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 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 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.     

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 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 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.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

Applications of thermal hazard analyses on process safety assessments

In 2011, a large petrochemical complex in Taiwan incurred several fire and explosion accidents, which had considerable negative impact for the industry on both environmental and safety issues. Reactive substances are widely used in many chemical industrial fields as an initiator, hardeners, or cross-linking agents of radical polymerization process with unsaturated monomer. However, the unpredictable factors during the process having risk to runaway reaction, thermal explosion, fire, and exposure to harmful toxic chemicals release due to the huge heat and gas products by thermal decomposition could not be removed from the process. This study used differential technology of thermal analysis to characterize the inherent hazard behaviors of azo compounds and organic peroxides in the process, to seek the elimination of the source of the harmful effects and achieve the best process safety practices with zero disaster and sound business continuity plan.     

Quantification of inherent safety aspects of the Dow indices

The Dow fire and explosion index (F&EI) and chemical exposure index (CEI) have been successfully implemented in a Visual Basic environment as a tool for the inherent safety assessment of chemical processes. Subprograms were developed to quantify the inherent safety aspects of the Dow indices. These aspects are presented graphically with the indices on the vertical axis and an inherent safety indicator on the horizontal axis. Dow indices of the MIC storage unit involved in the Bhopal disaster were evaluated to quantify the effects of process temperature, pressure and inventory of hazardous materials on the index values.

As operating pressure was reduced, the F&EI decreased in accordance with the principles of inherent safety. The change in F&EI due to reduction of inventory was more significant than that resulting from pressure reduction. The results show that the F&EI change, given the same range of the independent variables (quantity of hazardous materials, operating temperature and pressure), is larger when a unit in the process area is evaluated compared to a unit in a storage area (tank farm). Reduction of the inventory of hazardous materials had no direct effect on the CEI for vapor releases, whereas the size of the hole diameter impacted the CEI to a great extent. However, there is a significant change in the CEI as the inventory of materials decreases for liquid releases involving temperatures above their flash and boiling points. Pressure reduction decreases the CEI, whereas temperature reduction leads to an increase in the CEI when these parameters are treated independently.     

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.     

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.     

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.     

煤矿企业重大灾害预防与安全保障体系构建与运行评价

为提高煤矿企业重大灾害预防与安全保障能力,以典型煤矿企业为例,深入分析企业重大灾害的孕灾环境与类型,确定诱发煤矿重大灾害事故发生的关键因素,并提出构建以“安全文化理念”为1个核心,涵盖“组织”“制度”“人员”“技术”“信息”“装备”“资金”7个要素以及“危险源预控”和“灾害应急救援”2个关键环节的整体安全保障体系;最后,利用事故树模型和层次分析法评价某典型煤矿企业历年来的灾害事故实际情况,提出相关保障体系的持续优化方案,研究结果可为煤炭行业企业开展重大灾害预防与安全保障体系的设计与构建提供参考和借鉴。