Bhopal Disaster

Background
It was a quiet night in Bhopal, India, December 3rd 1984, until a series of chain catastrophic system failures, circumstances, and complete negligence at the Union Carbide pesticide plant led to the accidental release of approximately 40 metric tons of methyl isocyanate (MIC) [1]. This product, of extremely high toxicity, spread over the sleeping community of Bhopal (right next to the plant) killing and injuring several people. The estimates of the people affected by the accident, according to the U.S. Chemical Safety and Hazard

Investigation Board (CSB), goes up to more than 3,000 people that died within a few days and at least 100,000 who were injured, suffering from permanent injuries to the respiratory, mental, gastrointestinal and
Figure 1. Doctor attending a baby after the tragedy [1]

neurological systems [2]. A different report states the death toll went up to 8000 people within the first few weeks [3], so the official death count from the authorities does not match with the real numbers.

Theoretical safety measures in the plant

As previously mentioned, MIC is a highly toxic gas used to make the pesticide of the plant, which has a threshold limit value (TLV) of 0.02 ppm [4], one of the lowest values for any gas. Therefore, it stands to reason that several precautions in the storage must be made. MIC must be stored only in stainless steel tanks, filled to the half level. The rest of the tank must be filled with an inert atmosphere of nitrogen. Furthermore, the MIC storage tank must be refrigerated below 15C to avoid polymerization. Moreover, safety measures are also critical. In case there is any scape, there is a scrubber for neutralizing MIC, working at all times even if there is no spillage. Also, if unreacted gas escape from the scrubber, there is a water spray for MIC neutralization and a flare tower for burning

those gases. Finally, in case of spillage a public siren would warn the habitants around the plant.

Description of the incident

It was 11 PM in the evening that day when the pressure in one of the three storage tanks containing MIC rose from 3 psi to 10 psi [5]. This happened after an operator started washing the lines and blocked them after some water leaked through the valves, ending up with the seepage of 500 liters of water into the MIC storage tank. Operators, instead being concerned, thought it was a mistake as the instruments did not always work properly on the plant. There was a shift change 15 minutes before this incident, so the new operator thought the possible increase in pressure was due to a pressurization of the tank to transfer MIC and not because of the pipe washing. At 11:30 PM staff started to feel irritation in the eyes. One hour after the leak of water coming from the washing of the pipelines was detected and stopped. At 12:40 AM, an operator saw MIC escaping from the nozzle of the 33 meter-high atmospheric vent line, and 20 minutes after that, the warning siren went off (3 hours after the leak), but it was already too late, a gas cloud consisting of MIC and its decomposition products was spreading all over Bhopal city.

Causes of the incident

As previously stated in the description of the incident, there was a water leakage, which initiated the accident. The water entering the pipelines connected to the MIC could be related to poor maintenance of the valves connecting the pipelines to the tank. The main reason of the accident was a corrosion phenomenon which started once water leaked into the system. The company used the wrong material for building the pipes, as they were made of cast iron instead of stainless steel (which is much cheaper). As pure MIC polymerizes easily, phosgene is added in MIC storage to avoid so. In contact with water, phosgene contained in the pipes reacted generating hydrochloric acid, which corrodes the cast iron, generating ferric ions. These ferric ions (together with hydrochloric acid) acted as catalysts for the polymerization of MIC. As this reaction is exothermal, temperature in the tank rose to 4000C, increasing pressure in the tank drastically and decomposing MIC [5]. Because of the high temperatures and pressures, the concrete casing of the MIC tank burst. To top it all, the theoretical safety measures implemented in the plant did not work properly, as the flare tower that was supposed to burn off all the MIC escaping from the scrubber failed.

It was only able neutralize a maximum of 8 tons of MIC whereas 45 tons of MIC escaped from the tank [5]. Also, three water sprays used for dispersion of MIC in case of an incident, can reach a maximum of 10 meters height, whilst MIC escaped at a height of 33 meters [6]. There were human errors as well. As stated in the description of the incident, operators did not take any action when pressure rose from 3 psi to 10 psi, and took more than 1 and a half hours to recognize the entry of water into the tank. Furthermore, miscommunications between the shifts

Facts from Bhopal Unit Carbide Plant Accident

In the months of September and October of 1982 newspaper reports warned the plant was unsafe and prone to suffer an accident. In June of 1983, less than a year from the disaster, there was already a serious accident without deaths. There have been a total of six accidents between 1978 and 1983 and some maintenance and updates in the plant were made in November 1984, one month before the fatality, but they were clearly insufficient [5]. At the plant, safety instruments used to indicate pressure, temperature and high and low level alarms on Tank 410 (the one containing MIC) had been malfunctioning for over a year [7]. That made the workers not to be able to detect the rise in pressure until the cracking of the tank was heard. Additionally, the refrigeration system that kept MIC at 0C had been turned off months earlier to save costs [4]. However, Unit Carbide claimed the Bhopal plant to be a model facility using state of the art technology. According to its manager after being informed of the catastrophe, said The gas leak just cant be from my plant. Our technology just cant go wrong [4] To top it all, multiple negligence from the UCC Bhopal plant continued after the accident was made. The directors of the plant did not communicate to the local authorities what the leaking chemical was, and also did not give any recommendations for its cure.

Conclusions
After the incident has been thoroughly studied one can conclude it was not a single incident the one that caused the tragedy, but a series of errors (human, organizational and technological). One can learn the importance of choosing the right materials in the industry that can cause corrosion leading to a disaster. Furthermore, the appropriate safety systems implemented in the plant are also vital and must work perfectly in case of the worst case scenario. Moreover, an appropriate maintenance of all the elements in the plant must be

carried out to make sure everything works perfectly. Human errors can be diminished if a proper instruction of the operators is made. If the recommendations given above had been followed thoroughly, the Bhopal Accident would have never happened.

References
[1] H. Ernie, "Lessons Learned?," Environmental Health Perspectives, vol. 112, no. 6, pp. A354A359, May 2004. [2] A. Pusey, "A Chemical Leak Kills Thousands in India," ABA Journal, vol. 98, no. 12, Dec 2012. [3] I. Eckerman, "Bhopal Gas Catastrophe 1984: Causes and Consequences," in Encyclopedia of Environmental Health, Five-Volume Set, Elsevier, 2011, pp. 302-316. [4] J. Gupta, "The Bhopal tragedy: could it have happened in a developed country?," Journal of Loss Prevention in the Process Industries, no. 15, pp. 1-4, 2002. [5] B. Bowonder, "The Bhopal Accident," Technological Forecasting and Social Change, no. 32, pp. 169-182, 1987. [6] F. Sen and W. G. Egelhoff, "Six Years and Counting: Learning from Crisis Management at Bhopal," Public Relations Review, no. 17 (1), pp. 69-83, 1991. [7] F. Less, "Loss prevention in the process industries (2nd ed.)," Oxford: ButterworthHeinemann, 1996. [8] S. Kumar, "Bhopal disaster victims' cases reopened," The Lancet, vol. 347, no. 9016, p. 1687, June 1996.