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.     

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.     

Fault propagation behavior study and root cause reasoning with dynamic Bayesian network based framework

The Bhopal disaster was a gas leak incident in India, considered the world's worst industrial disaster happened around process facilities. Nowadays the process facilities in petrochemical industries have becoming increasingly large and automatic. There are many risk factors with complex relationships among them. Unfortunately, some operators have poor access to abnormal situation management experience due to the lack of knowledge. However these interdependencies are seldom accounted for in current risk and safety analyses, which also belonged to the main factor causing Bhopal tragedy. Fault propagation behavior of process system is studied in this paper, and a dynamic Bayesian network based framework for root cause reasoning is proposed to deal with abnormal situation. It will help operators to fully understand the relationships among all the risk factors, identify the causes that lead to the abnormal situations, and consider all available safety measures to cope with the situation. Examples from a case study for process facilities are included to illustrate the effectiveness of the proposed approach. It also provides a method to help us do things better in the future and to make sure that another such terrible accident never happens again.     

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 Bhopal gas tragedy—A perspective

We, the then Mayor and Chief of Police of Bhopal, were the two people on whom the responsibility of handling the world's worst industrial disaster fell unceremoniously on the cold night of December 2–3, 1984 when 41 tons of MIC gas was released from the Union Carbide plant in Bhopal. With the company initially in denial mode about the release and then calling it a ‘tear-gas’ type and providing no information on antidote, and with the limited means of evacuation, handling of medical emergency affecting hundreds of thousand, identification and disposal of the thousands of dead, it was probably the most challenging task faced by a duo in peace time. The local people, the medical community, the railway staff, the NGOs, were all very helpful. We narrate the happening and the handling of the consequences and the spot decisions that had to be made with the hope that no such accident happens anywhere.     

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.     

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.     

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 legacy of Bhopal: The impact over the last 20 years and future direction

Chemical process safety was not a major public concern prior to 1984. As far as chemical hazards were concerned, public fears focused on disease (cancer) and environmental degradation. Even a series of major process incident tragedies did not translate into widespread public concerns about major incidents in chemical plants that might disastrously affect the public. This situation changed completely after the December 1984 disaster at the Union Carbide plant in Bhopal. Not only was the public's confidence in the chemical industry shaken, the chemical industry itself questioned whether its provisions for protection against major incidents were adequate.

The recognition of the need for technical advances and implementation of management systems led to a number of initiatives by various stakeholders throughout the world. Governments and local authorities throughout the world initiated regulatory regimes. Has all that has resulted from the legacy of Bhopal reduced the frequency and severity of incidents? How can we answer this question? As we move into more and more globalization and other complexities what are the challenges we must address? According to the authors, some of these challenges are widespread dissemination and sharing of lessons learned, risk migration because of globalization, changing workforce, and breakthroughs in emerging areas in process safety.     

An evaluation of risk assessment framework for industrial accidents in India

Due to rapid industrialization, with high population density and constraints of land, it is expected that level of risks arising from the hazardous industries will increase in India in the coming decades. However, 30 years after the Bhopal accident (1984), except a few discrete regulations, there is as yet no integrated system for assessing and managing risks arising out of these hazardous industries in India. The gravity of aspects related to the management of industrial risk still remains crucially important. In particular, there is no standard guideline on risk analysis methodology, acceptability or tolerability criteria, nor is there an accident database or a risk reduction strategy for the areas where risk levels are already high. On top of this, there are technical and legislative gaps in the institutional framework to implement any of the above mentioned issues. With the backdrop of the Bhopal gas tragedy, the objective of this paper is therefore to evaluate the effectiveness of a comprehensive risk assessment framework for the emerging economy of India, in order to control and/or to reduce the risk level that exists. In this context, regulations and policies pertaining to industrial risk assessment were reviewed.     

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.     

Off-site emergency scenario, a case study from a LPG Bottling Plant

After Bhopal disaster, emergency planning in an industrial area has become inevitable. The off-site emergency plan is an integral part of any major hazard control system. Boiling Liquid Expanding Vapour Explosion (BLEVE) leads to fatal consequences. This paper highlights some salient features of the emergency scenario, which ultimately leads to fireball with enormous pressure wave all around.     

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.     

Aftermath of the world''s worst chemical disaster: Bhopal, December 1984

Current practice in preventive environmental health action includes chemical analysis of land, water and air for known (controlled) toxic chemicals and comparison against standards for identification of breaches of regulatory limits. This methodology is also followed after an accident or disaster to ensure air, water and food safety. Some problems, not easily addressed by this methodology include: unidentified toxic chemicals; non-conventional uses of toxic materials, unexpected synergestic effects of toxic mixtures, and human health consequences of exposure to toxic materials with unusual and unidentified pathways of exposures. In Bhopal we were faced with a mixture of about 27 toxic substances, a variety of exposures related to activities of the persons, for example, remaining in their homes or running in the toxic cloud, and a variety of perceived injuries not all of which would have been predicted by analyzing the chemicals involved. In this paper we will present the advantages of combinations of approaches including examination of health, social and cultural environment and economic situation of the victims of the Bhopal disaster and their effect on health. This more broad analysis provides a clearer big picture of the problems in the aftermath of exposure, and also clues to effective treatment and alleviation of future problems. We will present two effective strategies for connecting health problems ten years after exposure to the original disaster, and understanding the biochemical reactions in the body when invaded by a mixture of toxic substances and how such an understanding will in turn affect public policy planning, emergency preparedness and emergency medicine.     

Operational risk assessment: A case of the Bhopal disaster

Accidental releases of hazardous chemicals from process facilities can cause catastrophic consequences. The Bhopal disaster resulting from a combination of inherently unsafe designs and poorly managed operations is a well-known case. Effective risk modeling approaches that provide early warnings are helpful to prevent and control such rare but catastrophic events. Probability estimation of these events is a constant challenge due to the scarcity of directly relevant data. Therefore, precursor-based methods that adopt the Bayesian theorem to update prior judgments on event probabilities using empirical data have been proposed. The updated probabilities are then integrated with consequences of varying severity to produce the risk profile.This paper proposes an operational risk assessment framework, in which a precursor-based Bayesian network approach is used for probability estimation, and loss functions are applied for consequence assessment. The estimated risk profile can be updated continuously given real-time operational data. As process facilities operate, this method integrates a failure-updating mechanism with potential consequences to generate a real-time operational risk profile. The real time risk profile is valuable in activating accident prevention and control strategies. The approach is applied to the Bhopal accident to demonstrate its applicability and effectiveness.     

Export inherent safety NOT risk

The author presents a personal view that production of bulk chemicals and the attendant risks are being transferred from developed to developing nations. Some evidence is presented on the transfer of production. The transferred risk is increased because of the larger scale plants that are now built in locales that are less able to cope with the increased hazards. Bhopal was an example of an inherently unsafe plant, with major hazards that could have been avoided or drastically reduced by design. It behoves the industry to adopt the inherently safer philosophy and practice in the new plants that it builds, in order to minimise the opportunity for another accident like Bhopal and the threat to our industry that such an accident would pose.     

Dynamic modeling and bifurcation analysis for the methyl isocyanate hydrolysis reaction

The aim of this work was to characterize the methyl isocyanate hydrolysis reaction and to identify its operational criteria. The parametric sensitivity and dynamic stability methodologies were performed at the Bhopal disaster circumstances, over the relevant operating parameter space. Stable and unstable conditions, bifurcations points, turning points and oscillatory behavior were determined. The combined methodology give useful guidance on the operative conditions selection and the appropriate strategy to overcome hazardous situations. The obtained results demonstrated high sensitivity to small perturbations (thermal runaway) and prevalent oscillatory behavior. Moreover, the following critical parameters for the studied dynamic system were defined: the inverse residence time of 1.5700103 and the heat transfer coefficient of 752.394.     

For whom does safety pay? The case of major accidents

Government agencies regularly use the argument that ‘safety pays’ as a way of motivating employers to attend to occupational health and safety. This paper looks at the effectiveness of this argument in the case of catastrophic hazards. It suggests that, while it may be true that safety pays in an abstract sense, this is irrelevant unless it can be shown that safety pays for relevant decision makers. All too often it does not. The article illustrates its claims by drawing on the literature on the Zeebrugge, Bhopal and Piper Alpha disasters, as well as on a study of a mine disaster in Australia.     

Risk analysis of a cross-regional toxic chemical disaster by using the integrated mesoscale and microscale consequence analysis model

The rapidly growing capacity and scale of the world's petrochemical industries have forced many plants to have an even larger amount of hazardous substances. Once a serious leak occurs, the outcome of the effect zone could be very large or even uncontrollable just like the Bhopal disaster. In order to assess the risk of a cross-regional damage, this study aims to develop a model that can combine the benefits of both CFD model of the microscale simulation and the Gaussian dispersion model of the mesoscale simulation.The developed integrated model is employed on a toxic chemical tank leak accident of a process plant within an industrial park in order to explore the consequences and the risk of the toxic gas dispersion on three different scopes; one is the accident site, the second is the long-distance transmission route of the mesoscale area and the third is a target city. According to the simulation's results, it is obvious that the complexity of the structure surrounding the leaking tank will eventually affect the maximum ground concentration, the cloud shapes and cloud dilution rate, while the released gas is under dispersion. On the other hand, since the simple Gaussian dispersion model doesn't consider the above impacts, its calculation results will have many differences as compared to the realistic situation. This integrated model can be used as a tool for estimating the risk on a microscale or mesoscale areas and it can produce better results when an environmental impact analysis is required for a larger hazardous chemical process.