Case Studies
Case study: bhopal gas tragedy (1983-84).
Dr. Rhyddhi Chakraborty Programme Leader (Health and Social Care), London Churchill College, UK Email: [email protected]
What follows is a synopsis of the full article found in featured articles.
Please read the featured article Lesson from Bhopal Gas Tragedy (1983-84) By Dr. Rhyddhi Chakraborty Programme Leader (Health and Social Care), London Churchill College, UK describes in detail the elements of the Bhopal Gas Tragedy
Union Carbide India Limited (UCIL)
In 1970, in the North adjacent to the slums and railway station, a pesticide plant was set up by Union Carbide India Limited (UCIL). From late 1977, the plant started manufacturing Sevin (Carbaryl) by importing primary raw materials, viz. alpha-naphtol and methyl isocyanate (MIC) in stainless steel drums from the Union Carbide's MIC plant in USA. However, from early 1980, the Bhopal plant itself started manufacturing MIC using the know-how and basic designs supplied by Union Carbide Corporation, USA (UCC). The Bhopal UCIL facility housed three underground 68,000 liters liquid MIC storage tanks: E610, E611, and E619 and were claimed to ensure all safety from leakage.
Time Line of Occupational Hazards of the Union Carbide India Limited Plant Leading Before the Disaster
• 1976: Local trade unions complained of pollution within the plant. • 1980: A worker was reported to have accidentally been splashed with phosgene while carrying out a regular maintenance job of the plant's pipes. • 1982 (January): A phosgene leak exposed 24 workers, all of whom were admitted to a hospital. Investigation revealed that none of the workers had been ordered to wear protective masks. • 1982 (February): An MIC leak affected 18 workers. • 1982 (August): A chemical engineer came into contact with liquid MIC, resulting in burns over 30 percent of his body. • 1982 (October): In attempting to stop the leak, the MIC supervisor suffered severe chemical burns and two other workers were severely exposed to the gases. • 1983-1984: There were leaks of MIC, chlorine, monomethylamine, phosgene, and carbon tetrachloride, sometimes in combination.
In early December 1984, most of the Bhopal plant's MIC related safety systems were not functioning and many valves and lines were in poor condition. In addition, several vent gas scrubbers had been out of service as well as the steam boiler, intended to clean the pipes. For the major maintenance work, the MIC production and Sevin were stalled in Bhopal plant since Oct. 22, 1984 and major regular maintenance was ordered to be done during the weekdays’ day shifts.
The Sevin plant, after having been shut down for some time, had been started up again during November but was still running at far below normal capacity. To make the pesticide, carbon tetrachloride is mixed with methyl isocyanate (MIC) and alpha-naphthol, a coffee-colored powder that smells like mothballs. The methyl isocyanate, or MIC, was stored in the three partly buried tanks, each with a 15,000-gallon capacity.
During the late evening hours of December 2, 1984, whilst trying to unclog, water was believed to have entered a side pipe and into Tank E610 containing 42 tons of MIC that had been there since late October. Introduction of water into the tank began a runaway exothermic reaction, which was accelerated by contaminants, high ambient temperatures and other factors, such as the presence of iron from corroding non-stainless steel pipelines.
A Three Hour Time Line of the Disaster
December 3, 1984 12:40 am: A worker, while investigating a leak, stood on a concrete slab above three large, partly buried storage tanks holding the chemical MIC. The slab suddenly began to vibrate beneath him and he witnessed at least a 6 inche thick crack on the slab and heard a loud hissing sound. As he prepared to escape from the leaking gas, he saw gas shoot out of a tall stack connected to the tank, forming a white cloud that drifted over the plant and toward nearby neighborhoods where thousands of residents were sleeping. In short span of time, the leak went out of control.
December 3, 1984 12:45 am: The workers were aware of the enormity of the accident. They began to panic both because of the choking fumes, they said, and because of their realization that things were out of control; the concrete over the tanks cracked as MIC turned from liquid to gas and shot out the stack, forming a white cloud. Part of it hung over the factory, the rest began to drift toward the sleeping neighborhoods nearby.
December 3, 1984 12:50 am: The public siren briefly sounded and was quickly turned off, as per company procedure meant to avoid alarming the public around the factory over tiny leaks. Workers, meanwhile, evacuated the UCIL plant. The control room operator then turned on the vent gas scrubber, a device designed to neutralize escaping toxic gas. The scrubber had been under maintenance; the flow meter indicated there was no caustic soda flowing into the device. It was not clear to him whether there was actually no caustic soda in the system or whether the meter was broken. Broken gauges were not unusual at the factory. In fact, the gas was not being neutralized but was shooting out the vent scrubber stack and settling over the plant. December 3, 1984 1: 15- 1:30 am: At Bhopal’s 1,200-bed Hamidia Hospital, the first patient with eye trouble reported. Within five minutes, there were a thousand patients. Calls to the UCIL plant by police were twice assured that "everything is OK", and on the last attempt made, "we don't know what has happened, sir". In the plant, meanwhile, MIC began to engulf the control room and the adjoining offices.
December 3, 1984 3:00 am: The factory manager, arrived at the plant and sent a man to tell the police about the accident because the phones were out of order. The police were not told earlier because the company management had an informal policy of not involving the local authorities in gas leaks. Meanwhile, people were dying by the hundreds outside the factory. Some died in their sleep. Others ran into the cloud, breathing in more and more gas and dropping dead in their tracks.
Immediate Consequences
With the lack of timely information exchange between Union Carbide India Limited (UCIL) and Bhopal authorities, the city's Hamidia Hospital was first told that the gas leak was suspected to be ammonia, then phosgene. They were then told that it was methyl isocyanate (MIC), which hospital staff had never heard of, had no antidote for, and received no immediate information about. The gas cloud, composed mainly of materials denser than air, stayed close to the ground and spread in the southeasterly direction affecting the nearby communities. Most city residents who were exposed to the MIC gas were first made aware of the leak by exposure to the gas itself.
Subsequent Actions
Formal statements were issued that air, water, vegetation and foodstuffs were safe, but warned not to consume fish. The number of children exposed to the gases was at least 200,000. Within weeks, the State Government established a number of hospitals, clinics and mobile units in the gas-affected area to treat the victims.
Legal proceedings involving UCC, the United States and Indian governments, local Bhopal authorities, and the disaster victims started immediately after the catastrophe. The Indian Government passed the Bhopal Gas Leak Act in March 1985, allowing the Government of India to act as the legal representative for victims of the disaster, leading to the beginning of legal proceedings.
Initial lawsuits were generated in the United States federal court system in April 1985. Eventually, in an out-of-court settlement reached in February 1989, Union Carbide agreed to pay US$470 million for damages caused in the Bhopal disaster. The amount was immediately paid.
Post-settlement activity
UCC chairman and CEO Warren Anderson was arrested and released on bail by the Madhya Pradesh Police in Bhopal on 7 December 1984. Anderson was taken to UCC's house after which he was released six hours later on $2,100 bail and flown out on a government plane. Anderson, eight other executives and two company affiliates with homicide charges were required to appear in Indian court.
In response, Union Carbide said the company is not under Indian jurisdiction. In 1991, the local Bhopal authorities charged Anderson, who had retired in 1986, with manslaughter, a crime that carries a maximum penalty of 10 years in prison. He was declared a fugitive from justice by the Chief Judicial Magistrate of Bhopal on 1 February 1992 for failing to appear at the court hearings in a culpable homicide case in which he was named the chief defendant. Orders were passed to the Government of India to press for an extradition from the United States. From 2014, Dow is a named respondent in a number of ongoing cases arising from Union Carbide’s business in Bhopal.
A US Federal class action litigation, Sahu v. Union Carbide and Warren Anderson, had been filed in 1999 under the U.S. Alien Torts Claims Act (ATCA), which provides for civil remedies for "crimes against humanity." It sought damages for personal injury, medical monitoring and injunctive relief in the form of clean-up of the drinking water supplies for residential areas near the Bhopal plant. The lawsuit was dismissed in 2012 and subsequent appeal denied. Anderson died in 2014.
Long-term Health Effects
A total of 36 wards were marked by the authorities as being "gas affected," affecting a population of 520,000. Of these, 200,000 were below 15 years of age, and 3,000 were pregnant women. The official immediate death toll was 2,259, and in 1991, 3,928 deaths had been officially certified. The government of Madhya Pradesh confirmed a total of 3,787 deaths related to the gas release. Later, the affected area was expanded to include 700,000 citizens. A government affidavit in 2006 stated the leak caused 558,125 injuries including 38,478 temporary partial injuries and approximately 3,900 severely and permanently disabling injuries.
Ethical Negligence
The Corporate Negligence Argument: This point of view argues that management (and to some extent, local government) underinvested in safety, which allowed for a dangerous working environment to develop.
Safety audits: In September 1984, an internal UCC report on the West Virginia plant in the USA revealed a number of defects and malfunctions. It warned that "a runaway reaction could occur in the MIC unit storage tanks, and that the planned response would not be timely or effective enough to prevent catastrophic failure of the tanks". This report was never forwarded to the Bhopal plant, although the main design was the same.
The Disgruntled Employee Sabotage Argument: Now owned by Dow Chemical Company, Union Carbide maintains a website dedicated to the tragedy and claims that the incident was the result of sabotage, stating that sufficient safety systems were in place and operative to prevent the intrusion of water.
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In fact, the gas was not being neutralized but was shooting out the vent scrubber stack and settling over the plant. December 3, 1984 1: 15- 1:30 am: At Bhopal’s 1,200-bed Hamidia Hospital, the first patient with eye trouble reported. Within five minutes, there were a thousand patients.