This month’s case study is a
live case of an Industrial Disaster Risk. — the Bhopal Gas tragedy.
Since the early days of the
industrial revolution till date there have been many incidents, mishaps and
unfortunate accidents — both large and small in which many lives have been lost,
damage has occurred and financial loss has been suffered. Industrial activity
that harnesses technology has always been prone to the risk of disasters — be it
the Chernobyl nuclear incident or the Exxon Valdez oil spill. These have ranged
from explosions, crashes, fires, leaks causing massive loss of life to
contamination and environmental and financial damage.
Even with modern-day systems
and risk management and mitigation procedures in place and proactive steps
including effective disaster management mechanisms by governments and corporates
alike, this continues to be a key area of concern and the size, scale and scope
of disasters has not reduced significantly.
The Bhopal gas tragedy that
occurred in the early hours of December 3rd, 1984 — over 200 years after the
industrial revolution, was by far one of the biggest industrial disasters in the
modern times. It has been described as an endless nightmare for those who
suffered it.
Bhopal is once again in the
news with eight UCIL executives including former chairman Keshub Mahindra being
convicted of criminal negligence and sentenced to two years in jail on 7th June,
2010. The sentences are under appeal. On June 24, the Union Cabinet of the
Government of India approved a Rs.1265 cr aid package. It will be funded by the
Indian Government.
Twenty-five years have
elapsed since that night that witnessed a ‘dance of death’ in Bhopal,
which saw a cloud of deadly gases emerging out of a faulty tank in a pesticide
factory and silently spread into the homes of unsuspecting sleeping multitude.
Although no official count of casualties has ever been done, estimates based on
hospital and rehabilitation records show that about 20,000 people died and about
5 to 6 lakh suffered bodily damage, making it by far the world’s worst
industrial disaster ever. Disasters can strike at any time, at any place.
Disasters keep happening all the time, but the tragedy still remains, a
catastrophe with no parallel.
What really happened ?
In the early hours of
December 3, 1984, from the Union Carbide factory at Bhopal manufacturing the
pesticide ‘Carbaryl’, an estimated 43 tonnes of deadly Methyl Isocyante (MIC)
gas leaked out from the tank No. 610C and escaped into the atmosphere. The
sleeping city of Bhopal was converted into a gas chamber.
MIC as a gas has to be
stored in a liquid form. A potentially lethal practice since water reacts
exothermically with MIC releasing heat that can cause a violent explosion.
On the day of the disaster
water leaked into the tank No. 610C causing a build-up of pressure and
temperature. The management decided to release the gas into the atmosphere
rather than have the tank explode which could have caused a greater damage.
The release of gas into the
air was a contingency that was planned and known to the factory management and
accordingly safety systems existed, but they failed.
What was the setting ?
The Union Carbide plant was
set up in 1968. However the plant had no long-term permission for storage of
MIC. In December 1982 there was a massive gas leak of Chlorine. 16 workers were
affected. The issue of danger to Bhopal from a pesticide plant was raised in the
Legislative Assembly of the State. While the gas leaked, Union Carbide’s works
manager exhibited a rather chilling overconfidence. He stated “The gas leak
cannot be from my plant. The plant shuts down automatically”.
The Time Line of the
Disaster
— December 02/3, 1984 :
— 10.30 p.m. the
late-night shift at the plant starts.
— 12.00 a.m. (midnight)
the operator checks MIC tank No. 610C and finds that the rupture disc has
burst; the gas has started leaking into the atmosphere.
— 12.06 a.m. MIC vapors
leak into the atmosphere through the 33m high-flare tower
December 03, 1984 12.06 a.m. — 12.15 a.m.
— gas starts leaking
from MIC tank No. 610C safety systems collapse and efforts to ignite the gas
fail as the pilot flare system is inoperable.
— workers panic and
abandon all efforts to contain the leak.
— control room is
notified, and the rest is history.
Probable causes identified :
— Effect of MIC on
humans and the antidotal treatment was not known to the medical fraternity
and such knowledge if available was not disseminated to the emergency
services.
— Poor plant maintenance
practices.
— Economy measures,
overriding safety concerns.
— Densely populated
areas around the plant.
— Lack of effective
emergency medical facilities.
— People sleeping in
exposed areas, jhuggies, road-side, on pavements/ railway platforms.
— Administration
collapsed with key functionaries running for their lives instead of manning
key positions.
— Relief
operations became difficult as the disaster caused total confusion and
affected the ability and mental strength of those entrusted with
emergency relief.
Lessons learnt:
— knowledge of the chemicals that were being stored.
— Emergency — accident — management manual should exist.
— Emergency procedures should be rehearsed at pre-prescribed intervals.
— Maintenance procedures and schedules should be strictly followed.
— knowledge of nearest medical facilities
— System of contacting top factory management.
— Residents living in the vicinity should be aware of the risks and trained to respond to emergency services.
The
leak was a watershed in formulating environmental legislation the world
over. The laws also require civic bodies and local officials to plan on
how to address a potential disaster situation.
Hindsight and way ahead:
Sheila
Jasanoff in her book ‘Learning from Disaster?: Risk Management after
Bhopal’ has provided a deeper insight into what are the issues to be
really addressed and the lessons we need to learn from such disasters
that not only provide a wider perspective to risk management, but also
give us, as human beings, food for thought.
“Although ‘hard’
engineering played its part in precipitating the events, the plant’s
defective components — the leaking valve, the broken refrigeration
system, the malfunctioning warning signal, and the inadequate storage
tank — were themselves the symptoms of more deep-seated social problems.
These
included the dearth of medical and scientific knowledge about an
extremely hazardous technology, the imperfections of information
transfer across national boundaries, the lack of regulatory resources in
a still developing country, the absence of workable relief and
rehabilitation plans, and the profound imbalance of economic power and
legal and managerial expertise between nations of the North and the
South.
Many of these deficiencies became apparent only in the
aftermath of Bhopal. Corrective policies have to address not only the
design of artifacts, but also (indeed, perhaps even more so) the human
practices and presuppositions that determine their management and use.
Seen from this perspective, a serious technological mishap ceases to be
merely accidental, for it opens windows onto previously unsuspected
weaknesses in the social matrix surrounding the technology.
Stringent
environmental regulations in developed countries have driven ‘dirty’
technologies to developing countries, where they operate under
disaster-prone conditions. Disasters are particularly likely to happen
when there is a sharp disjunction between the social order that gives
birth to a technology and the one in which it is eventually deployed.”
The
recent ‘oil spill’ in the Gulf of Mexico has again highlighted the need
for availability and strict adherence to mitigation procedures as
non-availability of these impact the very existence of the entity.