Case Study: Bhopal Gas Tragedy (1983-84)

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

Background

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.

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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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Comments

  • There are multiple stakeholders involved in this disaster, Union Carbide Corporation (UCC), Union Carbide India Limited (UCIL), the companies’ employees, Indian and US governments, and citizens of Bhopal. This gas tragedy did not have a single positive impact on any of these stakeholders. Although before the tragedy these companies did have a positive impact as they created many jobs for many citizens in Bhopal, thus positively affecting the economy. After the tragedy, there was a great negative impact on all stakeholders. The gas leak causes Bhopal employees to lose their job if they did not yet lose their life due to exposure to gas. Hundreds of thousands of people lost their lives or were injured. Because this company had employees working with hazardous chemicals, there need to be regulatory safety checks. This should assess that the employees and company are taking all safety precaution to prevent any sort of accident or damage to occur. The employees need to be properly trained on all the chemicals and equipment they are working with; they also need about what could happen if they do not take precautions. And what to do if something were to not follow safety guidelines. This would need to be enforced on a day-to-day basis and there should be a supervisor and employees whose specific job is to implement and enforce safety. Companies should be hiring qualified employees who are educated engineers. A way to create greater civic engagement could be constantly promoting it as a company and teaching the employees the ethical responsibility they carry. I believe good morals were taught to me from a Christian standpoint to always care about the well-being of others and put that before any profit that one could make. Since this plant did not make safety a priority, my position of the right thing to do would be to educate myself on safety hazards and guidelines to follow. I would then look out for these hazards and follow the guidelines. If there was anything unsafe or that could possibly cause damage, I would bring attention to it and do everything I can to keep people safe. I would also encourage the employees around me to do the same.
  • In the Bhopal Gas Tragedy case study it is clear that an absence of ethical responsibility occurred and created a horrendous event which in turn created new laws and safety systems. The stakeholders in this case study are Union Carbide India Limited (UCIL), Warren Anderson the CEO and UCC chairman of UCIL, the United States government, the Indian government, the workers of the Bhopal plant, and the citizens which lived near the Bhopal plant. In this case study each stakeholder was negatively affected by either health issues which occurred due to the negligence, or by the legal proceeding which occurred as a result of the tragedy. In the world today corruption and unethical activity has become more common, and unfortunately has become common. To battle against the unethical nature of our current culture it requires first and foremost that people and engineers especially take ethics in a serious manner. Having the knowledge between what is ethical and what is not is the next step and providing people with a moral compass that they can rely on in difficult situations. Another skill is being patient and detail oriented to find places in which an issue or malfunction could occur in products and projects. Lastly being firm in a person’s ethical nature when unethical opportunities are presented allow for safe outcomes. While doing what is right is not easy, it is important and required if the world can safely function. Providing people with the simple tools to make the right choice allow for workable, appropriate, and sophisticated solutions in the ever-changing world. By allow people to take a simple look at varying issues, new and innovative solutions can be achieved. Allowing for different disciplines to debate issues allow for different perspectives and therefore different solutions. Culturally it has been my experience that all it takes is one person to make the right and ethical decision for others to join and also make such decisions. Also people bring all kinds of different perspectives and by hearing and learning from them, people can then make decisions as they better understand how decisions can impact different people. The right thing to do is to place life and people above financial concerns and other such issues. Human life is the most precious thing on earth and therefore should be protected at all costs. The right thing to do is not determined by what you can gain but by how you can help others and make the world a better place than it was before.
    • I agree that having the knowledge of what is ethical and was itsn't, is an important factor in creating a person's moral compass. This can be taught on a more specific level when training employees. Providing the employees with specific situations they could encounter in their workplace and teaching them what is the ethical thing to do can make it a quick thought for them when working and leave less room for mistakes. Thus, also adding to and building their moral compass.
  • In this paper, the main stakeholders are the Union Carbide India Limited, the Bhopal plant, workers in the plants, Bhopal authorities, and the United States and Indian governments. As you read the paper, you can agree that there was not a positive aspect of this incident. However, the only positive thing that can be drawn from this tragedy is that the area affected was expanded to include more citizens after being repaired. Moving on to the skills and knowledge required in order to prevent these types of accidents, it is important to value the safety guidelines provided in each plant. This means that guidelines need to be followed and respected as they are made to prevent accidents like this one. In addition to this, workers need to be presented with information regarding accidents in order to ensure immediate response and prevent bigger problems. In terms of interdisciplinary perspectives, research and projects are easy solutions that can improve safety and performance in plants, which means avoiding incidents where workers and the population may be affected.
    Regarding insights on how to enable greater civic engagement, I believe that when it comes to engineering, the best solutions come from different cultures and minds. This means that having a working community that works together will allow room for greater success and improvement in general. My position when it comes to doing the right thing is to always follow the guidelines and rules presented. I strongly believe that everything is done for a reason and we have to follow these guidelines in order to prevent access and promote success.
  • The stakeholders for the Bhopal gas tragedy are Union Carbide, UCIL workers, US government and Indian government, Bophal locals and Bophal authorities. I would argue that no one was affected positively by the incident. A plausible argument could be made that Union Carbide had a positive monetary benefit from operating in a developing country before the incident, however after the incident the company experienced a net negative impact.
    For starters, Union Carbide paid 470$ million dollars, was forced to clean up their own mess to an extent and has a damaged reputation. UCIL workers were both exposed to and failed to act ethically to the incident. The U.S. government spent years litigating and covering for a company with unethical practices. The Indian government had to both represent the victims in court and had to perform a costly cleanup and disaster response to the incident. The Bhopal authorities had to respond to the incident, and many medical workers were exposed. Most of all, the Bhopal residents suffered 4,000 confirmed deaths(20,000 theorized by other sources), 500,000 injuries, 700,000 exposed citizens and a polluted community to this day.
    Adequate practices need to be implemented in all areas of risk. Proper ethics need to be practiced. Although not a knowledge or skill, I think U.S. companies should be held liable for incidents at U.S. facilities overseas, even if it means extraditing citizens to face justice in foriegn courts.
    The only way to identify innovative solutions is to spend resources on research and development.
    As an engineering major, my insights tell me that equipment failure is not spontaneous and often has many warnings beforehand. My insights also tell me that if there are people to be held accountable for negligence, there would be less negligence for the fear of actually being held accountable.
    My position on the right thing is that the opportunity to do the right thing has passed. Union Carbide was clearly not practicing safe and ethical procedures at this plant. Many events that foreshadowed the disaster would have been outrageous at home. In addition the company policy to not alarm the public and turn off the alarm was likely the worst decision made. Although it is ambiguous as to how much blame the UCIL workers have to bear, they are not completely innocent in this. The company's lack of exchange with the authorities led to an improper response. The right thing would have been for Union Carbide to have practiced safety procedures abroad as though they were at home. The right thing to do, would have been to both notify the public and be transparent with local authorities about what had happened. In theory, UCIL workers could have chosen to keep the alarm on and notify the public. Although the opportunity to do the right thing has passed, there still exists a need to do a cleanup of the area, and provide health care to both the affected and the descendants of the affected.
    • I agree with you on most of what you commented about the tragedy. However, regarding the right thing to do, I believe that mistakes will always happen and the right thing to do is to evaluate those mistakes in order to ensure success in the future and to avoid more incidents. It is true that they did not practice safe and ethical procedures at the plant, but the best thing they can do is start practicing them from now on and ensure that it does not happen again.
  • 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.
    • I liked your statement comparing a leader to a shepherd, and how a leader must have respect and dignity toward others. I agree that a leader must hold themselves to a high standard and uphold the integrity and honor they try to imbue in others. Overall I thought you had great thoughts on the case study, and I agree with how leaders must act if the right thing is to be done. I will now need to read “The Way of the Shepherd”.
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