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THE BHOPAL GAS LEAK:

ANALYSIS OF CAUSES AND CONSEQUENCES
Author
Ingrid Eckerman, MD, MPH. Member of the International Medical Commission on Bhopal, 1994.
Medical advisor at Sambhavna Clinic, Bhopal.
Address: Statsradsvagen 11, SE 128 38 Skarpnack, Stockholm, Sweden.
E-mail: eckerman@algonet.se.

Abstract
The Bhopal Gas Leak, India 1984 is the largest chemical industrial accident ever. Haddons and Berger
s models for injury analysis have been tested, together with the project planning tool Logical
Framework Approach (LFA).
The three models provide the same main message: That irrespectively of the direct cause to the
leakage, it is only two parties that are responsible for the magnitude of the disaster: Union Carbide
Corporation and the Governments of India and Madhya Pradesh. However, the models give somewhat
different images of the process of the accident.

Keywords
Bhopal, gas leak, injury analysis, methyl-isocyanate, MIC.

Background
The Bhopal Gas Leak, India 1984 is the largest chemical industrial accident ever. 520,000 persons
were exposed to the gases, and more than 2,000 died during the first weeks. 100,000 persons or more
have got permanent injuries. The catastrophe has become the symbol of negligence to human beings
from transnational corporations. It has thus served as an alarm clock. All the same, industrial disasters
still happen, in India as well as in the industrialised part of the world. Although they are far from the
size of Bhopal, they are so numerous so that chemical hazards could well be considered as a public
health problem. The companies usually dispute their own roll to the accidents, and deny the health
effects of the accidents. The companies have also been reluctant to compensate the victims
economically.
There are still different opinions on the cause to the Bhopal disaster and who was responsible.
According to Union Carbide, it was sabotage by a disgruntled worker.
In injury analysis, the conception the process of the accident, including pre-event, event and post
event phases, is used. Many models for analysing the extent of injuries have been developed (Berger &
Mohan, 1996). Usually they are used for events like traffic accidents and childrens burns. Two models
for injury analysis was tested against a complex mega-accident. They were compared with the Logical
Framework Approach (Logical Framework Approach, 1996), which is a tool for project planning and
management.
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In these analyses, it is considered proved that the reason that water entered tank 610 was the washing
of pipelines.

The Haddon Model

The Haddon model has three components: the causal chain of events, the Haddon matrix, the Ten
technological strategies and the Four Es (Berger & Mohan, 1996).
To find which factors to include in the Haddon matrix, it is recommended that one should think of a
causal chain of events leading to injuries. Yet the reasons for this accident are much more
complicated. A number of chains could be drawn. I therefore suggest that the phrase a causal net of
events is more appropriate.
The Haddon matrix analyses injuries according to three phases: the pre-event, event and post-event
phases, and three factors: host or human, agent or processes/equipment, and environment. The
model can be used for analysing risk factors as well as possible interventions.
Dr Haddon has formulated ten technological strategies for reducing the frequency and consequences
of injury. Tested on the Bhopal Gas Leak, energy is defined as the toxic gases, and susceptible
structures are defined as the human beings. Important factors concern the design and the location of
the factory, the houses of the inhabitants, information and emergency organisation.
The ten technological strategies also include the 4 Es, that all can be applied on the Bhopal leak.
Engineering includes design and maintenance. Environmental modifications is the localisation of the
plant. Education of inhabitants, workers and operators, UCIL management as well as the authorities is
important. Enforcement includes demands on transnational companies, environmental laws as well as
work life laws.

The Berger Model

LR Berger pointed out the limitations of the Haddon matrix: prevention is not emphasised, the social
environment is hidden, and it is too complicated (personal communication). He has suggested a new
model for prevention, where the pre-event and the event phases are analysed (Fig. 1). The post-event
phase was also tested. Humans was defined as the different groups of humans involved.

The Logical Framework Approach

The Logical Framework Approach (LFA) is an analytical tool for objectives oriented project planning
and management. The key words are objectives oriented, target group oriented and participatory.
The LFA consists of the following parts: Participation analysis, problem and objectives analysis, both
visualised as trees, alternatives analysis and developing the LFA matrix (matrices).
The trees of problem and objectives look like chains of events from where there are branches and
roots. The matrix makes it possible to clarify what processes/changes from other instances are needed
if the project is to succeed. As this is an analysis of an accident that has already happened, the matrix
deals with both prevention and management. When planning a project, it may be clearer to create one
matrix for prevention and another one or several others for management.

Results of analyses
The three models provide the same main message: That irrespectively of the direct cause to the
leakage, it is only two parties that are responsible for the magnitude of the disaster: Union Carbide
Corporation and the Governments of India and Madhya Pradesh. However, the models give somewhat
different images of the process of the accident.
Analysis according to the LFA Problem Tree (Fig. 2) demonstrates that to create the mega-gas leak, it
was not enough that water entered the tank. The most important factors were the plant design and the
economic pressures. The same analysis shows that the most important factor for the outcome of the
leakage is the negligence of the Union Carbide Corporation and the Governments of India and Madhya
Pradesh.
The analyses give the following information (Eckerman 2001, 2004):

The direct cause of the leakage is still unclear. However, the water washing theory seems most
convincing.

The direct cause of the leakage is less interesting, as the magnitude of the disaster was
dependent on other factors.

The parties responsible for the magnitude of the disaster are the two owners, Union Carbide
Corporation and the Government of India, and to some extent the Government of Madhya
Pradesh.

The leakage could have been prevented, even if the direct cause was sabotage.

If the personnel management policy had been better, no disgruntled worker or negligent
employees would have existed.

The impact on health could have been reduced if the residents had been given information on
how to behave in case of a leakage, and if they had been warned by the siren early in the
leakage.

The effects on health caused by the leakage could have been mitigated if the medical, social,
and economic rehabilitation had been adequate.

The effects on health caused by the leakage could have been mitigated if the environmental
rehabilitation had been adequate.

Conclusions
Models developed for analysis of injuries can be used for analysing a complicated mega accident like
the Bhopal gas leak, although different models might stress different aspects.
The Haddon matrix gives us a good picture of the complexity, and gives us many ideas on actions for
prevention and management. The Ten Strategies add information on management of a disaster. The 4
Es tell us about important factors in the society. The Berger model used in this way give us the chance
of inventing all different groups of persons involved in the accident. It seems to invite to describe
soft data, like attitudes and politics.
The Logical Framework Approach (LFA) appears more complete and useful for a complex situation
like the Bhopal gas leak. The problem and objectives trees look like chains of event from where there
are branches and roots. Visualising causes and consequences in tree models might provide a new
understanding. It is obvious that chain or tree are not the right words. Net is more appropriate.

Discussion
Despite thorough knowledge of the Bhopal gas leak, developing the problem tree gave the author some
new insights on the connection between causes and effects. When drawing the tree of objectives, the
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author also acquired some new ideas on the measures necessary to prevent an accident or to mitigate
its effects. The matrix makes it possible to clarify what processes/changes from other instances that are
needed if the project should succeed. The tree of objectives is much more simple than the tree of
problem, indicating that it might be easier to prevent an accident than to mitigate the consequences of
it.

References
Berger, L.R. & Mohan, D. (1996). Injury control. A global view. Delhi: Oxford University Press.
Eckerman, I. (2001). Chemical Industry and Public Health. Bhopal as an Example. (MPH 2001:24). Goteborg: Nordic
School of Public Health.
Eckerman, I. (To be published, 2004).The Bhopal Saga. Causes and consequences of the worlds largest industrial disaster.
Hyderabad: Universities Press (India) Private Ltd.
The Logical Framework Approach (LFA). Handbook for objective-oriented planning. Oslo: Norad, 1996.

Figures
Figure 1. Matrix ad modum LR Berger.
Figure 2. Problem tree in LFA.

Human

Equipment

Physical Social
environment environment

Figure 2. Problem tree in LFA.

PLANT
DESIGN
Bad maintenance

Washing
pipelines
Storing
in large
tanks

Corroding
material

ECONOMIC
PRESS

Hazardous
chemicals

Water entered
tank 610

UCIL management
not competent

Operators not
competent

Contaminants
RUN AWAY
REACTION

Safety systems
not functioning

Mega gas
leakage

Safety systems
under designed

Conflicts
NGO
Not enough
equipment

Misleading
information

Conflicts
scientists
Health care
inappropriate

Many lived
close

500,000
persons
exposed

Long term
treatment
inappropate

Insufficient
work
rehabilitation

Location
of plant

No public
alarm

Acute
treatment
inappropriate
Antidote
not tried

No automatic
alarms

Operator
reacted
too late

No or bad
houses
Many dead
& injured

Approval of
authorities

Poverty

No vehicles
Not wet cloth
for face

SURVIVORS
POORER

No info
before

Prolonged
exposure

Economic
compensation low
and delayed

No info
after

Police

NEGLIGENCE OF
GOVERNMENTS
OF INDIA & MP

NEGLIGENCE OF
UNION CARBIDE
CORPORATION