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.     

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.     

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.     

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.     

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.     

Toward an integrative approach of the industrial risk management process in France

Management in the field of environmental protection and risk prevention has evolved to the increasing participation of all stakeholders in the decision-making process. It certainly results from the development of the Information society and the global increase of knowledge of the population, combined with the concerns of the populations related to a sustainable development of our civilisation. Our ‘risk society’, following the big industrial disasters (Flixborough,Tchernobyl, Bhopal, Challenger, and more recently Toulouse), has also developed a cautious attitude towards the role of the expertise when it comes to assessing risks, along with a question of the ability of science to give definite answers.

This has lead in particular to the adoption of the Aarhus convention in 1998 and the evolution of several regulations in the developed countries. For example, in France the new law no. 2003–699 of 30 July 2003 about the ‘prevention of the technological and natural risks and to the compensation for the damages’ has introduced an important innovation into the process of technological risks prevention.

This law has enabled the involvement of the stakeholders in the decision-making process related to risk prevention and has urged the development of specific tools to deal with the complexity of risk management issues, in particular for those related to land-use planning.

As technical support to decision-makers in risk management from both public and private sectors, INERIS has played an important role for the evolution of the French risk management system.

This paper describes an analysis on the difficulty to control major accident hazards in an evolving context where the industrial systems becomes more and more complex and where the expectations of the civil society has increased. Then, the authors describe how an integrated vision for industrial risk management has emerged in France and is being implemented in a new law adopted after the Toulouse disaster.     

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.     

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.     

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.     

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.     

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.     

Maintenance-related major accidents: Classification of causes and case study

The potential for major accidents is inherent in most industries that handle or store hazardous substances, for e.g. the hydrocarbon and chemical process industries. Several major accidents have been experienced over the past three decades. Flixborough Disaster (1974), Seveso Disaster (1976), Alexander Kielland Disaster (1980), Bhopal Gas Tragedy (1984), Sandoz Chemical Spill (1986), Piper Alpha Disaster (1988), Philips 66 Disaster (1989), Esso Longford Gas Explosion (1998), Texas City Refinery Explosion (2005), and most recently the Macondo Blowout (2010) are a few examples of accidents with devastating consequences.Causes are being exposed over time, but in recent years maintenance influence tends to be given less attention. However, given that some major accidents are maintenance-related, we intend to concentrate on classifying them to give a better insight into the underlying and contributing causes.High degree of technological and organizational complexity are attributes of these industries, and in order to control the risk, it is common to deploy multiple and independent safety barriers whose integrity cannot be maintained without adequate level of maintenance. However, maintenance may have a negative effect on barrier performance if the execution is incorrect, insufficient, delayed, or excessive. Maintenance can also be the triggering event.The objectives of this article are: (1) To investigate how maintenance impacts the occurrence of major accidents, and (2) To develop classification schemes for causes of maintenance-related major accidents.The paper builds primarily on model-based and empirical approaches, the latter being applied to reports on accident investigation and analysis. Based on this, the Work and Accident Process (WAP) classification scheme was proposed in the paper.     

Responses to accidents in different industrial sectors

Accidents produce external pressures on companies leading to new regulations and renegotiation of enforcement of regulations. Our perspective is institutional with a focus on the extended dialogue among regulators and the industry. The empirical focus is offshore oil and gas production, deep sea and coastal fisheries, and maritime transportation with a segment of older bulk carriers. The findings are that structural characteristics of both the industries and the regulatory regime determine the interactions between the regulated and the regulator. The paper illustrates that in industrial sectors where hazards and risks are visible and of public interest, it is easier to implement regulations through outside pressure from regulators and other stakeholders such as internationally organised unions.     

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.     

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.     

A proposed System of Hierarchical Scorecards to assess the implementation of maritime regulations

The successful implementation of a regulation in the modern complicated world is a major issue for states. A newly introduced regulation may cause conflicts of interest among various parties that are affected. A common conflict is that from one hand, the public demands the introduction of regulations that will increase safety, environmental and security standards while on the other hand industries are concerned about potential costs caused by new regulations. In this paper, the shipping industry, which is a typical example of an international industry, is chosen to carry out a cost and benefit analysis generated from the implementation of a newly introduced regulation. Consequently, a methodology is proposed capable of evaluating the implementation performance of a regulation in the shipping industry with respect to the costs and benefits that can be generated. For a simple and effective computation, a System of Hierarchical Scorecards (SHS) is developed to assist regulators in evaluating any proposed and/or existing regulations.     

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.     

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.     

The unfolding of Bhopal disaster

As an employee of Union Carbide India at the Bhopal plant, I know how the disaster happened. The merciless cost-cutting severely affecting materials of construction, maintenance, training, manpower and morale resulted in the disaster that was waiting to happen. Significant differences between the West Virginia, USA plant and the Bhopal, India plant show the callous disregard of the corporation for the people of the developing countries. The narrative below, if given a proper thought by the management and governments, should help in significantly reducing industrial accidents.