Bhopal gas tragedy: could it have happened in a developed

country?
*
J.P. Gupta
Department of Chemical Engineering, Indian Institute of Technology Kanpur, Kanpur 208016, India

Abstract

The Bhopal gas tragedy occurred in December 1984 wherein approximately 41 tonnes of deadly MIC was released in the dead
of night. It caused the death of over 3000 people and continued life-long misery for over 300,000 with certain genetic defects
passed on to the next generation. It happened in a plant operated by a multinational, Union Carbide Corporation, in a developing
country, India. The tragedy has changed the chemical process industry (CPI) forever. The results have been new legislation with
better enforcement, enhancement in process safety, development of inherently safer plants, harsher court judgements, pro-active
media and NGOs, rights-conscious public, and a CPI management willing to invest in safety related equipment and training. These
have already resulted in savings of several hundred lives and over a billion dollars in accident damages [Kletz, T. (1998a). Process
plants: a handbook of inherently safer designs. London: Taylor & Francis. Sutton, I. Chemical Engineering, 106(5), (1999). 114].
However, thousands did not have to die for the world to realise the disaster potential of CPI. The question that still remains is
whether such an accident could have happened in a developed country. The answer is yes, as a number of major accidents in the
developed countries since 1984, such as the Piper Alpha oil platform fire (1988, 167 killed), the Zeebrugge ferry disaster (1987,
167 killed), Phillips petroleum fire and explosion (1989, 23 killed), the Challenger disaster (1986, 7 killed), Esso Australia Longford
explosion (1998, 2 killed) have demonstrated. One or more of the following are the primary reasons for such disasters: The indifferent
attitude of the management towards safety, the lax enforcement of the existing regulations by the regulatory bodies as well as
unusual delays in the judicial systems. Such conditions can happen regardless of the level of development in a country. Hence, the
Bhopal gas tragedy could have happened in a developed country too, albeit with a lower probability. This paper is concerned with
the possibility and not with the probability value. It also points out that further significant advances in process safety will occur
with fundamental research into the causes of accidents and with a move towards inherently safer design. 2001 Elsevier Science
Ltd. All rights reserved.

1. Introduction lives and over a billion dollars in potential accident dam-

The Bhopal Gas Tragedy of December 1984 caused
the deaths of over 3000 and life-long suffering for over
300,000. The event has completely changed the chemical
process industry (CPI). With the governments, judiciary,
legislators, public, media and the NGOs taking a pro-
active attitude, the CPI has become more responsive
towards safety. With the continued expansion of the CPI,
building larger and larger plants, many more accidents
than actually occurred, would have taken place if the
pre-Bhopal state of managements attitude towards pro-
cess safety, and government apathy, had continued
throughout the world. It is estimated that several hundred
* Tel.: +91-512-597175/598505; fax: +91-512-590104/590007.
E-mail address: jpg@iitk.ac.in (J.P. Gupta).
age have already been saved (Kletz, 1998a; Sutton,
1999).
Thousands, however, did not have to die for the world
to realise the disaster potential of the CPI. The threshold
limit value (TLV) of MIC that was released in Bhopal
is 0.02 ppm, probably the lowest for any gas and was
well known before the tragedy. Thus, those responsible
for the plant knew of its tremendous hazard potential. It
would be like saying that tens of thousands had to die
in Hiroshima and Nagasaki for the world to realise the
havoc that atom bombs could cause. The potential of
these bombs had been proved by earlier tests in New
Mexico (Jungk, 1958).
In this paper we are discussing the release of 41 t of
deadly MIC within a period of less than 2 h without
warning the public or informing the authorities of the
consequences. The number of casualties would depend

0950-4230/02/$ - see front matter 2001 Elsevier Science Ltd. All rights reserved.
PII: S 0 9 5 0 - 4 2 3 0 ( 0 1 ) 0 0 0 2 5 - 0
2 J.P. Gupta / Journal of Loss Prevention in the Process Industries 15 (2002) 14
upon the rate and duration of release, the weather con-
ditions, the population density in the affected region and
the response of the civic authorities to wage a relief and
rescue operation.
2. The details
The management of most companies is concerned
mainly with profitability. Investment in safety appears
as a drain on resources with no immediate returns and
no quantifiable results even in the long run. Production
and cost drive the industry. Sacrificing a sure pro-
ductivity gain in favour of preventing a seemingly low-
probability accident may not seem like a reasonable
course of action (Leveson, 1995).
At the UCC Bhopal plant, there had been numerous
accidents before the 1984 tragedy. These were warning
signs that were ignored. At least six serious accidents
had occurred in the 4 years preceding 1984, including
one in 1982 that had resulted in the death of a worker.
The other staff were agitated, and a series of articles
were published in the local press warning of the impend-
ing disaster. However, neither the management nor the
civic authorities took action to analyse the situation and
take pre-emptive measures against any future accidents.
Their acts were to suppress the information and ignore
the news reports. The Piper Alpha tragedy of 1988 paral-
lels it: Previous accidents, including a fatality the year
before, had simply resulted in more memos being sent
(Blazier & Skilling, 1995). The Zeebrugge ferry disaster
report states, Ferries had sailed with their doors open
on previous occasions but this was not reported to the
directors responsible for safety (Spooner, 1995). Before
the TMI accident (1979), an NRC inspector had noticed
similar accidents at two other nuclear power plants using
similar reactors. For over a year he tried to tell NRC,
the power company, and the manufacturer of the reactor,
about his concerns. Finally, two NRC Commissioners
listened. Their memo to NRC staff asking for answers
to inspectors questions was delivered a day after the
TMI accident (Keenan, 1979). The Royal Commission
report (TCE, 1999) on the explosion in a gas processing
plant of Esso Australia in Longford (1998, 2 killed, most
of Victoria had no gas or hot water for 2 weeks) states
Analysis of and learning from a cold temperature acci-
dent about 4 weeks earlier and acting accordingly would
have avoided the accident. A UCC team from its head-
quarters in the US had, in 1982, identified 10 safety con-
cerns. The UCC Bhopal did not implement them and
headquarters never sought a compliance report (Lees,
1996). In July 1984, UCC W. Virginia informed of the
possibility of a runaway reaction with MIC. The report
was neither sent to Bhopal nor made public. Later, a US
congressman released it, after the Bhopal tragedy
(Pareek, 1998).
Neither the UCC Bhopal company, nor for that matter
any other company, states specifically that safety is their
least or last concern. They always claim it to be their
top most concern just as governments claim that citizens
welfare is their prime concern. Several safety slogans
were posted at the UCC Bhopal plant. However, actions
(or lack of actions) bring out evidence to the contrary.
The report on the Clapham Junction commuter train
accident in the UK (1988, 35 killed) states, The best of
intentions regarding safe working were permitted to go
hand in hand with the worst of inaction in ensuring that
such practices were put into effect (Hidden, 1990). The
report on the Piper Alpha oil platform fire states that
while the management was concerned about safety, it
did nothing actually to improve it (Blazier & Skilling,
1995). The Zeebrugge ferry disaster report states Means
to improve safety were not implemented by those who
were in a position to do so as well as by those who could
legally enforce it (Spooner, 1995).
In an interview published early 1999, the mechanical
engineer who was in charge of safety and had left UCC
Bhopal a year before the tragedy, has stated, On the
day of the tragedy, not a single safety mechanism was
in place (Pareek, 1999). The refrigeration system to
keep MIC at 0C had been turned off months earlier to
save cost. The volatile gas scrubber was not working.
The flare had been out of order for 3 months to replace
a corroded pipe. The report on the Piper Alpha fire
states, The deluge system was blocked. The fire pumps
did not start automatically (Blazier & Skilling, 1995).
The report on the Esso Australia explosion states, Plant
drawings were not up to date due to numerous modifi-
cations since start-up. They did not adequately show the
isolation points so the workers were unable to do so.
Leakages continued to feed the fire for 53 hours. No
HAZOP had been conducted else it would have ident-
ified the hazards (TCE, 1999). The report on the
explosion at the Texaco refinery, Milford Haven (1994,
none killed) states that while numerous modifications
had been made to plants and processes, the operators
were not trained on these (Kletz, 1998b). It is well
known that in the case of a hydrocarbon fire, initial
seconds and minutes matter significantly. Prompt action
can save the disaster by extinguishing the fire. After the
first couple of minutes the attempt can only be to contain
the fire from spreading to other locations.
In Bhopal, the work force had been reduced from
450 to 150 and made to do work they had not been found
qualified to do during their original job interviews. The
production team on the MIC facility was cut from 12 to
6 (Lees, 1996). The management never bothered to
employ good professionals to implement the safety mea-
sures (Pareek, 1999). The report on the Challenger
space shuttle disaster states, After the shuttle became
operational in 1980, the workforce and functions of sev-
eral shuttle safety, reliability, and quality assurance
 J.P. Gupta / Journal of Loss Prevention in the Process Industries 15 (2002) 14
offices were reduced. A safety committee, the Space
Shuttle Program Crew Safety Panel, ceased to exist at
that time (Leveson, 1995). At the Esso Australia plant,
staff downsizing and increasing operator responsibility
were cited as amongst the causes of explosion. Lack of
adequate training and insufficient supervision were
identified as prime causes (TCE, 1999).
At UCC Bhopal, critical instruments installed to indi-
cate pressure, temperature, high and low level alarms on
Tank 410 had been malfunctioning for over a year (Lees,
1996). Hence, the rise in pressure was ignored until the
sound generated by the cracking of the tank was heard.
It was too late and the tank cracked open releasing the
deadly MIC. The TMI accident (1979) was caused by
instruments that did not give the operators adequate
indication of the reactors true operating conditions and
such instrument malfunctioning had been detected on
similar reactors since 1970 but was ignored (Perrow,
1982). At Esso Australia, a faulty record controller with
lack of ink, faulty drives, site glasses, pumps and valves
were found though these may not have been contributing
factors (TCE, 1999).
UCC had claimed the Bhopal plant to be a model
facility using modern technology. Its manager, when
informed of the MIC leak, said, The gas leak just cant
be from my plant. Our technology just cant go wrong
(Bogard, 1987). UCC used to operate a similar plant in
Institute, West Virginia. There were nearly 60 leaks of
MIC in the W. Virginia plant between 1980 and 1984.
As per EPA investigation most of them went unreported
(Lagadel, 1990). After the Bhopal disaster, both the
UCC and US Occupational Safety and Health Adminis-
tration (OSHA) announced that the same type of acci-
dent could not occur at the Institute, WV, plant because
of the plants better equipment, better personnel and
Americas generally higher level of technological cul-
ture (Perrow, 1986). Yet, only 8 months later, a similar
accident occurred there leading to brief hospitalisation
of approx. 100 people. As in Bhopal, the warning signal
was delayed for some time and the company was slow
in making information available to the public (Lagadel,
1990). OSHA fined UCC US$1.4 million charging con-
stant, willful, and overt violations at the plant and a
general atmosphere and attitude that a few accidents
here and there are the price of production (Perrow,
1986). Only 8 months earlier OSHA had certified that
such an accident could not occur at that plant. At the
Esso Australia plant, the report stated that the company
failed to provide and maintain a safe working environ-
ment (TCE, 1999).
At the UCC Bhopal plant, the company did not tell
the civic authorities what the leaking chemical was and
did not recommend any antidote for it. The doctors treat-
ing the suffering public were in the dark for several days
and this adversely affected the treatment protocol used.
Similarly, at another UCC facility in the US, a leak of
3
toxic gas affected a shopping centre. Emergency treat-
ment was administered to several people. For 2 days
doctors did not know what the toxic chemical was or
where it came from because UCC denied the leaks
existence (Perrow, 1986).
In Bhopal, the local government did not act tough on
earlier accidents and ignored newspaper articles pre-
dicting disaster. In the UCC, Institute, WV, case, a Fed-
eral organisation (OSHA) gave a clean chit to the WV
plant after the Bhopal accident, and 8 months later a
serious toxic leak occurred there. The report on the Esso
Australia explosion states that the government had
diminished both the independence and power of the
OH&S Authority by placing it first under the department
of business and employment and then amalgamating it
with the workers compensation insurance agency (TCE,
1999). At the Texaco refinery, the report states that the
company had not learned from past experience on simi-
lar plants.
Therac-25, an accelerator for radiation treatment of
cancer patients, built by Atomic Energy of Canada Lim-
ited (AECL) was a successor to the earlier Therac-20
and highly automated. In 1985, it gave a severe radiation
overdose to a patient in Georgia, USA. Instead of 200
rad, the dose was 15,000 to 20,000 rad. AECL, a Canad-
ian Government undertaking, stated categorically that
the accident could not have been caused by their
machine. After a second overdose in Ontario, Canada,
AECL made some software changes and the US FDA
told the user hospitals that they could return to normal
operating procedures. A list of suggestions by the Can-
adian Radian Protection Bureau was not fully complied
with, though the law had so required. A total of 6 fatal
accidents occurred between 1985 and 1987 before all the
necessary alterations were made. These accidents were
never officially investigated. All law suits were settled
out of court (Leveson, 1995).
Due to financial problems, UCC Bhopal had started
cutting down the essential worker amenities. Pipelines
were repaired by using epoxy resins and seals with the
permission of the management (Pareek, 1998). An
unprofitable plant should have been shut down. How-
ever, UCC Bhopal tried to make it profitable or cut
losses by shutting down the safety systems!
Storage of a large quantity of MIC was not warranted
by the process. UCC Bhopal had not desired it but the
headquarters in the US had overruled the objection.
Further, an alternate production route was available that
did not produce MIC as an intermediate (Lees, 1996).
UCC either did not know of it or decided that the MIC
route was not as unsafe as it actually turned out to be.
3. Conclusions
The above discussion points out that major disasters
can happen in any country regardless of the level of
4 J.P. Gupta / Journal of Loss Prevention in the Process Industries 15 (2002) 14
development. Apart from the Bhopal gas tragedy, the
remainder of the accidents occurred in the developed
countries (Australia, Canada, UK, USA). We deliber-
ately chose such disasters that have occurred after the
Bhopal tragedy (except the TMI) to see if the latter has
had a salutary effect, at least in the developed countries.
As is evident, there was no such effect, at least until the
late eighties. Therefore, one is led to conclude that a
Bhopal type accident could have happened in 1984 even
in a developed country as long the management gave
only lip service to process and personnel safety and the
governments did not ensure compliance with the regu-
lations.
The situation since the early nineties has changed
overall for the better, as noted in the abstract at the
beginning of the paper. Based upon expansion in the CPI
and not a proportionate increase in the number of fatal-
ities and insurance claims for fire and explosion, it has
been concluded that several hundred lives and over a
billion dollars in damages have been saved (Kletz,
1998a,b; Sutton, 1999). (The cost of add-on safety meas-
ures has not been factored in.) However, major accidents
still do happen which could have been prevented.
It should be appreciated that the improvements in pro-
cess safety due to new legislation, stricter enforcement
and personnel training have, more or less, reached a
limit. These will, in future, produce only small
incremental improvements in safety. New legislation
results after each new type of accident. Learning from
accidents has its own limits and is very costly indeed in
terms of cost as well as human misery. If it is true that
technology advances as much by overcoming failures as
it does by achieving successes, then the price of better-
ment will always include heartbreaks (Kemp, 1986).
Fundamental R&D is needed in the causes of accidents
and in manufacturing processes used in the chemical
process industries. The challenge is daunting but there
is no alternate way out to make further significant
improvements in process safety. Fundamental research
to learn about the causes of accidents in other fields such
as boiler explosion have, in the past, led to significant
improvements in design as well as in producing new and
better materials. This is what is expected in the field of
process safety. The recent spurt in activity related to
inherently safer approaches will also play a significant
role in improving safety and the public image of CPI
(Kletz, 1998a).
References
Blazier, A., & Skilling, J. (1995). Potential source of data for use in
human factor studies. In Major hazards onshore and offshore II.
I. Chem. E. Symp. Ser, No. 139. Rugby, UK: Institution of Chemi-
cal Engineers.
Bogard, W. (1987). The Bhopal tragedy. Boulder, CO: Westview
Press.
Hidden, A. (1990). Investigation into the Clapham Junction railway
accident. London: HMSO.
Jungk, R. (1958). Brighter than a thousand suns. London: V. Gollancz.
Keenan, J. G. (1979). Report of the Presidents Commission on Three
Mile Island. Washington, DC: US Government Accounting Office.
Kemp, E. (1986). Calamities of technology. Science Digest, 7, 5059.
Kletz, T. (1998a). Process plants: a handbook of inherently safer
designs. London: Taylor & Francis.
Kletz, T. (1998b). Review of The explosion and fire at the Texaco
refinery, Milford Haven, 24 July 1994. Chemical Engineering Pro-
gress, 94 (4), 86.
Lagadel, P. (1990). States of emergency. London: ButterworthHeine-
mann.
Lees, F. P. (1996). Loss prevention in the process industries (2nd ed.).
Oxford: ButterworthHeinemann.
Leveson, N. G. (1995). Safewaresystem safety and computers. Read-
ing, MA: Addison-Wesley.
Pareek, K. (1999). The management did not adhere to safety norms.
Interview. Down to Earth, 8 (1), 56.
Pareek, S.K. (1998). Personal Communication.
Perrow, C. (1982). The Presidents Commission and the normal acci-
dent. In D. L. Sills, Accident at Three Mile Island: the human
dimensions. Boulder, CO: Westview Press.
Perrow, C. (1986). The habit of courting disaster. The Nation, October.
Spooner, P. (1995). Disasters: A family groups view. In Major haz-
ards onshore and offshore I. I. Chem. E. Symp. Ser, No. 139.
Rugby, UK: Institution of Engineers.
Sutton, I. (1999). Engineering process safety. Chemical Engineering,
106 (5), 114121.
TCE The Chemical Engineer (1999). July 8 and August 19.