CHAPTER 9: BHOPAL: THE WORLD’S WORST INDUSTRIAL DISASTER – OWEN GREGORY

‘Traditionally, the severity of accidents in chemical process industries has been gauged on the basis of the human lives [lost]. However, factors such as loss of assets, contamination of surroundings and the resultant trauma also contribute to a very large extent towards the adverse impact of such accidents.’ – (Khan & Abbasi, 1998, p. 305).

The chemical release in 1984 in the Indian city of Bhopal is arguably the worst industrial disaster ever. Fatality estimates vary dramatically from the Madhya Pradesh State Government’s estimate of 3,000 to Greenpeace’s 8,000. In fact, Greenpeace claim that as many as 20,000 have suffered premature deaths since the disaster, a statistic supported by the US Government’s National Center for Biotechnology Information.

Background

Following independence from Great Britain in 1947, the Indian Government attempted to increase wealth in the country. They planned to swiftly move away from a primarily agrarian economy by encouraging industrial development. The rapid development plan required collaboration from foreign firms to assist with:

‘[. . .]the rapid industrialisation of the country, [but] it is necessary that the conditions under which they may participate in Indian industry should be carefully regulated in the national interest.’ – (Peterson, 2009, p. 1).

This regulation took the form of a limit on foreign shareholding in ‘Indian’ firms, rather than in terms of health and safety, business continuity and emergency planning. In one sense, this rapid expansion of Indian industrial capability made the country comparable with the UK during the industrial revolution almost 200 years before – it became vulnerable to accidents and tragedies.

‘Developing countries confer upon Multi-National Companies a competitive advantage because they offer low-cost labour, access to markets, and lower operating costs. Once there, companies have little incentive to minimize environmental and human risks. Lax environmental and safety regulation, inadequate capital investment in safety equipment, and poor communications between companies and governments compound the problem.’ – (Cassels, 1993, p. 279).

Union Carbide India Limited (UCIL), a part-owned subsidiary of the US-based Union Carbide Company (UCC), wished to establish a plant for making fertilisers and pesticides in the 1960s to support increased food production for a growing population and to support the supply of locally grown cotton for the increasingly important textile industries. Initially, the majority of chemical plants were located in the Bombay area, but the local government of Madhya Pradesh were keen to increase industry in the area and UCIL were provided with land for the proposed chemical plant.

Circumstances contributing to the enormity of the tragedy

At this time the population of Madhya Pradesh was increasing at 2% a year. Bhopal was one of the fastest-growing cities in India during the 1960s and 1970s as unemployed people from the surrounding countryside came looking for better opportunities. By 1984 it was home to 900,000 people.

The increases in population led to problems with the haphazard settlement of unoccupied areas of land, including those around the many industrial complexes. Indeed, in 1975 a ‘hazardous industry’ district was created 15 miles from the centre of Bhopal. Despite the dangerous production process and highly toxic methyl isocyanate (MIC) produced on site, however, the UCIL pesticide plant remained classified as ‘general industry’ and it stayed within the metropolitan area. It is important to note that UCC wished UCIL to import ready-made MIC, but the Indian government insisted on local production for economic reasons.

In addition to the changes in production methods, cheaper locally produced alternatives to UCIL’s pesticide products became available. This had two effects. First, the UCIL plant was only operating at 20% capacity in 1984. Secondly, the technical staff operators at the plant, who had been trained by UCC in America, were moving away from the Bhopal facility to other jobs across India, diluting the levels of experience at the Bhopal plant. It was against this background that the disaster occurred, thanks to the 62 tonnes of MIC on the Bhopal site at the beginning of December 1984.

A disaster in waiting

‘Shaving costs and maximizing profits took precedence over ensuring the safety of plant workers and the surrounding communities.’ – (Chemical Industry Archives, 2009).

In the very early morning of 3 December 1984 at least 2,500 people were killed in the immediate aftermath of the release of MIC into the atmosphere. The pressurised gas release was caused by a water-contaminated runaway reaction in Tank 610 of the UCIL plant. The resultant cloud of highly toxic gas spread over a wide area including a railway station, a hospital and a densely populated settlement area.

‘Exposure to MIC has resulted in damage to the eyes and lungs and has caused respiratory ailments such as chronic bronchitis and emphysema, gastrointestinal problems like hyperacidity and chronic gastritis, ophthalmic problems like chronic conjunctivitis and early cataracts, vision problems, neurological disorders such as memory and motor skills, psychiatric problems of various types including varying grades of anxiety and depression, musculoskeletal problems and gynaecological problems among the victims.’ – (The Lancet, 1989, p. 952).

The cause of the incident is not in dispute, but the reasons why water might have entered MIC Tank 610 have been a matter of much debate. UCIL and the Indian government claim that the cause was the error of a technician, who flushed a release valve without inserting a necessary slip-blind (a method of preventing flows of liquid by sealing a pipe at a point between two pipe flanges). If true, this would be a fault with the training and operation of the plant.

An alternate cause put forward by UCC considers sabotage by a disgruntled employee. The suggestion was that they had placed a rubber hose on a release valve of Tank 610 in order to contaminate the tank’s contents. Minor incidents of sabotage by employees had occurred previously at the Bhopal plant. No one was ever accused or charged with sabotage however.

Once the chemical reaction was underway, neither the efforts of the plant staff or the safety devices in situ could prevent gas venting. Some 40 tonnes of gas was released over a period of about two hours. The combination of factors that prevented an on-site solution to the problem included:

‘[. . .]the long-term storage of MIC in the plant, the potentially undersized vent gas scrubber, the shutdown of the MIC refrigeration units, the use of the backup tank [611] to store contaminated MIC, the company’s failure to repair the flare tower, leaking valves, broken gauges, cuts in manning levels, crew sizes, worker training and skilled supervision.’ – (Moreorless, 2011).

Moreover, a 1982 safety inspection had been virtually disregarded and both the government and UCIL had not heeded the complaints of the trade unions representing the Bhopal workers over the reduction in shift crews and supervision. Fault was not limited to UCC and UCIL – the Indian and state governments were found complicit in allowing a potentially dangerous process to be carried out in proximity to a densely populated area.

It was also found that after the gas release hospitals which had been inundated with the victims did not know what chemical poisoning or toxicity they were dealing with. There are also pertinent points that can be raised about the capability of the local hospitals to handle the size of the population seeking assistance, and about the immediate response from the local police force in evacuating the locality after the gas release.

The tragic human legacy

‘Nearly 28 years after one of the worst industrial catastrophes in history, toxic chemicals abandoned on the site are still contaminating the groundwater.’ – (Bouissou, 2012).

While various sources report conflicting number of initial fatalities, the pollution legacy lives on. As much as 12,000 metric tonnes of toxic waste still remains at the abandoned UCIL site, which has resulted in local groundwater pollution. Toxic substances are known to have infiltrated the soil long before the disaster, however. In 1982 UCIL acknowledged several leaks throughout the plant which also coincided with farmers reporting cattle dying after grazing close to the site.

‘The contamination of soil and groundwater in and around the UCIL premises is solely due to dumping of the above mentioned wastes during 1969 to 1984, and the MIC gas tragedy has no relevance to it.’ – (The Hindu, 2010).

Malformed children continue to be born near the site and many local inhabitants are being diagnosed with complaints such as anaemia, skins disorders and cancer. Moreover, hundreds of thousands have been left chronically ill.

There is no question that the MIC gas release caused so many fatalities and left a legacy of human suffering for those exposed to its toxic effects. Evidence suggests, however, that the disaster may have served to conceal another potent cause of this on-going tragedy. Either way, the blame can be firmly placed at UCIL’s door.

Effects on the local economy

‘Hopes were high that the mere presence of such a large, global company would attract large-scale industrial investment to the city. The gas leak changed everything. Since Union Carbide there has been no major investment by foreign companies here.’ – Rajendra Kothari, 2009.

In fact by 2009, although India’s annual growth rate was around 8%, Madhya Pradesh lagged behind at 4%. While many developed countries would have been delighted with the level of growth, for Madhya Pradesh and Bhopal this was simply not enough.

With loss of employees due to illness being acknowledged globally as a threat for many companies, the Bhopal workforce was decimated overnight, leaving many local organisations exposed. This includes not only fatalities but also the thousands of chronically sick, many of whom were left unable to work. Potential investors may well be deterred by a workforce left with a legacy of unremitting illness.

Although arguably adding insult to injury for the inhabitants of Bhopal, the Madhya Pradesh State Government is reported to have been considering promoting dark or thana-tourism at the BCIL site.

‘The state’s move to turn the defunct Union Carbide factory premises into a site for ‘disaster tourism’ could be inspired by the Chernobyl site in the former USSR where visitors pay homage to the victims.’ – (Dutta, 2009).

Litigation

In the intervening years since the tragedy, litigation has continued. The defunct Bhopal chemical plant was handed over to the Indian government. UCC agreed to fund a memorial hospital at the cost of US$470 million, a figure agreed by the Indian Supreme Court.

UCC has since been bought out by Dow Chemicals who refuse to accept any liability for events prior to their ownership. As recently as 2012, the drive to secure further compensation for Bhopal victims cast a shadow over the London Olympics. Some in India were taking issue with Dow Chemicals being a top-tier sponsor for the event. In response, the International Olympics Committee stated that, ‘Dow had no connection with the Bhopal tragedy. Dow did not have any ownership stake in Union Carbide until 16 years after the accident.’

Lessons learned

The lessons that can be taken from this tragedy can primarily be sub-divided into three factors – human, operational and technical failings. The human factors that contributed towards the situation included:

• Attrition of skilled employees leading to low level of experienced staff compounded by limited training for plant personnel.
• Reduction of shift operating staff to minimum (ineffective) levels.
• Slow response to escalating situation.
• Process employed that could introduce water to the MIC tank.

From an operational perspective the following observations were made:

• UCIL production policies and procedures weak; adapted from UCC but with local differences.
• The Bhopal plant was a low profit plant in an unimportant division (pesticides) for UCC and UCIL.
• Plant established at a time when its economic viability was uncertain.
• Eight managers in 15 years.
• Move from alpha-napthol processes to use of methyl isocyanate did not trigger any concerns over manufacturing methods.
• Need for industry exceeding the need for proper planning and mitigation – failure of government oversight.
• Lack of disaster planning.
• Lack of information disseminated to local authorities and health organisations regarding the materials vented into the atmosphere around the plant.
• Potentially dangerous plant permitted in heavily populated area.
• Little or no management or government response to in-plant safety reports or complaints.

Finally, a number of technical failings that contributed towards the disaster:

• General conditions increasing probability of serious accident.
• Process design allowed for large tank storage of MIC; other process designs use smaller storage tanks or a flow process that uses MIC immediately after it is made.
• Manual, non-computerised, sometimes non-redundant, control/monitoring systems.
• Immediate enablers of massive leak on 3 December 1984 included:
• Lack of positive nitrogen pressure, allowing contaminants in through nitrogen line.
• Water entered tank through relief valve and process pipes.
• Water by-passed either the blow-down valve or the safety valve.
• Both flare tower and gas scrubber off-line, no redundancy as each safety device operated with no substitute on failure.
• No empty tank for operators to shunt MIC into when they realise there is a problem.
• Tank over-full (75%-80% of capacity when manual says 50% max).
• No investigation of what kept water flowing out of drain valve when water flushing was begun on 2 December 1984.

Conclusion

The analysis of threats and risk mitigation or contingency measures is the primary component of business continuity management or emergency planning. In this case study the absence of appropriate levels of risk management both caused and increased the impact of the event. It is clear that the organisation’s risk appetite was profit driven, culminating in caution being thrown to wind vis-à-vis the health and safety of its employees and the local population.

The Bhopal chemical plant did have a series of safety devices established, but their suitability and operability were found to be lacking when the MIC runaway reaction commenced. Undertrained employees and inadequate staffing levels seriously constrained an appropriate response to an on-going situation. The unaddressed risks, associated with the plant itself, must be laid firmly at the door of UCIL. But even before the MIC release, UCIL toxic waste had been contaminating the local land and groundwater for around 15 years.

UCC should not be excused from a level of responsibility as they had the major capability for on-going training of the plant operations staff. Even so, it seems that as soon as the Bhopal plant became uneconomical to run the remaining 62 tonnes of MIC was left without necessary safety measures to control any untoward event.

The Indian government and the state government cannot be absolved of blame. They not only failed to follow up on an inspection that revealed safety flaws, but also permitted hazardous processes to be carried out immediately adjacent to a dense human settlement.

The emergency response to the MIC leak was also flawed with no apparent pre-planning or preparation undertaken during the plant’s existence. It seems that no lessons were learnt from a dioxin leak from the Seveso chemical manufacturing plant in 1976. Although the Seveso disaster did not have a fatal outcome of the same magnitude as Bhopal, the large numbers of those affected around the Seveso area was due to the proximity of the industrial plant to a populated area.

The conclusion is that threats must be constantly monitored and analysed to ensure that the correct actions can be carried out for their immediate mitigation. As part of risk mitigation a sound business continuity plan, emergency plan or combination of the two must be in place to cover both public and private interests as necessary.