Dr. Rhyddhi Chakraborty Programme Leader (Health and Social Care), London Churchill College, UK Email: rchak2012@gmail.com

What follows is a synopsis of the full article found in featured articles.

Please read the featured article Lesson from Bhopal Gas Tragedy (1983-84) By Dr. Rhyddhi Chakraborty Programme Leader (Health and Social Care), London Churchill College, UK describes in detail the elements of the Bhopal Gas Tragedy


Union Carbide India Limited (UCIL)

In 1970, in the North adjacent to the slums and railway station, a pesticide plant was set up by Union Carbide India Limited (UCIL). From late 1977, the plant started manufacturing Sevin (Carbaryl) by importing primary raw materials, viz. alpha-naphtol and methyl isocyanate (MIC) in stainless steel drums from the Union Carbide's MIC plant in USA. However, from early 1980, the Bhopal plant itself started manufacturing MIC using the know-how and basic designs supplied by Union Carbide Corporation, USA (UCC). The Bhopal UCIL facility housed three underground 68,000 liters liquid MIC storage tanks: E610, E611, and E619 and were claimed to ensure all safety from leakage.

Time Line of Occupational Hazards of the Union Carbide India Limited Plant Leading Before the Disaster

• 1976: Local trade unions complained of pollution within the plant.
• 1980: A worker was reported to have accidentally been splashed with phosgene while carrying out a regular maintenance job of the plant's pipes.
• 1982 (January): A phosgene leak exposed 24 workers, all of whom were admitted to a hospital. Investigation revealed that none of the workers had been ordered to wear protective masks.
• 1982 (February): An MIC leak affected 18 workers.
• 1982 (August): A chemical engineer came into contact with liquid MIC, resulting in burns over 30 percent of his body.
• 1982 (October): In attempting to stop the leak, the MIC supervisor suffered severe chemical burns and two other workers were severely exposed to the gases.
• 1983-1984: There were leaks of MIC, chlorine, monomethylamine, phosgene, and carbon tetrachloride, sometimes in combination.

In early December 1984, most of the Bhopal plant's MIC related safety systems were not functioning and many valves and lines were in poor condition. In addition, several vent gas scrubbers had been out of service as well as the steam boiler, intended to clean the pipes. For the major maintenance work, the MIC production and Sevin were stalled in Bhopal plant since Oct. 22, 1984 and major regular maintenance was ordered to be done during the weekdays’ day shifts.

The Sevin plant, after having been shut down for some time, had been started up again during November but was still running at far below normal capacity. To make the pesticide, carbon tetrachloride is mixed with methyl isocyanate (MIC) and alpha-naphthol, a coffee-colored powder that smells like mothballs. The methyl isocyanate, or MIC, was stored in the three partly buried tanks, each with a 15,000-gallon capacity.

During the late evening hours of December 2, 1984, whilst trying to unclog, water was believed to have entered a side pipe and into Tank E610 containing 42 tons of MIC that had been there since late October. Introduction of water into the tank began a runaway exothermic reaction, which was accelerated by contaminants, high ambient temperatures and other factors, such as the presence of iron from corroding non-stainless steel pipelines.

A Three Hour Time Line of the Disaster

December 3, 1984 12:40 am: A worker, while investigating a leak, stood on a concrete slab above three large, partly buried storage tanks holding the chemical MIC. The slab suddenly began to vibrate beneath him and he witnessed at least a 6 inche thick crack on the slab and heard a loud hissing sound. As he prepared to escape from the leaking gas, he saw gas shoot out of a tall stack connected to the tank, forming a white cloud that drifted over the plant and toward nearby neighborhoods where thousands of residents were sleeping. In short span of time, the leak went out of control.

December 3, 1984 12:45 am: The workers were aware of the enormity of the accident. They began to panic both because of the choking fumes, they said, and because of their realization that things were out of control; the concrete over the tanks cracked as MIC turned from liquid to gas and shot out the stack, forming a white cloud. Part of it hung over the factory, the rest began to drift toward the sleeping neighborhoods nearby.

December 3, 1984 12:50 am: The public siren briefly sounded and was quickly turned off, as per company procedure meant to avoid alarming the public around the factory over tiny leaks. Workers, meanwhile, evacuated the UCIL plant. The control room operator then turned on the vent gas scrubber, a device designed to neutralize escaping toxic gas. The scrubber had been under maintenance; the flow meter indicated there was no caustic soda flowing into the device. It was not clear to him whether there was actually no caustic soda in the system or whether the meter was broken. Broken gauges were not unusual at the factory. In fact, the gas was not being neutralized but was shooting out the vent scrubber stack and settling over the plant.

December 3, 1984 1: 15- 1:30 am: At Bhopal’s 1,200-bed Hamidia Hospital, the first patient with eye trouble reported. Within five minutes, there were a thousand patients. Calls to the UCIL plant by police were twice assured that "everything is OK", and on the last attempt made, "we don't know what has happened, sir". In the plant, meanwhile, MIC began to engulf the control room and the adjoining offices.

December 3, 1984 3:00 am: The factory manager, arrived at the plant and sent a man to tell the police about the accident because the phones were out of order. The police were not told earlier because the company management had an informal policy of not involving the local authorities in gas leaks. Meanwhile, people were dying by the hundreds outside the factory. Some died in their sleep. Others ran into the cloud, breathing in more and more gas and dropping dead in their tracks.

Immediate Consequences

With the lack of timely information exchange between Union Carbide India Limited (UCIL) and Bhopal authorities, the city's Hamidia Hospital was first told that the gas leak was suspected to be ammonia, then phosgene. They were then told that it was methyl isocyanate (MIC), which hospital staff had never heard of, had no antidote for, and received no immediate information about. The gas cloud, composed mainly of materials denser than air, stayed close to the ground and spread in the southeasterly direction affecting the nearby communities. Most city residents who were exposed to the MIC gas were first made aware of the leak by exposure to the gas itself.

Subsequent Actions

Formal statements were issued that air, water, vegetation and foodstuffs were safe, but warned not to consume fish. The number of children exposed to the gases was at least 200,000. Within weeks, the State Government established a number of hospitals, clinics and mobile units in the gas-affected area to treat the victims.

Legal proceedings involving UCC, the United States and Indian governments, local Bhopal authorities, and the disaster victims started immediately after the catastrophe. The Indian Government passed the Bhopal Gas Leak Act in March 1985, allowing the Government of India to act as the legal representative for victims of the disaster, leading to the beginning of legal proceedings.

Initial lawsuits were generated in the United States federal court system in April 1985. Eventually, in an out-of-court settlement reached in February 1989, Union Carbide agreed to pay US$470 million for damages caused in the Bhopal disaster. The amount was immediately paid.

Post-settlement activity

UCC chairman and CEO Warren Anderson was arrested and released on bail by the Madhya Pradesh Police in Bhopal on 7 December 1984. Anderson was taken to UCC's house after which he was released six hours later on $2,100 bail and flown out on a government plane. Anderson, eight other executives and two company affiliates with homicide charges were required to appear in Indian court.

In response, Union Carbide said the company is not under Indian jurisdiction. In 1991, the local Bhopal authorities charged Anderson, who had retired in 1986, with manslaughter, a crime that carries a maximum penalty of 10 years in prison. He was declared a fugitive from justice by the Chief Judicial Magistrate of Bhopal on 1 February 1992 for failing to appear at the court hearings in a culpable homicide case in which he was named the chief defendant. Orders were passed to the Government of India to press for an extradition from the United States. From 2014, Dow is a named respondent in a number of ongoing cases arising from Union Carbide’s business in Bhopal.

A US Federal class action litigation, Sahu v. Union Carbide and Warren Anderson, had been filed in 1999 under the U.S. Alien Torts Claims Act (ATCA), which provides for civil remedies for "crimes against humanity." It sought damages for personal injury, medical monitoring and injunctive relief in the form of clean-up of the drinking water supplies for residential areas near the Bhopal plant. The lawsuit was dismissed in 2012 and subsequent appeal denied. Anderson died in 2014.

Long-term Health Effects

A total of 36 wards were marked by the authorities as being "gas affected," affecting a population of 520,000. Of these, 200,000 were below 15 years of age, and 3,000 were pregnant women. The official immediate death toll was 2,259, and in 1991, 3,928 deaths had been officially certified. The government of Madhya Pradesh confirmed a total of 3,787 deaths related to the gas release. Later, the affected area was expanded to include 700,000 citizens. A government affidavit in 2006 stated the leak caused 558,125 injuries including 38,478 temporary partial injuries and approximately 3,900 severely and permanently disabling injuries.

Ethical Negligence

The Corporate Negligence Argument: This point of view argues that management (and to some extent, local government) underinvested in safety, which allowed for a dangerous working environment to develop.

Safety audits: In September 1984, an internal UCC report on the West Virginia plant in the USA revealed a number of defects and malfunctions. It warned that "a runaway reaction could occur in the MIC unit storage tanks, and that the planned response would not be timely or effective enough to prevent catastrophic failure of the tanks". This report was never forwarded to the Bhopal plant, although the main design was the same.

The Disgruntled Employee Sabotage Argument: Now owned by Dow Chemical Company, Union Carbide maintains a website dedicated to the tragedy and claims that the incident was the result of sabotage, stating that sufficient safety systems were in place and operative to prevent the intrusion of water.


As you read and analyze this case study, your reflective comments are requested on all of the following:

  • Who are the stakeholders and how are they impacted both positively and negatively?
  • What knowledge and skills are needed to implement sophisticated, appropriate, and workable solutions to the complex global problems facing the world today?
  • What interdisciplinary perspectives would help identify innovative and non-obvious solutions?
  • What insights can you articulate, based on your culture and other cultures with which you are familiar, to help understand your worldview and enable greater civic engagement?
  • What is your position on the right thing(s) to do?

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  • In this unfortunate tragedy, I would say the stakeholders of this event were the local Indian government, Union Carbide India Limited (UCIL), and Union Carbide Corporation (UCC). I say these parties because they all had a part in this unfortunate event. The local Indian government and management of the corporation poorly invested in safety concerns which allowed for this leak to even occur. The UCC failed to make aware of the poor safety audit completed on a different plant and forward it to Bhopal plant. To implement sophisticated and workable solutions to global complex problems, good practice of ethics must be attained. Without a good practice of ethics, tragedies such as this gas leak India can happen. Obviously there are ones who take account for this tragedy by not prioritizing safety in a plant which is ridiculous when talking about a plant which deals with toxic gasses which can injure and kill people. Number one I’d say to help innovative and non-obvious solutions is to first ask why the situation occurred and nobody prevented it. Then you have possible answers such as proper safety and ethics knowledge wasn’t required to be part of management and even the local government. I think making sure the people of power have great knowledge in the importance of ethics and safety. One concept my culture stresses importance on is the idea that a chain is only as strong as the weakest link. With that being said making sure the weakest link is strong is of much importance and when you talk about real life, it means educating the uneducated. This is so they have the knowledge to see things such as what happened in this tragedy and get ahead of it before many casualties. I think that’s the best approach to preventing cases like this from happening because I believe knowledge is one of the most important things a person can have because without knowledge tragedies can happen.
  • The stakeholders in this disaster included millions of people around the world. Including UCC (shareholders, employees, and management), UCIL (shareholders, employees, and management), the US government, the Indian government, as well as all of the workers and residents in Bhopal. The UCC and UCIL companies faced major lawsuits as well as criminal charges, however there were law changes to uphold environmental and ethical standards moving forward. The governments of The United States and India faced tension from the leading causes and aftermath of the leakage. Finally, the citizens of Bhopal who were struck with deadly toxins with no warning and no prevention measures. The Bhopal area will be stained with toxic pollution for many years to come. There must be ethical standards that are globally recognized and taught in order to maintain safety for humanity and the environment. Politicians must accept these standards as non-negotiable and engineers must be knowledgeable and persistent in their communication to leadership. Having input from company leaders, architects, political leaders, local dwellers, engineers, and environmentalists will create a well rounded view on problems, solutions, and future impacts.It must be understood that other countries and governments do not uphold the same economic, social, and environmental standards that the US and other leading countries hold. This fact does not excuse lowering those standards when companies outsource factories. The US holds influence over other countries’ future regulations and trends. Once we show them that we will proudly support ethical standards, then other countries will follow suit, forced by public opinion or in the presuit to match our economical success.
    As a comment towards Lolo. I understand the specific view that you took on this case. However, I would argue that the workers and citizens that died and were injured in this disaster are not just collateral damage or means to an end, but they themselves are stakeholders in this case. These people had so much to gain from such a big refinery being brought into their town, but the risk caught up to them as well through lack of knowledge and precaution.
  • The stakeholders in this tragedy were Union Carbide Corporation (UCC), Union Carbide India Limited (UCIL), the Indian government, company workers, hospital workers, and the local citizens in Bhopal. There were no positive impacts for any associated party; thousands of people died and tens of thousands were seriously injured, and hundreds of thousands were hurt or affected in some way by the carelessness of UCC and UCIL. To implement the required solutions to the world’s complex problems, people in power must have strong intuition and careful contingency plans for when things go wrong. Also, people who are not in authority must still speak up and call out those who may be hurting others, or are allowing possible dangerous situations to exist. The workers could have tried to draw enough attention to the accidents before the major gas leak to force management to make legitimate safety regulations to protect each other and the locals from more chemical dangers. There should have been safety engineers on call at the plant, making sure that the equipment and machines were working properly to minimize any risk of a safety breach. In American culture we have come around as a society to shun and shame these types of ignorant managers and CEOs, and we look back shamefully on our own history like during the Gilded Age and the Great Depression, when employers and company owners treated workers as fodder instead of human beings. The right thing to do is to treat workers with respect and dignity. There’s a book I love called “The Way of the Shepherd,” and it compares leading people to being a shepherd, and shows how a leader should care deeply about each of his or her followers (which also applies to CEOs/managers and their employees). You don’t need to be best friends or get along perfectly with everyone who works for/with you, but as a leader you must hold yourself to high standards of honor and integrity, and take care of those under your lead.
  • The stakeholders in this case study are Union Carbide India Limited and Union Carbide
    Corporation. The mismanagement of the plant by CEO Warren Anderson, accompanied by some
    of the executives and 2 company affiliates had enormous consequences that resulted in devastating
    results such as thousands of worker injuries and deaths. If the managers had been more competent,
    such a disaster could have been avoided, but the safety measures in the factory had not been
    respected. They could have been beefing up machinery and providing employees with appropriate
    personal protective equipment. On the other hand, some employees testified that they had been
    exposed to phosgene leaks in the factory, and none of them had been ordered to wear protective
    masks. The interdisciplinary perspective that would identify solutions, in this case, is
    communication. It would be necessary to put in place a lot of tests before declaring that a factory
    is functional. If the person in charge had set up alarms to alert the employees of the danger, he
    should not have hurt so much. For me, I think that we should not make people work in these kinds
    of conditions knowing that the factory presents a danger to the lives of the employees. The right
    thing to do is always to follow the engineering code of ethics, putting the public's safety, health,
    and welfare first.
    • True there were thousands of worker injuries and deaths, but don't forget about the innocent Bhopal residents who were killed. I think you're spot on about communication, it seems like either the workers hardly reported the incidents or the managers deliberately ignored them. There's good reason why we have the engineering code of ethics, and this is a prime example of exactly why we need them.
  • The main stakeholders of this event were the indian government, UCC, and UCIL. There were only negative consequences to this event, but these were well deserved. This event caused the death and injuries of thousands and thousands of civilians which as engineers its the one thing we are trying to avoid. This event was avoidable if the plant focused more on keeping everything safe not only for the workers but for the civilians that were right next to them. The ATCA was a needed solution for this problem because before any further actions can be done they have to clear up the mistake that had been made. There are many changes that need to be done one of these being better communication. The fact that the authorities were not contacted at the start of it all shows the lack of communication. There should be many inspections done when it comes to dealing with this type of machinery. Something this dangerous requires safety inspections and knowledge on how to use them properly. The rules to using these machines should be clear and strict because it endangers the lives of many innocent people. It is expected that after a catastrophic event like this that there is a change in how things are done in order to keep the world safe. Some interdisciplinary perspectives that should be accounted for are definitely from the engineers. They had to work with these machines everyday which makes it their duty to offer any solutions that can be done to the machine to make it safer. Some other perspectives should be from the safety inspectors. They saw and studied these machines to make sure that they were safe. I believe that the right thing to do would be to hold on any activity done at the plant. During this time the employees at this plant should be reconsidered in order to make sure that they will do the right thing. Any old machinery should be replaced with better and safer machines. A new safety protocol should be put in place that would inform everyone of the right and wrong things to do. The number one rule that should be put in place should be “Keep everyone safe” and do anything possible in order to follow this rule.
  • The Bhopal Gas Tragedy took place in Bhopal, India on December 3, 1984. The tragic incident was the result of a major chemical leak on a plant ran by the United States company titled Union Carbide. The plant was manufacturing pesticides from necessary toxic chemicals such as carbon tetrachloride, methyl isocyanate, and alpha-naphthol. The gas and chemical leak affected a population of 520,000 people and killed roughly 4,000 individuals.
    The Bhopal Incident was a terrible tragedy and negatively affected almost every stakeholder involved. The stakeholders involved in the incident included the employees working at the plant during the spill, the men, women, and children of Bhopal India who were exposed to the airborne chemicals, Warren Anderson (the CEO of Union Carbide), and the government of India.
    Tragedies like the Bhopal incident are very common instances all across the world, especially in less developed countries. It is a factual statement that U.S. companies can develop products, commodities, and other goods for far cheaper in foreign countries with tempered labor laws and regulations. Many U.S. companies seem to prey on these less expensive alternatives in order to reduce manufacturing costs in hopes to gain a larger profit. It would be greatly beneficial for companies such as Union Carbide to stop placing the value of cost/benefit ratios over the cost of human lives. Whenever money is removed from the equation, the haze between right and wrong seems to be lifted. Companies in the U.S. dealing with foreign operating locations should, at the least, be held responsible for practicing the same safety regulations as in the United States. This would require a multitude of worldwide lawsuits that more than likely could never be pushed through without some form of globalization. The “American Dream” is undeniably held up by pillars of regulations and accountability, companies that find loopholes disregarding these ideas fall short of ethical ideology.
    It seems almost unrealistic to be able to fix the global-wide conflict of simple ethical challenges, but one would believe that there is a slim chance. A federal organization would almost have to be created in order to perform this idea. All of the U.S. companies tied to foreign operations would have to be held responsible for reporting information of soon-to-be-built foreign plants to the organization. The organization would then be responsible for performing checkups on all U.S businesses in foreign countries and holding them to the U.S regulatory standards. This is the only way one would think true change could be made.
    The difference between right and wrong seems to be a very simple idea. The idea can become very complex as more views are considered valuable. Personally, I find the difference between right and wrong fairly simple. I have a religious background, and my beliefs largely affect the decisions I make. I find it wrong to put any individual in the way of harm but find it right to do things for a good cause. If the decision I make benefits the well-being of myself and others, I consider it good. If the decision I make is based on deceit and promotes, dishonestly, harm, or death to anyone I consider it bad.
  • The Bhopal Gas Tragedy impacted several different parties negatively and positively when it was up and running. The parties that were the leading cause of the tragedy were the Union Carbide Corporation, Union Carbide India Limited (UCIL), and the Government officials that allowed the plant to continue its operation despite its failure to keep workers safe. Parties affected negatively by the incident were the employees and their families and the residents living in the surrounding areas. Thousands of residents were killed, many more injured, and it could have all been avoided if the UCIL had followed appropriate safety measures.
    As reported in the case study, the UCIL plant was similar to the Union Carbide plant, so it should also need mechanical and chemical engineers to oversee the plant's operations to ensure that all safety precautions were functioning correctly. However, they did not, so this responsibility would fall on the Plant Manager, who didn't even arrive until 3 hours after the first signs of a problem presented. The plant's safety record reflects the plant manager's complete disregard for safety protocols. Occupational hazards range from simple safety precautions like wearing a mask to the poorly maintained pipes and wires that ran through the facility.
    I believe that if the UCIL supervisors and management had followed these procedures, then this tragedy and the others that occurred up to it would have never happened, and the residents of the surrounding areas would never have been in harm's way either.
  • The stakeholders are the Union Carbide India Limited plant employees, Union Carbide executives, the Union Carbine consumers, Indian government officials, United States government officials, local government officials, local emergency services, and the nearby communities. In the Bhopal Gas Tragedy everyone was impacted negatively. Union Carbide lost production, employees, customers, a plant, and had to make a $490 million dollar settlement. The effects of the gas on the plant employees and nearby communities lead to a combined 700,000 injured and 4,000 dead. The local emergency services and government were unprepared and slow to act as a result of Union Carbide India Limited not properly disclosing the situation. The Indian and United States Governments spent valuable time and resources on civil proceedings, criminal proceedings, extradition.
    Going forward, the proper skills and knowledge necessary would include knowledge of the current plant condition, the dangers posed by the plant, proper maintenance of the plant, and the skills to respond to the dangers of the plant. The first three would all be vital to avoid another tragedy with proactive maintenance and emergency response. The last two would be vital for emergency services and local authorities to properly respond to any disasters at the plant.
    For a plant that produces pesticides the proper disciplines needed are mechanical, computational, electrical, industrial, chemical, and civil engineering along with certified professionals in the medical, legal, and environmental fields. The engineers need to work together to design the plant and process so that it's products are safe for the workers and consumers and that any dangers posed by the plant are identified so they can be properly dealt with. Medical, Legal, and Environmental professionals need to work together to identify and report any potential safety, legal, or environmental dangers the plant poses and disclose all information of these dangers to the engineers, local emergency services, and authorities.
    Reading this, my insight of the Bhopal Gas Tragedy was that it was a preventable disaster caused by negligence. The fact that not only did the Union Carbide plant not disclose the severity of the disaster to the authorities, there were numerous measuring and safety systems still out of order after months of maintenance, but that there was a documented buildup of problems related to the disaster is horrifying.
    I would say in response to this tragedy the right thing to do would be for Union Carbide to provide relief to the workers and communities that were affected, enact procedure and oversight to keep plant condition and employee safety training at peak, and in the future disclose any dangers immediately to the local authorities so they can prepare accordingly. The Indian government should increase oversight and be more stringent with safety regulations. Then for the people responsible for letting the plant fall into disarray be tried accordingly.
  • In the Bhopal Gas Tragedy, the stakeholders of this situation are the Union Carbide's MIC, Union Carbide India Limited (UCIL), Union Carbide Corporation, USA (UCC), and the Bhopal UCIL, the hospital workers, and the city residents. When looking at the positives and negatives, the negatives easily out way the positives. Right out the gate you see the UCIL had to deal with many dangerous leaks involving phosgene and methyl isocyanate (MIC). Another significant action was the settlement payout the Union Carbine Corporation had to make of 470 million dollars to cover the whole situation. The lives lost and the outcome for everyone adds to the negatives.

    Looking at ways to prevent this from happening or having control over the situation are pretty straightforward. If the people in charge took it seriously and a better protocol was in place, lives would’ve been saved and the outcome could become less severe or even avoided. The second aspect that needs to significantly improve would be the communication between everyone. From reporting the troubles of things not meeting guidelines in the factory leading up tragedy and in the moment of everything going on. With better communication, the containment and control of everything would’ve been far better.

    Flowing into interdisciplinary perspectives that would help identify innovative and non-obvious solutions, starting with the people involved everyday would be a good place to focus. The structure of the equipment and building goes on the hands of the mechanical/civil engineers. The levels of the chemicals and toxicity are on the the chemical engineers. The people that relay messages are critical so action can be taken in any manner. If all these things were kept at guidelines and rules were followed through ethics laws, all this could’ve been avoided.

    Insight I can add is the first thing that should always be at the top is following the Engineering Ethics Laws. If that was done here, things could’ve definitely been better. You have to put aside money or pride and focus on the bigger picture of everything and everyone’s safety.

    When looking at the big picture, I would just keep everything up to date. Make sure all guidelines are followed and the efficiency for the company is sustainable. If it gets bad enough, you have to do what’s right for everyone and just shut everything down until it’s safe again.
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