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Presented To:

Mr. Iqbal Baig

Presented By:

Syed Waqar Ahmed UW-10-ME-BE-005

BHOPAL GAS TRAGEDY

2-3 December 1984

INTRODUCTION
On December 3, 1984, in the city of Bhopal, a highly toxic cloud of methyl isocyanate(MIC) vapor burst from the Union Carbide pesticide plant. Of the 800,000 people living in Bhopal at the time, a sum of 25000 people died, and as many as 300,000 were injured. MIC was a major component for the production of the pesticide Sevin by the Union Carbide factory at Bhopal. This incident we now refer to as the Bhopal Gas Tragedy is one of the worst commercial industrial disasters in history.

Bhopal Gas Tragedy Sad Statistics

Happened in the night of 2nd & 3rd December 1984 when a pesticide plant of Union Carbide India Limiteds (UCIL) spewed about forty to forty five tons of highly lethal MIC gas in Bhopal, Madhya Pradesh, India. One of the worst industrial disasters in human history Among people, who were exposed to the gas:
25,000 people died 558,125 injured

120,000 continue to suffer devastating health effects

LOCATION

BHOPAL
City of India. Capital of Madhya Pradesh. An agricultural city. UCIL plant was located just on the outskirts of the city. 3 km away from two major hospitals. 1 km away from railway station.
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Background
Indian government decided to join Green revolution initiative started by United States, aimed to increase the food production in underdeveloped countries. Capitalist farming required many inputs including Pesticides. That's why Bhopal plant was established in 1968.
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Union Carbide India limited(UCIL)

Started in 1969 in Bhopal, situated at the northern edge of Bhopal city. Phosgene, Monomethlyamine, Methyl Isocyanate (MIC) and the pesticide Carbaryl, also known as Sevin were manufactured here.

Production
UCIL used to produce SEVIN, a pesticide. Methyle-iso-cyanate (MIC) was one of the major components for SEVIN.

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MIC and its toxicity

Isosyanate consists of R-N=C=O Highly reactive due to the adjacent double bond. Boiling point 39.1C. Vaporizes at room temperature. Odorless and colorless gas. Highly reactive with water exothermally. More adverse to health when inhaled than injected, explaining the catastrophic effect caused on that fatal day.
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 Its effects can result in watering of eyes and irritation in throat. Exposure limit for MIC has set 0.02 ppm per 8 hour by Occupational Safety and Health Administration (OSHA)

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The Accident
December 2, 1984: 89 pm: The MIC plant supervisor was ordered to wash out several pipes running from the phosgene system to the scrubber through the MIC storage tanks. The maintenance department is responsible for inserting the slip blind (a solid disk) into the pipe above the water washing inlet. However, the MIC unit workers were not aware that the installation of these slip blinds is a required safety procedure, and the slip blind was not installed. The temperature of MIC in tanks was between 15 and 20 C .
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SLIP BLINDS

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 9:30 pm: The water washing begins. The plant supervisor ordered that the washing continue until it had risen past a leaking isolation valve in the lines being washed and got into the relief valve pipe 20 feet above ground.

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 11 pm: The operator in the control room noticed pressure gauge connected to Tank E610 had risen from 2 psi to 10 psi. The rise in pressure didnt arouse any concerns to the operator since 10 psi is within the normal 225 psi range.

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 11:30 pm: The unit workers in the area noticed MICs smell and saw an MIC leak near the scrubber. They also found MIC and dirty water leaking out of one of the relief valve pipes on the downstream side of the safety valve, away from the tank area.

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December 3, 1984
12:1512:30 am: The control room operator noticed that control room pressure indicator for Tank E610 reads 2530 psi. About 12.30 am, the pressure was 55 psi. The safety valves popped out and clouds of lethal gas were discharging from the plant stack vent scrubber and spreading rapidly through Bhopal
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 12:40 am: The plant supervisor turned on the inplant and external toxic gas sirens. The operators also turned on the fire water sprayer. However, water could not reach the gas cloud formed at the top of the scrubber stack. Moreover, attempts to cool the tank with the refrigeration system failed because the Freon had been drained.
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 1 am: Plant supervisor realized that the spare tank, E619, was also not empty, so workers failed to reduce the pressure in E610 by transferring any MIC to E619. The gas smell was obvious outside the plant.

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Management failure
1. Union Carbide claimed MIC is merely a mild throat and ear irritant 2. Sloppy safety procedures 3. Management neglect of general plant operations 4. Lack of investment in plant safety 5. Cost cutting:
Employee training and factory maintenance were radically cut. Skilled employees were replaced with lower paid workers Stainless valves and pipes were replaced with Carbon Steel
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6. 7. 8. 9.

No onsite emergency plan Locating the plant in a densely populated area Haphazard urbanization in surrounding areas Indian governments acceptance of the plant for political reasons without any safety analysis 10. Failure of Indian government to identify hazards and mandate safety standards 11. The lack of written reference manuals/instructions for the workers reference 12. Data logging of both technical and general activities was not enforced by management
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Operational and Safety Failures

1. Storage of MIC for a period longer than permissible 2. Chloroform was fully not separated from MIC before storage, this played an important role in the runaway reaction. 3. Non functional and nonexistent detection and warning devices

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4. Temperature and pressure gauges at various parts of the plant were extremely faulty and were generally ignored by workers 5. Insufficient and untrained staff a. Faulty pipe washing b. Storage of contaminated MIC

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6. Failure of Union Carbide to respond to defects and lapses pointed out earlier 7. Shutdown of MIC refrigeration unit

8. Shutdown of caustic soda spray system

9. Out of order flare towers

10. Excess MIC in the tank

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11. Lack of a spare tank for diverting MIC from the main tank, the emergency tank present to hold any excess MIC was being used for something else. 12. Misinformation about the toxic effects of MIC and the treatment 13. No valves to prevent water entering the tank
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SAFETY DEVICES
Safety devices defective: a. Vent gas scrubber lacked sodium hydroxide for neutralizing the gases; it was also not prepared to handle the high pressures reached during the tragedy. b. Pipe leading to the flare tower had been dismantled for repairs and could not be used to burn escaping gases c. Water curtains around the plant could not be used because they lacked sufficient pressure to reach the height of the release d. Lack of coolant in the MIC tank refrigerator
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Ethical Issues
The Union Carbide in the home country was fully aware of the dangers of the new technology while transferring. When designing the Bhopal plant, Union Carbide did not transfer all the available safety mechanisms. In USA, it uses computerized instruments to control the safety systems to detect the leaks. But in Bhopal all safety controls were happened to be manual.
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Ethical Issues
The Union Carbide did not take much care in giving training to the personnels by taking them to USA. In 1982, due to financial pressures, it reduced its supervision on Bhopal plant. In subsequent years, the safety practices were reduced due to high turnover of employees, failure in giving training to new employees properly and lack of technical awareness of Indian laborers. Due to this, the workers learned more about the dangers of pesticides from their personal experience than from the study of safety manuals. The Bhopal gas tragedy happened only because of the total unpreparedness of the home country as well as the host 30 country.

Safety Measures in UCC Plants - the USA and India

UCC plant in West Virginia was better equipped compared to the plant in Bhopal. There were a number of critical differences in levels of design and operations of the Bhopal and Institute plants.
Institute, West Virginia, USA Capacity High production of MIC matched with high processing capacity. MIC not stored for long periods of time. Bhopal, Madhya Pradesh, India High production capacity of MIC but low processing capacity. MIC stored in large quantities for long periods of time. No emergency caustic scrubber to neutralize any MIC leak.

Emergency scrubbers

MIC storage tank equipped with emergency scrubbers (to neutralize any escaping MIC) designed to operate under emergency conditions. Computerized monitoring of instruments (gauges, alarms, etc) and processes to support visual observation. MIC field storage tanks used a cooling system based on chloroform (inert and nonreactive with MIC). Refrigeration unit to control temperature in the tanks was never turned off. MIC was always maintained under nitrogen pressure.

Computerized monitoring

No computerized monitoring of instruments and processes. Relied solely on manual observation.

Cooling system

MIC tanks used a cooling system based on brine (highly reactive with MIC). Refrigeration unit had been turned off since June 1984. MIC tanks had not been under nitrogen pressure since October 1984. 31

Refrigeration unit

Nitrogen pressure

Safety Measures in UCC plants - the USA and India

Institute, West Virginia, USA Emergency plan An elaborate four-stage emergency plan to deal with toxic releases, fires, etc, including a general public alert linked to community police, river and rail traffic and local radio stations. Various emergency broadcast systems in place to alert and disseminate appropriate information to the public. A maintenance programmed to determine and evaluate replacement frequency for valves and instrumentation and alarm systems. Weekly review of safety valves and reviews and maintenance recorded extensively. A lab analysis of MIC was conducted to test quality and check for contamination prior to storage, processing or distribution. Extensive employee training programme to ensure high level of training and information among all employees of normal and emergency procedures. Extensive provision of appropriate personal protective equipment to employees including protective clothing, air respirators, etc. Bhopal, Madhya Pradesh, India No system to inform public authorities or the people living adjacent to the plant. No emergency plan shared with communities living adjacent to the plant; no system to disseminate information regarding emergency to the public with the exception of a loud siren.

Maintenance programme

No evidence of an effective instrument maintenance programme. Safety valve testing programme largely ineffective and no proper records maintained of reviews of instruments, valves and alarm systems, etc. No lab analysis of quality was undertaken. MIC stored for long periods without testing for contamination.

Lab analysis

Training

Operators put in charge without sufficient training.

Protective equipment

Personal protective gear and breathing air equipment not easily accessible, inadequate and of poor quality. 32