Lessons after Bhopal: CSB a catalyst for change

The Bhopal tragedy was a defining moment in the history of the chemical industry. On December 3, 1984, a runaway reaction within a methyl isocyanate storage tank at the Union Carbide India Limited pesticide plant released a toxic gas cloud that killed thousands and injured hundreds of thousands. After Bhopal, industrial chemical plants became a major public concern. Both the public and the chemical industry realized the necessity of improving chemical process safety.

Bhopal served as a wake-up call. To prevent the same event from occurring in the United States, many legislative and industrial changes were invoked—one of which was formation of the U.S. Chemical Safety and Hazard Investigation Board (CSB). The ultimate goal of CSB is to use the lessons learned and recommendations from its investigations to achieve positive change within the chemical industry—preventing incidents and saving lives.

Although it seems clear that the lessons learned at Bhopal have improved chemical plant safety, CSB investigations indicate that the systemic problems identified at Bhopal remain the underlying causes of many incidents. These include:

• Lack of awareness of reactive hazards.

• Lack of management of change.

• Inadequate plant design and maintenance.

• Ineffective employee training.

• Ineffective emergency preparedness and community notification.

• Lack of root cause incident investigations and communication of lessons learned.

The aim of this paper is to present common themes from recent cases investigated by CSB and to discuss how these issues might be best addressed in the future.

This paper has not been independently approved by the Board and is published for general informational purposes only. Any material in the paper that did not originate in a Board-approved report is solely the responsibility of the authors and does not represent an official finding, conclusion, or position of the Board.     

The Bhopal tragedy: its influence on process and community safety as practiced in the United States

The chemical accident at 12:45 AM on December 3, 1984 in Bhopal India had a profound effect on the practice of chemical process safety in the United States. Fearing the possibility of similar events occurring in the United States, the United States Congress convened several hearings and investigations into the causes of the disaster. The inquiries focused both on the state of process safety within the US chemical industry and on the readiness of communities located near chemical operations to respond to sudden and dangerous toxic discharges. Of equal significance were concerns over the safety of workers in chemical plants. This paper reviews the major legislative, academic, and industrial changes initiated in the area of process safety after the event, their influence on saving lives, and on improving living conditions surrounding chemical complexes in the United States.     

Challenges and needs for process safety in the new millennium

Process industries have made quite a bit of progress in process safety since the tragic night of December 2, 1984 in Bhopal. Nonetheless, incidents continue to occur on a regular basis due to insufficient understanding of the urgency to identify best practices and drive for process safety improvements in the organization. This paper addresses some of the critical challenges in implementing effective safety programs: (a) failure to learn from past incidents and to capture those lessons into process design, procedures, training, maintenance, and other programs, (b) insufficient attention to leading indicators, and (c) an increase in complexity of process operations and lack of communication. In the presence of these challenges, there is a great need to develop better solutions by utilizing good science based approaches and best practice studies. Potential research areas include, but are not limited to, incident database analysis, reactive chemicals, inherently safer design, combustible dust explosion, facility siting, and the flammability of fuel mixtures and aerosols. In addition, an example was presented on LNG industry safety to illustrate that science-based research is needed to ensure the safe operation and to avoid or mitigate unintended consequences.     

Literary and economic impact of the Bhopal gas tragedy

The 1984 Bhopal disaster is widely regarded as a watershed event in the field of process-safety and has been largely responsible for a paradigm shift in the outlook of both industry and the public towards risk management within the processing industries. The Bhopal disaster has led to increased regulations and awareness for process-safety related activities across the globe. This paper reports the effect of the infamous Bhopal incident on the research community and examines the performance of manufacturing industries following the disaster.

For this paper, databases of scientific publications were used to investigate research trends in the safety area following the 1984 Bhopal disaster. Our analysis focuses on prominent safety-related research fields that have emerged following the gas tragedy as well as economic indicators of the processing industries. The study reveals that the process industry has consistently progressed over the years, in spite of added regulations and a worsened public image following the Bhopal disaster, and promises to be a stable economy in the future.     

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

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.     

The post-Bhopal and post-9/11 transformations in chemical emergency prevention and response policy in the United States

The United States' approach to incident prevention and response to hazardous chemical facilities has undergone two major transformations in the last 20 years. The first was triggered by the Bhopal tragedy in 1984, which led to major changes within the US chemical industry and a series of Federal laws and regulations intended to prevent major chemical accidents. A more recent transformation is currently underway in the wake of the 9/11 attacks on New York and Washington. It involves the advent of various security-related requirements affecting many of the same facilities covered under the existing accident prevention rules. This paper provides an overview of these transformations and their impacts.     

Harnessing database resources for understanding the profile of chemical process industry incidents

Analyzing historical databases can provide valuable information on the incident occurrences and their consequences for assessing the safety of the chemical process industry. In this study, the RMP and HSEES databases were utilized to understand the patterns and the factors influencing chemical process industry incidents. Frequency exceedance curves were generated by utilizing the different incident consequences from the databases to understand the profile of societal loss from reported incidents. Understanding the statistics and trends of the historical incidents could serve as important lagging indicators in order to assess the probable proximity to major consequences from the low-probability/high-consequence incidents. To this regard, the safety pyramids were also generated to better understand the relationship between the different consequences of the reported incidents. Furthermore, the safety pyramids were analyzed in comparison with the traditional safety pyramid proposed by Heinrich to understand the US process industry incident occurrence trends.     

Optimizing the design of storage facilities through the application of ISD and QRA

Four strategies can be used to achieve safety in chemical processes: inherent, passive, active and procedural. However, the strategy that offers the best results is the inherent safety approach, especially if it is applied during the initial stages of a project. Inherently Safer Design (ISD) permanently eliminates or reduces hazards, and thus avoids or diminishes the consequences of incidents. ISD can be applied using four strategies: substitution, minimization, moderation and simplification. In this paper, we propose a methodology that combines ISD strategies with Quantitative Risk Assessment (QRA) to optimize the design of storage installations. As 17% of major accidents in the chemical industry occur during the storage process and cause significant losses, it is essential to improve safety in such installations. The proposed method applies QRA to estimate the risk associated with a specific design. The design can then be compared to others to determine which is inherently safer. The risk analysis may incorporate complex phenomena such as the domino effect and possible impacts on vulnerable material and human elements. The methodology was applied to the San Juanico tragedy that occurred in Mexico in 1984.     

Safety analysis approach based on thermodynamic and chemical reactions modelling

Safety analysis of nuclear and chemical/petrochemical facilities is the systematic process that is carried out throughout the design process to ensure that all the relevant safety requirements are met by the proposed design of the plant. Safety analysis should incorporate both deterministic and probabilistic approaches. These approaches have been shown to complement each other and both should be used in the decision making process on the safety and ability of the plant to be licensed.This paper deals with the deterministic safety approach in order to distill the experience of nuclear and chemical/petrochemical protection engineering through a safety analysis approach aiming at analysis of chemically reacting processes including thermodynamic and chemical reactions modelling that are present in both industries. For instance, there are some similarities between the Bhopal disaster and Three Mile Island-Fukushima-like H₂ deflagration-detonation scenarios in nuclear containments. The phenomenology is similar in that the temperature and the pressure caused by exothermic reactions had increased dramatically leading to a loss of containment.The study aims to translate and adapt to general chemically reacting modelling, major features of the equivalent analysis inside the nuclear containments. Compartment containment for H₂ deflagrations has been translated and adapted, with fixed tools, to the methyl-isocyanate storage tank 610 of the Bhopal plant.     

Justice for Bhopal! And No More Bhopals! Three decades of national and international campaigning

Dissatisfaction with the responses of the responsible corporation, Union Carbide, and the Indian government to Bhopal resulted in a campaign by national and international NGOs (non-governmental organisations) over the past three decades. While initially the Indian and international campaigns were separate, over time greater international cooperation took place. In the immediate aftermath of the disaster local NGOs prioritised health, justice and rehabilitation issues, while international NGOs used Bhopal to question chemical industry process and environmental safety in their own countries, as well as internationally. Indian NGOs called on international NGO resources to gain legitimacy for their campaign, to use NGOs as proxies and to extend the geographical scope of the campaign, while international NGOs used Bhopal as an example to advance NGOs analyses and policies. Over the period of the campaign, Indian NGOs became more sophisticated in their campaigning. The international campaign has increasingly become an online campaign, involved in an image or reputational war with Dow Chemical, which took over Union Carbide, while the original campaign issues of justice and reparations over the process safety disaster were joined by similar issues related to environmental safety of abandoned toxic waste.     

Learning from the Bhopal disaster to improve process safety management in Singapore

The Singapore process industry is mainly made up of chemical and energy companies such as Mitsui Chemicals, Clariant, Exxon Mobil, Shell, Sumitomo, Petrochemical Corporation of Singapore and Infineum. Majority of these companies are located on Jurong Island, southwest of Singapore. Jurong Island houses nearly 100 leading petroleum, petrochemicals and specialty chemicals companies and the total investment is about S$42 billion in total. With a land surface area of only 716 km² and a high concentration of process plants, the Singapore government places strong emphasis on safety and risk management. In this paper, four process industry veterans from the government, academic and private sectors were interviewed. Through the interviews, the authors sought to understand the veterans’ perspectives on lessons that the Singapore process industry should learn from the Bhopal disaster. The veterans expanded their thoughts beyond the Bhopal disaster and provided many insights and suggestions critical to process safety management in Singapore and other countries. A systemic model of process safety management was derived from the interviews and key elements of operational process safety management were identified. In addition, a research agenda was identified based on the inputs from the veterans.     

Method for identifying errors in chemical process development and design base on accidents knowledge

It has been claimed that the high accident rate in the chemical process industry is due to poor dissemination of accident knowledge that affects directly the level of learning from accidents. In response to this situation, this paper utilized past accident knowledge as a basis to develop a safety oriented design tool whereby the accident information were directly disseminated into plant design. The method was developed based on our previous accident analysis of design error in which the common design errors were ranked in accordance to their frequency and its origins during normal plant design project. Based on the design error ranking and its origin at a specific design phases, a method for design error detection is proposed. The method is expected to be able to identify the possible design error and its causes throughout chemical process development and design. The main objective is to trigger safe design thinking at the specific design phases so that appropriate action for risk reduction could be timely implemented. The Bhopal and BP Texas tragedies are used as case studies to test and verify the method. The proposed method can detect up to 74% of design errors.     

化工园区安全监控系统研究

化工园区内重大危险源数量多、密度大,存在着发生重特大事故的现实性和可能性。因此,亟需建立化工园区安全监控系统对化工园区内的固定危险源、危险工艺过程、危化品车辆和公共区域重要部位进行动态监控和安全监管,预防和消除事故风险,并为化工园区安全监控与事故应急提供技术支持。提出了化工园区安全监控系统系统硬件架构,介绍了化工园区安全参数设置方法、安全监控流程和事故预警机制,提出了系统软件的总体架构和功能。     

Communicating costs and benefits of the chemical industry and chemical technology to society

Risk Communication is increasingly important to the chemical and manufacturing industries in the wake of a wave of major incidents in recent years. However, risk communication strategies as they are currently implemented tend to place the chemical industry on the defensive. Renewed attempts should be made to place the life-saving benefits of the chemical industry back in the public eye and counter-balance the popular political view that the chemical industry is often responsible for loss of life. In truth, while the chemical industry suffers on the job fatalities like many industries, the frequency is much less than many common industries and the chemical industry provides benefits to society that ultimately save far more lives.     

Factors contributing to US chemical plant process safety incidents from 2010 to 2020

Process safety incidents can result in injuries, fatalities, environmental impacts, facility damage, downtime & lost production, as well as impacts on a company's and industry's reputation. This study is focused on an analysis of the most commonly reported contributing factors to process safety incidents in the US chemical manufacturing industry. The database for the study contained 79 incidents from 2010 to 2019, partly investigated by the Chemical Safety Board (CSB). To be included in the study, the CSB archive of incident investigations were parsed to include only incidents which occurred at a company classified as 325 in the North American Industry Classification System (NAICS), assigned to businesses that participate in chemical manufacturing. For each incident, all of the identified contributing factors were catalogued in the database. From this list of identified contributing factors, it was possible to name the ‘top three’ contributing factors. The top three contributing factors cited for the chemical manufacturing industry were found to be: design; preventive maintenance; and safeguards, controls & layers of protection. The relationship between these top contributing factors and the most common OSHA citations was investigated as well. The investigation and citation history for NAICS 325 companies in the Occupational Safety & Health Administration (OSHA) citations database was then analysed to assess whether there was any overlap between the top reported contributing factors to process safety events and the top OSHA citations recorded for the industry. A database consisting of the inspection and citation history for the chemical manufacturing industry identified by NAICS code 325 was assembled for inspections occurring between 2010 and 2020 (August). The analysis of the citation history for the chemical manufacturing industry specifically, identified that the list of the top contributing factors to process safety incidents overlapped with the most common OSHA violations. This finding is relevant to industry stakeholders who are considering how to strategically invest resources for achieving maximum benefit – reducing process safety risk and simultaneously improving OSHA citation history.     

Systematic incorporation of inherent safety in hazardous chemicals supply chain optimization

Increasing globalization has made many chemical supply chains large, interdependent and complex. Process incidents often affect the reliability of a supply chain and can cause large disruptions at different segments of the industry. We propose an optimization-based framework that systematically takes into account the trade-offs between process safety and supply chain economics for decision-making. We quantify the hazard at various supply chain echelons in the form of a safety index that takes both fire and toxic hazards into account. A mixed-integer nonlinear programming (MINLP)-based model is developed to either maximize profit for specified hazard limits, or to minimize hazard in a supply chain with multiple production plants, technological options, warehouses and distribution nodes. The MINLP model is used to generate trade-off optimal solutions for various toxic and fire hazard limits. The framework is demonstrated by applying it to an end-to-end ammonia supply chain case study which resulted in several non-intuitive observations regarding hazardous supply chain design and optimization.     

The Bhopal gas leak: Analyses of causes and consequences by three different models

The Bhopal Gas Leak, India 1984 is the largest chemical industrial accident ever. Haddon's and Berger's models for injury analysis have been tested, together with the project planning tool Logical Framework Approach (LFA).

The three models provide the same main message: That irrespectively of the direct cause to the leakage, it is only two parties that are responsible for the magnitude of the disaster: Union Carbide Corporation and the Governments of India and Madhya Pradesh. The models give somewhat different images of the process of the accident.

Models developed for analysis of injuries can be used for analysing a complicated mega accident like the Bhopal gas leak, although different models might stress different aspects.     

Bhopal disaster—a personal experience

Bhopal Gas Tragedy was the worst industrial accident in the world where several thousand persons lost their lives. It occurred at the Union Carbide plant located inside the city of Bhopal and close to the railway station, at midnight of December 2-3, 1984 due to the leakage of MIC gas which took the local sleeping and floating population unawares.

This paper describes the experience of a transit passenger who reached the Bhopal Railway Station by train at about the same time when the deadly gas leakage occurred.     

The role of local communities in chemical accident prevention and preparedness

Since the adoption of community right-to-know programs in the US there has been an increase in the number of groups known as local emergency planning committees. These committees have matured in focus over the intervening years since the Bhopal incident and even more so since the events of September 11, 2001. There is a strong recognition that local communities working very closely with chemical handling facilities in their areas can directly and meaningfully reduce the threat of a chemical release incident, regardless of cause. Likewise, through similar means they can better prepare themselves to respond should an incident occur. Especially as regards modern concepts of process chemical safety and facility security, local communities can be of great assistance to smaller facilities that do not otherwise necessarily have the resources to accomplish these tasks. As the vulnerabilities of a facility to accident or intentional act, the impacts of these events and the ability of communities to react are all a function of local conditions, it is clear that these local efforts can be more meaningful than large-scale national efforts. While national legislation is certainly helpful to the process of bringing people together, it is the local relationships that produce results.