response to large scale sudden disasters has lagged behind …€¦ · · 2017-11-15lessons from...

Lessons Learned – Bhopal

Lessons from theBhopal Disaster:

Part I8 HazMat Responder World Spring 2012

Dr Efraim Laor looks atthe incidents ofDecember 1984 inBhopal, India, and askshow relevant the lessonslearnt from them are now

Response to large scale sudden disasters has lagged behind other research fields ©Daniel Berehulak


9Spring 2012 HazMat Responder World

One might wonder why the field of response to LSSDs (Large-Scale,Sudden Disasters) has been at such an inferior stage of evolution, interms of its attendant research, theory, coping mechanisms, training andprofessional personnel. It is my contention that the main obstacle toviable responses to LSSDs remains problem recognition. More precisely, itis the lack of our leaders' courage to face the literal reality of LSSDs andto have faith in their competence to cope with unpleasant consequences.This means that leaders and officials need to alter their states of mind,and realise that we live under the weight of a constant and fundamentalthreat. LSSDs will strike in the future, there is no doubt about that.Nothing should be consigned to fate or force majeure; indeed, many ofthe disasters we will face will be man-made. While there is no reason towaive technological progress, nor abandon the benefits of nuclear,biological and chemical substances, authorities cannot absolvethemselves of their responsibility to act rapidly, competently and savelives when disaster does strike. The penalty for a reluctance to takeappropriate measures will be enormously high, moreover intolerable.Furthermore, leaders must acknowledge the failings of previousadministrative attempts to cope with LSSDs, in spite of the fact thatsome irresponsible authorities continue to convince the public thatpreviously implemented responses were the most feasible ones availableat the time. The authorities must, today, be convinced that a viablealternative exists. In addition, persons of authority need to realise thatevacuation, notwithstanding its high social and economic costs, is oftena Hobson's choice with regard to large-scale crisis response, even in theevent of a permanent evacuation. In all the human cases studied naturalinstinct has, generally speaking, led people to take evacuative measures.It would, therefore, be wise for the authorities to support it.

BHOPAL: THE CONSEQUENCES OF INCREDULITY, INDECISION AND INACTIONThis chapter is comprised of two principal parts. Part I briefly familiarisesthe reader with the background of the Bhopal disaster. It alsodemonstrates that all parties involved made numerous mistakes, whichintensified the presence of the ‘Disaster Triad’ and, at the same time,refrained from taking appropriate precautions, so that the plant was, infact, a time bomb waiting to explode at an unforeseeable time. Part IIexplores the patterns of response to the accident from many angles,namely: the local community; the Indian authorities; the US parentcompany, Union Carbide Corporation (UCC), and its Indian subsidiary,Union Carbide India Limited (UCIL); as well as the internationalcommunity. This section describes and analyses the performance of therelief services. It also emphasises the inherent weakness of the Indianresponse, in terms of rescuing large populations under extremecircumstances, as well as the fragility of developing nations with regardto tackling large-scale and sudden chemical accidents.

PART I: BACKGROUND In 1969, UCC set up a small plant in Bhopal, the capital of MadhyaPradesh, India, to develop a range of pesticides and herbicides derivedfrom a carbyl base. The process of carbyl manufacture begins with thereaction of carbon monoxide with chlorine to yield the intermediatephosgene. Among the products derived from phosgene is methylisocyanate (MIC), created when phosgene reacts withmonomethylamine. This was the principal gas (but not the only one)involved in the Bhopal accident.

In the final stage, MIC reacts with alpha naphthol to producecarbaryl. Different concentrations of carbaryl are used to formulate theend product under the brand name Sevin. For further information onmethyl isocyanate, see Martin Abraham, The Lessons of Bhopal: ACommunity Action Resource Manual on Hazardous Technologies, IOCU(International Organization of Consumers Unions), Penang, Malaysia;September, 1985; pp., 49-50.

The Carbide plant was located close to a residential neighbourhoodand roughly one and a half kilometers from a major railway station. Theplant, the water conduits and the roads that accompanied it attractedsquatters who had no other place to go. Most of these people worked asunskilled labourers at construction sites or performed service jobs. Thebuild-up of the population around a potential disaster agent did,eventually, alert the proper authorities. In 1975, when the MIC facilitywas in the midst of construction, M.N. Buch, administrator of themunicipal corporation, recommended in the Bhopal Development Planthat the plant be removed. Instead, Mr. Buch was removed and the plantremained. Carbide received a go-ahead from the central government (theMinistry of Industries and Civil Supplies) and continued construction ofthe MIC unit close to large concentrations of people, even though analternative site was available (in fact, sixteen smaller industries wererelocated to a new region, roughly 25 kilometers from the city). Thisproblem was compounded by large population growth in Bhopal. Thenumber of residents increased threefold between the time the UnionCarbide plant was first set up and the year of the accident – from justover 300,000 to close to 900,000 – largely due to a constant influx ofjob-seekers. Narrow interests reinforced the tendency of authorities toignore the potential for disaster. The managers of the MIC plant wereattracted by the availability of low-cost labourers, the unions favored theshort journey to work, local officials were happy with tax revenues and itwas suggested that factory inspectors enjoyed the handouts they gotfrom the company they were supposed to oversee. UCIL and the MadhyaPradesh state government had numerous links, which prevented officialsfrom taking steps against the company and encouraged them to ignorethe forewarnings. For instance, the company made a contribution of10,000 Rupees to a development project in Chief Minister, Arjun Singh.Other interests were more personal:, relatives of several ministers andsenior bureaucrats of the local and central governments were on thecompany's payroll, such as the former Inspector General of police and thenephew of a former minister. Union Carbide kept the local ‘Netajis’

10 HazMat Responder World Spring 2012

[officials] happy by placing its luxuriousguesthouse in the exclusive Shamla Hills atthe disposal of Arjun Singh and other high-ranking visitors. The guesthouse was thescene of a Congress Party regional meeting in1983, roughly one year prior to the accident.High state officials and politicians from NewDelhi stayed there during visits to Bhopal. Inessence, chaotic town planning, unchecked

urban growth, severe shortcomings in thephysical infrastructure and irresponsibleauthorities who ignored forewarnings allcontributed to the magnitude of animpending disaster.

Sequence of EventsMIC, a toxic and highly volatile compound,reacts violently with water. To ensure

maximum dehydration, the chemical is storedunder pressure and protected by dry nitrogen.Although Indian engineers wanted to designthe plant without MIC storage (so that itwould be used without delay in manufacturingthe end product) the parent company vetoedthe idea, thereby intensifying the proximity ofthe disaster agent to the population. The MICwas stored in two of three tanks, 40 feet long


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and 8 feet in diameter, code numbered E610, E611 and E619. Each had astorage capacity of between 41 tons and 43 tons of MIC. The third was areserve tank that was meant to be kept empty or to store materials inthe event of an emergency in either of the other tanks. On 2 December,1984, at roughly 21:30, workmen began washing out four gas linesdownstream of the MIC storage area. The operator concerned startedpumping water under high pressure into the line. He noticed that, "Theoutflow of bleeder valves on these four lines was not releasing water atthe same rate it was being pumped in". The worker reported the problemto his supervisor. Notwithstanding these indications of trouble, he wasinstructed to continue washing the pipelines. At 23:30, the operatingstaff in the utility area sensed a little irritation in their eyes because of asmall MIC leak. However, this did not alert them because tiny leaks hadbeen common. It was roughly midnight before the operators around theMIC unit also sensed the leak and they reported it to the shift manager,Shakeel Ibrahim Qureshi. At the same time, Suman Dey, the MIC controlroom operator, reported to Qureshi that the pressure in tank E610 wasunusually high. A few minutes after midnight, Qureshi and the operatorchecked tank E610 and found that the rupture disc, a device that burstswhen the pressure reaches 40 psi, had indeed burst and the safety valve,which is the next check point, had popped. It was not until at least 00:30that the water washing the pipes was turned off, but at that point thedamage was already done. At this time, the 75 workers of the night shiftevacuated the plant and all of them survived. Between 00:30 and 02:00,tank E610 leaked and released immense quantities of deadly materialsinto the air. The cloud contained methyl isocyanate (MIC), phosgene,cyanide (apparently) as well as 25 other materials that are poisonous andlethal to humans. The density of the gas (2.2 times heavier than air),combined with the low surface and air temperatures (about 13-15degrees Celsius), caused the cloud to move slowly and remain close tothe ground. Within a short time, people and animals in the path of thecloud died of cardiopulmonary edema (accumulation of fluid in thelungs) and thousands of others suffered various degrees of respiratory,nervous and ocular damage, depending on their proximity to the gascloud. This incident ultimately sent thousands to their death and causedhundreds of thousands to suffer chronic sickness and misery. Atapproximately 00:45, people living in Jayaprakash Nagar (100 metressouth of the plant) woke up feeling asphyxiated, their eyes and throatsstinging. They rushed out into the open to find the air outside even moreunbreathable. Panicking, they started escaping away from the factory butin the same direction that the gas was moving. At roughly 01:15, thepolice control room was informed that there had been a major gas leakin the north of the city and that people were fleeing the area. The policecontacted Union Carbide immediately and were informed by the plant’sshift manager that he did not know of any leak. The police called Carbideseveral times in the course of the next hour, only to receive a similarreply. The company did not convey the literal circumstances to the policein order for them to have warned communities that lay in the path of thegas. In fact, until the leak was confirmed, the police advised everyonewho contacted them not to panic and to stay indoors.

At 02:15, Carbide's public siren sounded, and a little later anengineer from the plant walked into the police control room toannounce that the "leak has been plugged". That was the firstconfirmation that there had been a leak at all (by that time almost theentire contents of E610 had been released). Fifteen minutes later, localauthorities decided to evacuate the city. Had Carbide informed thepolice of both the direction of the wind, as seen from the wind sock onthe MIC plant, as well as the toxicity of the gas earlier, people couldhave been told to move away from it. This would have been advice thatcould have saved many lives. At 03:00, when the first deaths werereported to the police, the authorities realised the extreme gravity ofthe situation, but by then it was too late. Having missed the propertiming for problem recognition, they missed the opportunity for an on-time response. Many of those who lived near the plant in slum areassuch as Jayaprakash Nagar and Kazi camp had already been exposed tohigh concentrations of the gas and died in their sleep. Others who fledthe city died in forests and fields around Bhopal. Still others, whoescaped from the city but had inhaled lethal doses of the gas, died in

towns as far as 40 kilometers from Bhopal. It was the worst accident inthe history of the chemical industry.

Effects: Casualties There remains a controversy about the number of deaths and injuriescaused by the disaster; in fact, the true magnitude of casualties maynever be known. Between 250,000 and 600,000 residents of Bhopal mayhave been exposed to varying concentrations of the highly active toxiccompounds. The most badly affected were people in the poorer areasadjacent to the plant. Jayaprakash Nagar, one of the worst hit areas, lostbetween 1,800 and 3,000 of its 7000 inhabitants. The governmentadmitted that many hundreds of squatters at the bus and railwaystations vanished without a trace, such as gypsies who had set uptemporary dwellings in the affected areas. These people had no record ofhabitation in Bhopal and have therefore been excluded from the surveysthat have been conducted to calculate the number of dead and injured.The fact that people were found dead in villages and cities outside ofBhopal suggests that there may have been many other casualties thatwere never taken into account. As will be demonstrated here, it seemsto be an impossible task to collect accurate operative data in real time.During the first three days, the listed fatalities reflected a count ofbodies at the Hamidia Hospital morgue. However, hospital figures wereclearly too low. On 3 December, although only 574 deaths wereregistered at hospitals, the number of corpses received by crematoriumsand burial grounds exceeded 1,200. The next day, government inspectorsvisited graveyards, as well as the cremation ghats, to look at theregistration of those buried and burned. Maintaining a count of thedead was also greatly hindered by the urgent need to remove thecorpses from the city so as to dispose of a serious menace to publichealth. Numerous voluntary agencies played an important role in thistask, the inevitable consequence being that authorities lost control overthe number of casualties.

As suggested in Table 1, the figures published by official sources seemto have played down the severity of the disaster, while those in unofficialreports and guesses were generally higher. For instance, in July 1986, therelief commissioner declared that his department had confirmed 2,100deaths; later, the government alleged 4,037 deaths in its compensationsuit. In contrast, Bowonder estimated that the accident caused the deathof 5,000 persons and affected about 100,000. Banerjee and Sarin placedthe death toll at 10,000 to 15,000. The number of injured was estimatedat between 200,000 and 400,000.

It is worth noting that, although the authorities had reasonablegrounds to assume that the number of casualties they were aware of wasmuch lower than the truth, they nevertheless based their officialresponse on the lower figures. It is the contention of this author thatmany interested parties (in India, the US and industrial circles dealingwith such types of materials) were fond of these figures and did notinvest much effort in finding more comprehensive data that might pointto much higher numbers. One of the more comprehensively documentedconsequences of the accident was its effect on unborn foetuses. Therewere stories of pregnant mothers who lost their children or who gavebirth to deformed babies. Shocking accounts were given by hospitaldoctors, midwives and nurses who insisted they had never seen such afrequent cycle of birth and immediate death of babies on this scale.Senior doctors, it should be noted, were not permitted to talk to anyoneabout this experience. The survivors were born premature, under weight,with blackish skin and club feet, and with their flesh eaten away.Following the accident, the number of stillbirths increased among womenwho had been exposed to the MIC. Abortions for medical reasons rosethreefold among women who were in their second or third trimester atthe time of the accident. In fact, doctors advised women who had beenpregnant at the time of the accident to abort, but this advice did notreach every pregnant woman. This episode once more exemplifies theinadequacy of the communication with the affected population.Compounding these circumstances were the vulnerable physicalconditions of many of the victims due to malnutrition, unsanitaryenvironments and infected drinking water. That meant that thousandsdied prematurely as a result of exposure to MIC, phosgene and perhaps



13Spring 2012 HazMat Responder World

cyanide and other poisons. Some delayed effects of exposure to MICappeared after a latent period of many years.

Causes Although this study primarily focuses on the response phase to LSSDs,exploration into the causes of the Bhopal tragedy help to further ourunderstanding of the response patterns. The accident resulted from bothfundamental and circumstantial failures.

Fundamental Causes: The fundamental problems that led to the disaster derived fromprevailing misconception that current safeguards were sufficient toprevent a major accident. Warren Anderson, Chairman of Union Carbide,as well as other senior Carbide officials, insisted that safety standards indesign, maintenance and operation were the same at Carbide facilitiesthroughout the world, i.e., high. He denied charges of criminal liability,claiming that the "Bhopal plant was as good as the main factory atInstitute, Virginia, US." In this context, it is illuminating to consider thesituation at Institute: Gilbert Flores, director of security at West VirginiaState, affirmed that there was no direct emergency network betweenthe plant and the university (4,000 students), and that there has neverbeen a practice evacuation. There is still no evacuation plan for thetown. If an immediate full-scale evacuation were ever needed, it mightwell prove to be disastrous. In response to this, the Institute plant'sspokesman pointed out that because of the plant's safety features, suchan evacuation would be unlikely.

This conception was based on the understanding that adequateconfiguration and design of chemical plants, appropriate construction offacilities, properly trained operators and suitable safety regulations – allmonitored by an internationally experienced company – would ensurethe safety of plants and neighbouring residential areas. Indeed, one ofthe reasons UCC had been favored by the Indian government was itssophisticated technology. Opposing views, such as those of journalistRajkumar Keswani and the Workers' Union in the UCIL, were ignored.Though the Bhopal tragedy was an accident waiting to happen, thewarning signals were disregarded. Fundamental shortcomings in designand operation of the plant contributed to the accident. The vent gasscrubber and the flare tower could not prevent the escape of MIC intothe atmosphere, because the gas was flowing into the scrubber at a rateof more than 200 times its capacity. The UCIL management admittedthat if the flare had been ignited, it would have caused an explosion. Afreon-based, 30-ton refrigeration system designed to keep MIC stored ata temperature of roughly 0 degrees Celsius (a prime safety precaution)had been disconnected six months prior to the accident. A pipeline hadconnected tank E610 to the spare tank E619 through a suction pump. Ifthe valves had been opened (which takes three minutes) the buildup ofpressure and the higher level of liquid in E610 would have moved theMIC into E619. In the confusion however, the valves were not opened.There were also consistent deviations from safety regulations: theplant's manual was not followed; the equipment was faulty; pressuregauges, refrigeration, cleaning procedures and safety tanks were notmaintained, even approximately. Both the manual and common senseprescribe all these things. The force became accustomed to the laxitywith which the technical standards of the physical plant weremonitored, possibly adding their own laxity. Maintenance and repairwere inadequate. Warren Anderson affirmed a number of events thatwere not in compliance with standard operating procedures. UCIL didnot implement the kind of safety standards that are common atfactories producing MIC elsewhere, such as in France or Germany. Therewere at least three faulty instruments in the warning system of the MICtanks: namely the temperature indicator alarm (TIA), the pressureindicator control (PIC) and the level indicator (LI) on the control roompanel. According to MIC plant operators, the TIA had been faulty for thelast few years. The PIC and LI had also been faulty. To make mattersworse, a critical panel in the control room had been removed, thuspreventing the leak from showing up on monitors. That may explainwhy, when the PIC indicated a tank pressure of 10 psi – which,incidentally, is five times the normal level – the operators ignored it.

There were also shortcomings in the public address system. In 1982,the plant's management disconnected the siren from the alarm system inorder to avoid "unnecessary" panic in the neighbouring community. Anintact siren could have saved many lives, if not most of them. Clearly, thefactory failed in exactly what it was supposed to do, which was tooversee technical operations. These factors demonstrate further aspectsof the local infrastructure that were incapable of providing safeconditions for the population. They also point to a biased policy choicebetween the ‘political health’ of the system and public health.

Circumstantial Causes:While it is clear that water entered the tank and set off a rapidexothermic reaction, experts are in dispute about the way by which sucha quantity of water got into the tank. Some argue that there were tworunaway reactions. The first, and the dominant one, was the reaction ofMIC with itself, and the MIC was catalysed by a source of iron that waswashed into the tank from the corroded walls of the process vent header(PVH) line. The second reaction was of MIC with water. However, allagree that the MIC in tank E610 quickly got out of control and triggereda reaction. Carbide's team of experts reported (on 20 March, 1985) thatthey were unable to determine the exact source of the water. Carbidewould have liked to believe that the Bhopal disaster was caused by"sabotage" and that, in simple language, nothing was within the span ofresponsibility of the UCC. Those who are familiar with the history of theUCIL plant in Bhopal should not be surprised by the accident.Notwithstanding the claims of prominent American experts such as DanEdwards, director of health and safety for the Oil, Chemical and AtomicWorkers International Union, and Hugh Kaufman, a hazardous-wastespecialist at the Environmental Protection Agency (EPA), who bothpublicly defended UCC's safety standards, the Bhopal plant had areputation as an unsafe installation. In 1979, a major fire broke out atCarbide's alpha-naphthol plant in Bhopal, making it inoperable for weeks.No one, however, was injured. The first reported death at the Bhopalplant occurred on 26 December, 1981, when plant operator Mohammed


Ashraf died due to a phosgene leak. The company attributed it to"human error". On 9 February, 1982, another leak of phosgene seriouslyaffected 24 people. In May, 1982, a three-member safety audit teamfrom Carbide's headquarters in the US listed as many as ten deficienciesin safety procedures, such as: the potential for release of toxic materialsin the phosgene/MIC unit and storage areas, the lack of water sprays inseveral areas and deficiencies in safety valves and instrumentmaintenance programs, the high turnover in plant personnel and thepractice of employees signing permits that they could not read. In spiteof these findings, the audit team contributed to the administration’stendency to ignore forewarnings by concluding that, "The team was veryimpressed with the number and quality of operating and workprocedures developed [...] and with the job safety analysis activity thataccompanied that effort", adding that, "no situation involving imminentdanger or requiring immediate correction was noted during the courseof the survey". As little as five months later though, in October, 1982, aleak of MIC gas also seriously affected residents of the nearby shantycolonies. This occurrence did not deter the Labour Minister from arguingjust two months later that there is no danger to Bhopal. When theBhopal incident occurred, American officials such as Jackson Browning,a UCC vice president for health, safety and environmental affairs,assured the American public that an accident of this kind could nothappen at Institute. When this notion was put to the test, it becameclear that even though physical and safety conditions of the WestVirginia plant were better than those in Bhopal, nevertheless incidentsof leakage and near disasters had occurred frequently. During a week inJuly, 1984, a team of professionals led by J.M. Poulson conducted anoperational safety and health survey of the MIC II unit at the Instituteplant. The team concluded their survey by stating that: ‘No imminenthazards requiring immediate correction were noted, but two concernsclassified as major were identified by the team.’ Firstly, they noted apotential for runaway reaction in unit storage tanks and, secondly, apotential for serious chloroform overexposure. Congressman Henry A.Waxman, chairman of the House Subcommittee on Health and theEnvironment, criticised the attitude of Union Carbide management withregard to the hazards raised in that report, asking, "What confidencecan we have that a corporation that dismisses this kind of informationas not requiring immediate action can be trusted to regulate itself?" On11 August, 1985 (six months after Browning's statement and Waxman'squery) the plant in Institute leaked poisonous aldicarb oxime andmethylene chloride gases, sending more than 130 people to hospitals.Numerous criticisms have been raised by Morehouse, Kletz, Bertell andothers that emphasise the volatility of the situation, caused by poordecisions, indecision, unsound actions and inaction. The following is aselected list: manufacturing Sevin with methyl isocyanate, when lesshazardous alternatives were known; storage of MIC in large quantities;undersized safety systems; use of substandard materials, known to be asource of contamination of MIC; gradual but sustained erosion ofmaintenance practices; growing neglect of safety standards; decliningquality of technical training of plant personnel, especially its supervisorystaff; building the plant close to a densely populated area; and failure todevelop and communicate to local authorities and the surroundingcommunity through an emergency response network, even after internalcompany recommendations to do so.

In light of the above, the ineffectiveness of those post-disasterresponses comes as no surprise, as no real danger was admitted and nopreparations were made to cope with a major accident. In fact, UnionCarbide officials confirmed that there were no evacuation plans forresidents of either Bhopal or Institute. "The safety of the material as wehad used it and handled it for over 20 years,” they stated, “just did notlead us to believe that this was an incident which required [emergency]planning". Yet, as in the Chernobyl case, and in other cases elsewhere,what experts rejected as impossible eventualities did in fact come to be..

HRW

The second part of this article is available onwww.hazmatresponderworld.com and will be printed in future versionsof the magazine. Ed.


How would today’s responders cope with a Bhopal type incident? ©HMRW

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