BHOPAL GAS TRAGEDY

ABSTRACT
On 3 December 1984, more than 40 tons of methyl isocyanate gas leaked from a pesticide
plant in Bhopal, India, immediately killing at least 3,800 people and causing significant
morbidity and premature death for many thousands more. The company involved in what
became the worst industrial accident in history immediately tried to dissociate itself from
legal responsibility. Eventually it reached a settlement with the Indian Government through
mediation of that country's Supreme Court and accepted moral responsibility. It paid $470
million in compensation, a relatively small amount of based on significant underestimations
of the long-term health consequences of exposure and the number of people exposed. The
disaster indicated a need for enforceable international standards for environmental safety,
preventative strategies to avoid similar accidents and industrial disaster preparedness.

December 2004 marked the twentieth anniversary of the massive toxic gas leak from Union
Carbide Corporation's chemical plant in Bhopal in the state of Madhya Pradesh, India that
killed more than 3,800 people. This Report examines the contributing factors that led to the
disaster and the role of Personnel and Human Resource Department.
 INTRODUCTION
In the 1970s, the Indian government initiated policies to encourage foreign companies to
invest in local industry. Union Carbide Corporation (UCC) was asked to build a plant for the
manufacture of Sevin, a pesticide commonly used throughout Asia. As part of the deal,
India's government insisted that a significant percentage of the investment come from local
shareholders. The government itself had a 22% stake in the company's subsidiary, Union
Carbide India Limited (UCIL). The company built the plant in Bhopal because of its central
location and access to transport infrastructure. The specific site within the city was zoned for
light industrial and commercial use, not for hazardous industry. The plant was initially
approved only for formulation of pesticides from component chemicals, such as MIC
imported from the parent company, in relatively small quantities. However, pressure from
competition in the chemical industry led UCIL to implement "backward integration" – the
manufacture of raw materials and intermediate products for formulation of the final product
within one facility. This was inherently a more sophisticated and hazardous process.

At 11.00 PM on December 2 1984, while most of the one million residents of Bhopal slept,
an operator at the plant noticed a small leak of methyl isocyanate (MIC) gas and increasing
pressure inside a storage tank. The vent-gas scrubber, a safety device designer to neutralize
toxic discharge from the MIC system, had been turned off three weeks prior. Apparently a
faulty valve had allowed one ton of water for cleaning internal pipes to mix with forty tons of
MIC . A 30 ton refrigeration unit that normally served as a safety component to cool the MIC
storage tank had been drained of its coolant for use in another part of the plant.

Pressure and heat from the vigorous exothermic reaction in the tank continued to build. The
gas flare safety system was out of action and had been for three months. At around 1.00 AM,
December 3, loud rumbling reverberated around the plant as a safety valve gave way sending
a plume of MIC gas into the early morning air. Within hours, the streets of Bhopal were
littered with human corpses and the carcasses of buffaloes, cows, dogs and birds. An
estimated 3,800 people died immediately, mostly in the poor slum colony adjacent to the
UCC plant. Local hospitals were soon overwhelmed with the injured, a crisis further
compounded by a lack of knowledge of exactly what gas was involved and what its effects
were. It became one of the worst chemical disasters in history and the name Bhopal became
synonymous with industrial catastrophe.
 PROBLEM IDENTIFICATION

➢ System related errors-The alarm system of the Union Carbide did not work for hours.
No alarm was raised by the factory managers. Suddenly thousands of people started
running to hospitals on the morning of December 3 with their complaints.
➢ Management error-People were suffering ,finding it difficult to breathe and confused
,so were doctors ,who did not immediately know the reasons for the sudden illness
that affected every new rushing patient.
➢ Government declared that the gas leakage was contained in eight hours , but the city is
still finding it difficult to over out of its grip even 33 years later.
➢ The company did not reached its market expectations and they got the losses.
➢ Unavailability-Non availability of sufficient number of gas masks, is a hardware error
caused by poor safety concerns at the corporate level.
➢ Operator related errors-There was serious confusion about the nature of the released
gas itself. This caused severe problems for medical authorities for handling mass
emergencies .Not having emergency rehearsals to check safety inadequacies.
➢ Prime cause-Partly leaking isolation valves. Omission to insert a slip plate. A
remotely operated valve being open when it should have been shut. And plant
modification connecting relief valve process vent headers.
 CASE APPLICATION
➢ This case is all about management failure in the organisation and it describe what the
bad impact they face after incident happened. After 30 years of the tragedy people of
the area face the health related challenges in their lives,
➢ Lets discuss in the Human Resource Management story what the requirement or the
lacking of the things at that time-
➢ Safety management error-mainly describe that before adapting a new technology there
should be maintained proper management and employee training.
➢ Safety management error occurs when the defect in the training , education,
management and task design. Safety program defect-This program gives the detail
about the proper data collection and analysis before date are applied for removing the
defects .Information revision ,data collection, data analysis and application are the
main content of this defect.
➢ Management/Command error-For the management and control of any possible error
or incidents needs the good training. Training may not have desired impacts in error
control mechanism if minimum basic education is missing. A various serious task
design is needed with proper motivation. In brief the effective management of error
will have training, education, motivation and task design.
➢ System Defect- To overcome the system defect we need the effective standard
operating processors(SOPs), proper enforcement of national regulation and company
policy by circulars.
➢ Operating error- Operating error leads to small accidents and if this small accidents
have not been proper addressed then any one of the small accident may become the
major accident. The operating error can be controlled effectively by engineering
control training and awareness , motivation.
 RECOMMENDATIONS/SOLUTIONS
➢ Along with the running of the plant through detailed safety management practices
supported by appropriate corporate safety management.
➢ Supervisor could have been placed on night shifts and the readings and feedsback of
the equipments could have been taken for every one hour.
There should have been 4 stage back up system (Union Carbidse Plant of USA)
instead of a one manual back up system.
➢ At regular proper intervals proper maintainance and servicing of flare towers pressure
valves ,gas scrubbers must be made.
➢ Strict regulations and methods must have been used according to the manual.
➢ Proper pressure gauges should have been used.
➢ Industry and government need to bring proper financial support to local communities
so they can provide medical and other necessary services to reduce morbidity,
motality and material loss in the case of industrial accidents.
➢ Reduction of running cost could not be taken from expenses of safety.
➢ Motivation of employees needed.
➢ Skilled and experienced workers should be appointed for this plant.
➢ Operators will be under severe stress and there should be minimum intervention by
the operators at the initial stages of an emergency. Steps to be taken if anything
unusual is noticed and also complete logging and monitoring of all parameters even if
some of them may be concerned to be unnecessary by the operator has to be made
statutory.
➢ At bhopal if the corporation had been open about the hazardous nature of MIC to the
govt of monitoring instrumentation and reduction of operator intervention through
automated early warning systems. Hazardious facilities should completely eliminate
non formalized operator intervention in reduce the need for operators rolling actuating
early warning signals.
➢ Carrying out detailed rehersals of emergency on the hazardious facilities with the
active involvement of all the level of management,at regular intervals must be made
statuatory. In adequences of systems should be evaluated during such rehersals and
corrective actions initiated.
➢ Only by emphasizing safety at corporate level, can safe operations of hazardous
facilities be insure. Regulatory agents have to create a safety climate and inspection
capability and procedure by institutionalizing hazard management procedure.
➢ To sum up, hazard management has to be started along with the preparation of the
feasibility report as an inherent part of the project appraisal procedure for all
hazardous facility. This has to be pushed into the operations
 CONCLUSION
The tragedy of Bhopal continues to be a warning sign at once ignored and heeded. Bhopal
and its aftermath were a warning that the path to industrialization, for developing countries in
general and India in particular, is fraught with human, environmental and economic perils.
Some moves by the Indian government, including the formation of the MOEF, have served to
offer some protection of the public's health from the harmful practices of local and
multinational heavy industry and grassroots organizations that have also played a part in
opposing rampant development. The Indian economy is growing at a tremendous rate but at
significant cost in environmental health and public safety as large and small companies
throughout the subcontinent continue to pollute. Far more remains to be done for public
health in the context of industrialization to show that the lessons of the countless thousands
dead in Bhopal have truly been heed.