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


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 re (1988, 167 killed), the Zeebrugge ferry disaster (1987, 167 killed), Phillips petroleum re 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 signicant 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 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 proactive 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 process safety, and government apathy, had continued throughout the world. It is estimated that several hundred

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lives and over a billion dollars in potential accident damage 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

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upon the rate and duration of release, the weather conditions, 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 protability. Investment in safety appears as a drain on resources with no immediate returns and no quantiable results even in the long run. Production and cost drive the industry. Sacricing a sure productivity gain in favour of preventing a seemingly lowprobability 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 impending 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 parallels 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 accident about 4 weeks earlier and acting accordingly would have avoided the accident. A UCC team from its headquarters in the US had, in 1982, identied 10 safety concerns. 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 specically 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 re 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 are had been out of order for 3 months to replace a corroded pipe. The report on the Piper Alpha re states, The deluge system was blocked. The re 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 modications since start-up. They did not adequately show the isolation points so the workers were unable to do so. Leakages continued to feed the re for 53 hours. No HAZOP had been conducted else it would have identied the hazards (TCE, 1999). The report on the explosion at the Texaco renery, Milford Haven (1994, none killed) states that while numerous modications 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 re, initial seconds and minutes matter signicantly. Prompt action can save the disaster by extinguishing the re. After the rst couple of minutes the attempt can only be to contain the re 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 qualied 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 measures (Pareek, 1999). The report on the Challenger space shuttle disaster states, After the shuttle became operational in 1980, the workforce and functions of several shuttle safety, reliability, and quality assurance

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ofces 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 insufcient supervision were identied as prime causes (TCE, 1999). At UCC Bhopal, critical instruments installed to indicate 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 Administration (OSHA) announced that the same type of accident could not occur at the Institute, WV, plant because of the plants better equipment, better personnel and Americas generally higher level of technological culture (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 ned UCC US$1.4 million charging constant, 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 certied 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 environment (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 treating 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

toxic gas affected a shopping centre. Emergency treatment 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 predicting disaster. In the UCC, Institute, WV, case, a Federal 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 rst under the department of business and employment and then amalgamating it with the workers compensation insurance agency (TCE, 1999). At the Texaco renery, the report states that the company had not learned from past experience on similar plants. Therac-25, an accelerator for radiation treatment of cancer patients, built by Atomic Energy of Canada Limited (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 Canadian 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 Canadian 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 ofcially investigated. All law suits were settled out of court (Leveson, 1995). Due to nancial 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 unprotable plant should have been shut down. However, UCC Bhopal tried to make it protable 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

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development. Apart from the Bhopal gas tragedy, the remainder of the accidents occurred in the developed countries (Australia, Canada, UK, USA). We deliberately 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 regulations. 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 fatalities and insurance claims for re 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 measures has not been factored in.) However, major accidents still do happen which could have been prevented. It should be appreciated that the improvements in process 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 betterment 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 signicant improvements in process safety. Fundamental research to learn about the causes of accidents in other elds such

as boiler explosion have, in the past, led to signicant improvements in design as well as in producing new and better materials. This is what is expected in the eld of process safety. The recent spurt in activity related to inherently safer approaches will also play a signicant role in improving safety and the public image of CPI (Kletz, 1998a). References
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