APPENDIX 5/2 BHOPAL Early in the morning of 3 December 1984 a relief valve lifted on a storage tank containing highly toxic methyl isocyanate (MIC) at the Union Carbide India Ltd works at Bhopal, India, A cloud of MIC gas was released onto housing, including shanty towns, adjoining the site Close on 2000 people died within a short period and tens of thousands were injured, The casualty figures are discussed further in Section ASS ‘The accident at Bhopal is by far the worst disaster which has ever occurred in the chemical industry. Its impact has been {elt world-wide, but particularly in India and the USA. Following the accident the Government of India (Gol) ‘set up an inquiry which reported at the end of 1985 (Varadarajan, 1985). An investigation was conducted by the US parent company the Union Carbide Corporation (UCC), which issued its own report (Whe Union Carbide Report) Union Carbide, 1975). Another investigation was carried out by the ICFTUICEF (1985). In its initial investigation Union Carbide had limited access to documents and personnel, and it subsequently caused to be published further findings (Kalelkar, 1988). These investigations are described in Section AS. Besides the investigations mentioned, other accounts have been given in Bhopal Anatomy of a Crisis by Shrivastava (1987) and by Badhwar and Trehan (1984), Bhushan and Subramanian (1985), Bowonder (1985, 1987, 1988), Bowonder and Miyake (1988), Kalelkar (1988), Kletz (1988h), van Mynen (1990) and Bowonder, Arvind and Miyake (1991) Selected references on Bhopal and MIC are given in Table A5.1 Table AS.1 Selected references on Bhopal and MIC ‘Anon, (1984); Badhwar and Trehan (1984); Anon (1985b-<, k, 1 gg, i); Anon. (1985 LPB 63, p.1); Basta, (1985); Basta et al. 1985); Bhushan and Subramanian (1985); Bowonder (1985, 1987); Bowonder, Kasperson and Kasperson (1985); Chowdhury ef al. (1985); IBC (1985/39); ICFTUACEF (1985); Kharbanda (1985, 1988); Klotz (1985), p, 1988h, n, 1980g, 199%b); Lepkowski (1985, 1986); Lihow (1985); Resen (19852); Union Carbide Corp. (1985); Varadarjan (1985); Webber (1985, 1986); Anon. (19860, D); Bellamy (1986); Bisset (1986) Shrivastava (1987); MP. Singh and Ghosh (1987); Anon, (1988b, 0}; Bowonder and Miyake (1988); J. Cox (19884); Emsley (1988); Kalelkar (1988a, b); Kharbanda (1988); V.C. Marshall (19882); Sriram and Sahasrabuhde (1988, 1989); Tachakra (1988); van Mynen (1990); MP. Singh (1990); Bowonder, Arvind and Miyake (1991); Narsimhan (1993) ‘Methyl isocyanate Kimmerle and Bhen (1964); ten Berge (198: ‘AS.1 The Company and the Management Union Carbide began operations in India in 1904 and by 1983 had 14 plants operating in the country. Its Indian interests were held by Union Carbide India Ltd (UCIL) LUCIL was owned 50.9% by the American parent company Union Carbide Corporation (U hare, having persuaded the Indian government to waive its usual requirement for Indian majority shareholding, on the basis of the technological sophistication of the plant and the export potential UCIL began operations at Bhopal in 1969, Initially the plant formulated carbamate pesticides from concentrates imported from the USA. In 1975 UCIL was licensed to manufacture its own carbaryl with the trade name Sevin, The process selected was the same as al the UCC plant at W. Virginia, but initially the MIC intermediate was imported irom the latter source. Production began in 1979. The plant had a capacity of 5250 te/y, but the market was less than expected. Production peaked at 2704 te in 1981 and fell to 1657 te in 1983. At these levels of sales the plant had problems of profitability. Prior to the accident the management structure of UCIL changed and the Bhopal pesticides plant was put under the direction of the Union Carbide battery division in India, ‘AS.2 The Site and the Works ‘The location of the UCIL works at Bhopal is shown ia. Figure AS.1. The works was in a heavily populated area, Much of the housing development closest to the works hhad occurred since the site began operations in 1968, including the growth of the JP. Nagar shanty town, Although these settlements were originally illegal, in 1984 the government gave the squatters rights of ownership on the land to avoid having to evict them, Other residential areas which were affected by the gas cloud had been inhabited for over 100 years ‘AS.8 The Process and the Plant In the process used at Bhopal methyl isocyanate (MIC) was made using the reaction scheme shown in Figure AS2. The process itself is shown in Figure ASS. Monomethylamine (MMA) is reacted with excess phos- gene in the vapour phase to produce methylcarbamoyl chloride (MCC) and hydrogen chloride and the reaction products are quenched in chloroform. The unreacted phosgene is separated by distillation from the quench liquid and recycled to the reactor. The liguid from the stil is fed to the pyrolysis section where MIC is formed, ‘The stream from the pyrolyser condenser passes as feed to the MIC refining still (MRS). MIC is obtained as the top product from the still The MIC is then run to storage. Phosgene was produced on site by reacting chlorine and carbon monoxide. The carbon monoxide was also produced on site The MIC storage system (MSS) consisted of three storage tanks, two for normal use (Tanks 610 and 611) and one for emergency use (Tank 619). The tanks were Bit diameter x 40 ft long with 2 nominal capacity of 5000 USgal. They were made of 304 stainless stee] with a design pressure of 40 psig at 121°C and with hydrostatic test pressure of 60 psig. A diagram of the storage tank system is shown in Figure ASA ‘A-30 ton refrigeration system was provided to keep the tank contents at 0°C by circulating the liquid through an. external heat exchanger,BHOPAL APPENDIX 5/3 Towards Aguoulural ~ 00%, Researen insite Sy +6 Brops YA Mes cawe s by Oe os Wi [[oaamaana ff (OP aac 7 lnabso Bl! fa \ S5tohy ff Ee Om gory! | a_i Li jj BAG! ' ae Oho: =: i 1$> ins af y Ee [Pern JESS, citaneho JL Mey Nag 7] SSSTAND } ~\aisHeac: ‘STADIUM JAMA ASIC 27 ANARGIAR. aN CENTRAL SCHOOL ff Ministers AL parqaows //// 5 GAS AFFECTED a /; } AeA B40"N bs sora) an zesn ‘i ——— 0 csmm) ‘ 45 min ) oS Adopted vené directors for w £ model evaluations Figure AS.1_Simpitied plan of the area near the Union Carbide india Ltd works at Bhopal (M.P. Singh and Ghosh, 1987). The diagram aiso shows the estimated dimensions of the gas cloud. (Courtesy of Elsevier Science Publishers) ‘There was on each storage tank a pressure controller valve to admit nitrogen and a blowdown valve to vent which controlled the pressure in the tank by manipulat- vapour. Each tank hada safety relief valve (SRV) ing two diaphragm motor valves (DMVs), a makeup protected by a bursting dise. It also had a highAPPENDIX 5/4 BHOPAL 1 oe eae = cunecoch =e Heat Srostene " Monamelyianne —— Mthycaleamoy Hydrogen satay sronce onde mec ea cHNco (2) cHNHeOE Heat Merny 'socvanal 41 wee) ech Figure AS.2 Reaction scheme (Union Carbide, 1985, Reproduced by permission) Tess Tals . mic | Pees ce 7 1 P= t Resiives rae Reacion Mic ~| Sater surage Moromerylamns 1 mi ons Pa on caste Heo we | wc i dervatives ust L vente Figure AS.3. Process for production of MIC (Union Carbide, 1986. Reproduced by permission) temperature alarm and low and high level alarms. Avent gas scrubber (VGS) and a flare were provided to handle vented gases. The VGS was a packed column Bit Gin. diameter in which the vent gates were scrubbed with caustic soda, There were two vent headers going into the coluran: the process vent header (VED, which collected the MIC system vents, and the relief valve veat header (RVVE), which collected the safety valve discharges. Each vent header was connected both to the VGS and the flare and could be routed to either. The vent stack after the VGS was 100 ft (33 m) high. A diagram of the vent gas scrubber system is shown in Figure A535. ‘The VGS had the fametion of handling process vents from the PVH and of receiving contaminated MIC, in either vapour or liquid form, and destroying it in a controlled manner. ‘The function of the Mare was to handle vent gases from the carbon monoxide unit and the MMA vaporizer safety valve and also vent gas from the MIC storage tanks, the MRS and the VGS. In the two years preceding, the number of personnel on site were reduced, 300 temporary workers being Inid off and 150 permanent workers pooled and assigned as needed to jobs, some of which they said when interviewed they felt unqualified to do, The production team on the MIC facility was cut from 12 to 6 ‘AS.4 MIC and Its Properties MIC is a colourless liquid with a normal boiling point of 39°C. Tt has a low solubility in water. Tt is relatively stable when dry, but is highly reactive and in particular can polymerize and will react with water. Itis flammableBHOPAL APPENDIX 5/5 =e ‘agmen re gig 20 Key: Ttacconnacton RYH 7. Nivegen nenaer canon | 7 Ininresnnartsn Pv satanen —G RUWH alan vee io ame 8 AYU tleeder 5 Pit ateion vee 58 Patel vate ts | a. ow ann ona Fag nuh oat |: tee ewe ten 8. Sresk vale tes manages ne 12. Fara Puts moles ve fr L | = Jeng ro Protea cond oer Concrete coves Vv rant valve vant Meade? aS. sentote tenner fae WE tence soe LE Aart oe aarp Soto Com seam ‘Seaton vanes ttre 9038 ha 22.20 20,25 nade: waives —> Route ot ge leakage after bo80 meee Met Figure A5.4. Flow diagram of Tank 610 systom (Bhushan and Subramanian, 1985) (Courtesy of Business Incia) and has a flashpoint of 18°C and a lower flammability limit of 6% v/v. It is biologically active and highly toxic ‘The high toxicity of MIC is indicated by the fact that its TLV at the time was 0.02 ppm. This is very low relative to most typical compounds handled in industry. MIC is an irritant gas and can cause lung oedema, but it also breaks down in the body to form cyanide. The cyanide suppresses the cytochrome oxidase nevessary for ‘oxygenation of the cells and causes cellular asphyxiation Information on the inhalation toxicity of MIC is given by Kimmerle and Eben (1964) and ten Berge (1985). MIC can undergo exothermic polymerization to the trimer, the reaction being catalysed by hydrochloric acid and inhibited by phosgene. It also reacts with water, iron being a catalyst for this reaction, This reaction is strongly exothermic. AS.5 Events Prior to the Release In 1982 2 UCC safety team visited the Bhopal plant. ‘Their report gave a generally favourable summary of the visit, but listed ten safety concerns, including 3, Potentials for release of toxic materials in the phos ‘gene/MIC unit areas and storage areas, either due to equipment failure, operating problems, or maintenance problems. 4, Lack of fixed water spray protection in several areas of the plant. 7. Deficiencies in safety valve and instrument main- tenance program, 8. Deficiencies in Master Tag/Lockout procedure appli cation, 10, Problems created by high personnel tuover at the plant, particularly in operations, Following this visit valves on the MIC plant were replaced, but degraded again. At the time of the accident the instruments on Tank 610 had been malfunctioning {or over a year, Between 1981 and 1984 there were several serious accidents on the plant. In December 1981 three workers ‘were gassed by phosgene and one died. Two weeks later 24 workers were overcome by another phosgene leak. In February 1982 18 people were affected by an MIC leak In October 1982 three workers were injured and nearby residents affected by a leak of hydrochloric acid and chloroform. Following this latter accident workers from the plant posted a notice in Hindi which read: ‘Beware of fatal accidents... Lives of thousands of workers and citizens in danger because of poison gas... Spurt of accidents in the factory, salety measures deficient’ These posters were also distributed in the community. ‘About a year before the accident a jumper line’ was connected between the process vent header and the relief valve vent header. Figure A54 shows the MIC storage tank and pipework arrangements. The jumperAPPENDIX 5/6 BHOPAL Tera portioramowe tive 28 Crusis sean cacharoe waive 29. Cur wean qucven vavve 26 Atmoaphenc vent aoenon valve 28.30, 31" aunion ven is hgh ct 900 Saat i Tracers & roe tans et ae pane wo puree = Poin (ae tons by Figure AS.5 Flow diagram of the vent gas scrubber system (Bhushan and Subramanian, 1985) (Courtesy of Business India) line is between valves 1 and 2. The object of the ‘modification was to allow gas to be routed to the VGS if, repairs had to be done on one of the vent headers. In June 1984 the 30 ton refrigeration unit cooling the MIC ‘storage tanks was shut down. The charge of Freon refrigerant was drained from the system. In October the VGS was turned off, apparently because it was thought unnecessary when MIC was only being stored not manufactured. In the same month the flare tower was taken out of service, a section of corroded pipe leading to it being removed so that it could be replaced, ‘Another feature was that dilficulty was being experi ‘enced in pressurizing MIC storage Tank 610. t appeared that since nitrogen was passing through the makeup valve satisfactorily, the blowdown valve was leaking and preventing pressurization. ‘According to plant workers there were other instr ‘mentation faults. The high temperature alarm had long been faulty. There were also faults on the pressure controller and the level indicator. ‘The plant had a toxic gas alarm system. This consisted of a loud siren to warn the public and a muted siren to warn the plant. These two sirens were linked and could be activated from 2 plant toxic alarm box. The loud siren could be stopped irom the control room by delnking the two, A procedure had been introduced according to which after delinking the loud siren could be turned on only by the plant superintendent Plant workers stated that on the morning of 2 December washing operations were undertaken. Orders ‘were given to flush out the downstream sections of four filter pressure safety valves lines. These lines are shown in Figure A54. In order to carry out this operation Valve 16 on the diagram was shut, Valves 18-21 and 22-25 opened and then Valve 17 opened to admit water. Tt was. suggested water might have entered MIC storage Tank 610 as a result of this operation — the water washing theory. On this hypothesis, water evidently leaked through Valve 16, into the RVVIL hheader and passed through the jumper line into the PVH header and thence into Tank 610. This would require that Valves 3 and 12 were open to connect the tank to the PVH and Valves 1 and 2 open to connect the RVVH to the PVE via the jumper line, ‘AS.6 The Release On the evening of 2 December a shift change took place on the plant at 22.45, At 23.00 the control room operator noticed that the pressure in Tank 610 was 10 psig. This was higher than normal but within the 2-25 psig operating pressure of the tank. At the same time the field operator reported a leak of MIC near the VGS. At 00.15 the feld operator reported an MIC release in the process area and the control room operator saw that the pressure on Tank 610 was now 30psig and rising rapidly. He called the supervisor and ran outside to theBHOPAL APPENDIX 5/7 tank, He heard rumbling sounds coming from the tank ‘and a screeching noise from the safety valve and felt heat from the tank. He returned to the control room and tured the switch to activate the VGS, but this was not in operational mode, the circulating pump not being on, ‘At 00.20 the production supervisor informed the plant superintendent of the release. At 00.45 operations in the derivative unit were suspended due to the high concen ‘ration of MIC, ‘At 01.00 an operator in this unit turned on the toxic sas alarm siren. After five minutes the loud siren was ‘Switched off leaving the muted siren on. At about the same time the plant superintendent and control room operator verified that MIC was being emitted from the VGS stack to atmosphere and turned ‘on and directed at the stack fixed fire water monitors to knock down the vapour. ‘Water was also directed at the MIC tank mound and at the vent header to the VGS. Steam issued from the cracks in the concrete showing that the tank was hot. One plant supervisor tried to climb the structure to plug the gas leak but was overcome, falling and breaking. both legs. ‘Some time between 01.30 and 02.30 the safety valve on tank 610 reseated and the release of MIC ceased, ‘About 02.30 the loud siren was switched on again ‘The cloud of MIC gas spread from the plant towards the populated areas to the south, There was a light wind and inversion conditions, People in the housing around the plant felt the irritant effect of the gas. Many ran out of their houses, some towards the plant. Within a short period animals and people began to die. At Railway Colony some 2 km from the plant, where nearly 10 000 people lived, it was reported that within our ‘minutes 150. died, 200 were paralysed and 600 rendered unconscious ‘and that 5000 were severely: affected. People tried to telephone the plant but were tunable to get through. At 01.45 a magistrate contacted the plant superintendent. ‘The cloud of toxic gas bung around the arca for the whole of 3 December. During the day it stopped moving towards the city, but resumed its movement in that direction during the night. ‘AS.7 The Emergency and the Immediate Aftermath Large numbers of people were affected by the toxie gas and very large numbers fled their homes. ‘The two hospitals principally concerned, the Hamidia and the Javaprakas Hospitals, were overwhelmed with casualties, The dificuties were compounded by the fact that it was not known what the gas was or what its effects were. Speculation about the gas, including suggestions that it was phosgene, continued in the world press for some days. ‘The company provided litle advice. Initially, it stated that MIC causes eye irvitaion but is not lethal ‘As early as noon_on 3 December doctors at the Gandhi Memorial College carried out postmortems which gave strong evidence of cyanide poisoning Victims had died of respiratory arrest, but there was no evidence of the cyanosis due to the deoxygenation of the blood which normally accompanies pulmonary asphyxiation and there were cases where there was 20 evidence of pulmonary oedema, ‘There developed a conflict of views on the appropriate treatment. The standard treatment for cyanide poisoning is sodium thiosulphate. One group took the view that this should not be given until cyanide poisoning was established by analyses, another argued that it was well known that in cyanide poisoning the cyanide may be metabolized, leaving hile trace. There followed a period in which the advice given was not clear. It was not until 3 February that an authoritative and unambiguous recommendation that sodium thiosulphate be used was issued by the Indian Council for Medical Research. ‘The Indian Central Bureau of Investigation (CBD took control of the site and began a criminal investigation. ‘A5.8 The Investigations A5.8.1 Government of Inaia investigation ‘An investigation of the incident was undertaken by the Government of India (GoD. It issued in December 1985 the Report on Scientific Studies on the Factors Related to Bhopal Toric Gaz Leakage by a team chaired by Dr Varadarajan (1985). ‘The report relers to the fact that it was reported that about 2130 on 2 December an operator was clearing a possible choke in the RVVH lines downstream of the phosgene stripping stil filters by water fishing, without inserting a blind. The 6 in. isolation valve on the RVVH ‘would presumably be closed but if it had not been leak- light, water could enter the RVVH. This water could hhave found its way into the Tank 610 via the blowdown DMV or through the SRV and bursting disc. ‘AS.8.2 Union Carbide investigation - 1 ‘A team from UCC arrived in Bhopal on 6 December charged with the tasks of assisting in the safe disposal of the remaining MIC and investigating the accident. The first task was completed on 22 December and the team returned home on 2 January, The investigation was severely constrained by the CBI control of the site and by the criminal investigation. The team were allowed only limited access to plant records and personnel. They were permitted to talk to certain persons, but not to interview statf directly involved in the incident. They were allowed to take samples from Tank 610, but not to open and inspect the tank and its piping or to take samples from elsewhere on the plant. Aa account of the situation is given by Kalelkar (19886) On their return home the investigators carried oul programme of some 500 experiments to establish what hhad occurred, The most abundant component in. the residues was MIC trimer, others present in significant quantities being the components conveniently referred to as DMI, DMU, TMU, TMB and TRMB, There were also iron, chromium and nickel in approximately their proportions in 304 stainless steel and some 5% chloride. ‘Trimerization bad obviously occurred, but it was unclear what other reactions had taken place. The investigators carried out experiments in which the principal materials believed to have been in the tank, namely MIC, chloroform, water and iron, were heated at 200°C and developed a reaction scheme which accountedAPPENDIX 5/8 BHOPAL for the production, starting from these materials, of the components found in the residue with the exception of ‘TRMB, which they considered they could account for: From plant records Tank 610 contained prior to the incident “{1 te (00400Tb; 11290 USgal) of liquid. The team estimated that Tank 610 had originally contained 1000-2000 Tb (120-240 USga)_ water and 1500-3000 Ib chloroform. The source of the water was uncertain, ‘The chloroform could be accounted for by the fact that the MIC refining still had been operated at a tempers: ture higher than normal and in preparation for shutdown MIC with a high chloroform content has been sent to Tank 610 rather than Tank 619, The iron could have come from corrosion, given high chloroform and water contents and high temperature ‘The scenario which the investigators invoked to explain the events is as follows. The contents of Tank 610 were intially at 15-20°C. Some 1000-2000 Ib water entered the tank in a manner unknown, The exothermic reaction between MIC and water led to an increase in temperature and also in pressure due to evolution of carbon dioxide, The higher temperature and presence of chloroform caused accelerated corrosion, The iron thus produced catalysed the exothermic timerization of MIC Calculations showed that reaction of some 40% of the MIC would generate enough heat to vaporize the rest ‘This would give some 36000 Ib of solids in the tank, but only an estimated 10000 Ib were found. There may have been appreciable loss of solids and liquid through the relief vent. ‘The period during which the relief valve was open was reported to have been about 2 hours, It was calculated that in order to vent most of the tank contents in this time the discharge rate would have had to be 40000 Ib/h, of which 29000 Ib/h were vapour and 11000 Ib/tt solids/liquid mixture and that this would have required a pressure averaging 180 psig. The temperature reached was estimated as in excess of 200°C, These conditions would have been attained during the course of the venting. With the safety valve iting at 40 psig the inital discharge would have been 100000 Ib/h. ‘The report puts forward the hypothesis that the water was directly introduced into Tank 610, either inadver tently or deliberately through the process vent line, nitrogen line or other piping. It refers to the washing operation on the fiter pressure safety valve lines and states that this section of line had not been isolated using @ blind, but that passage of water to Tank 610 through several reportedly closed valves is unlikely. The report draws attention to a number of factors which contributed to the accident. Taese include the facts that refrigeration had been discontinued, that blind was not used to isolate the lines being washed out, that the MIC refining still was operated at a higher than normal temperature, that the VSG did not work, and that the flare was out of commission [At the press conference held to present the report the UCC spokesman suggested that the water may have come irom 2 nearby utility station which supplied water and nitrogen to the area: ‘If someone had connected fubing to the water line instead of the nitrogen line, either deliberately or intending to introduce nitrogen into the tank, this could account for the presence of the "The press interpreted this as 2 suggestion by ‘hat the cause of the accident was sabotage. uct Subsequently UCC agreed that there was no direct evidence for this hypothesis. ‘AS.8.3 Union Carbide investigation - 2 Following the involvement of the Indian Government in litigation in the US courts, UCC was allowed access to personnel who had been involved on the plant and was able to gather evidence in support of ‘its original hypothesis. An account of this extension of the UCC investigation is given by Kalelkar (1988b). ‘Against the water washing hypothesis he makes the following points, First, the water Was introduced through Jin, inlet (Valve 17). The difference in head between this point and the inlet to Tank 610 was some 10. f. ‘There were three open bleeder valves close to the inlet point which would limit the backpressure of water to 07 i Second, there were a number of valves between the inlet point and the tank and for water to pass these ‘would have had to be open or not leakctight. One of these valves, close to the inlet point, had been shut since 29 November 1984. It was given a onehour test during which no water leaked through it. Third, for water to reach Tank 610 it would have had to fil the 6 in diameter connecting pipe, 65 of 8 in. RVVIL, with numerous branches running off, and then some 340 to ‘in. RVVH. The amount of water todo this was estimated as 4500 Ib, On 8 February 1985 the CBI ordered a hole to be drilled in the lowest point of the PVH. For the hypothesis to hold this section, which had no bleeders or flanged joints, should have been full of water; it was completely dry. In_support of the hypothesis of direct entry of water into Tank 610 the arguments presented by Kalelkar may be summarized as follows. First, an instrument super- visor, not on duty that night, stated that he had found the local pressure indicator on the tank missing; this was one of the few points to which a water hose could be connected, Second, 2 water hose was found nearby. ‘Third, there was evidence that the operators had become aware earlier in the evening that water had entered Tank 610 and had taken steps to deal with the situation Fourth, the plant logs showed evidence of extensive ‘tampering and alteration The plant could be supplied with MIC from Tank 610 or Tank 611, the MIC being passed to a one tonne tank the Sevin charge pot. There were difficulties with the pressure in Tank 610 and the transfers had been made from Tank 611. However, investigation showed that the MIC in the Sevin charge pot contained water. It had evidently come from Tank 610, Water is heavier than MIC and Tank 610 had a bottom offtake. The hypothesis is that the operators, aware that water had got into Tank 610 and wishing to remove it, on this occasion drew the MIC from that tank rather than from Tank 611 Kalelkar suggests that the addition of water to Tank 610 may have been the act of a disgruntled employee, AS.9 The Late Aftermath ‘The precise numbers of the dead and injured at Bhopal are uncertain. The scale of the accident was such that it led to much confusion. People have continued to die of the effects over a period of years. The official Indian Government estimate of the death toll about two years ater the event was 1754. By 1989 this had risen to 3150BHOPAL APPENDIX 5/9 and by 1994 to 4000. Other figures given are 30000 permanently or totally disabled; 20000 temporary cases; ‘and 50000 with minor injury. ‘The ICFTUICEF report in 1985 states that the number of people treated in the state hospitals had been given by Dr Nagu, the Director of Health Services for Madhya Pradesh, as approximately 170000, Some 130000 were treated in Bhopal hospitals, mainly for lung and eye injuries, and some 40000 in 22 other districts. Some 12000 of the 170000 were in a critical condition and 484 died, He estimated the total number of dead as 2000, ‘The disaster led to various sets of court proceedings. ‘The Government of India instituted criminal proceedings against UCC, which at the time of writing remain extant. ‘The Gol also became a party to proceedings in the US| courts. In 1987 UCC made a ‘inal settlement’ with the Go of $470 m. Vietims tried to challenge this in the US courts, but the US Supreme Court ruled that they lacked legal standing to do so. ‘85.10 Some Lessons of Bhopal ‘AS.10.1 Some lessons “The lessons to be learnt from Bhopal are numerous. A list of some of them is given in Table A52. They combine many of the lessons of Flixborough and Seveso. ‘Some of these lessons are now considered Public control of major hazard installations ‘The disaster at Bhopal received intense publicity for an extended period and put major hazards on the public agenda world-wide, but particularly in India and the USA, which had not reacted so strongly to Flisborough and Seveso, whose impact had been felt most in Europe Siting of and development control at major hazard installations Very large numbers of people were at risk from the plant at Bhopal. This situation was due in large part to the ‘encroachment of the shanty towns, which came up to the site boundary. Although these settlements were illegal, the Indian authorities had acquiesced in them, Table AS.2_ Some lessons of Bhopal Public control of major hazard installations Siting of and development control at major hazard installations ‘Management of major hazard installations Highly toxic substances Runaway reactions in storage Water hazard in plants Relative hazards of materials in process and in storage Relative priority of safety and production Limitation of inventory in the plant Set pressure of relief valves Disabling of protective systems ‘Maintenance of plant equipment and instrumentation Isolation procedures for maintenance Control of plant and process modifications Information for authorities and public Planning for emergencies In this instance, however, this was not the whole story. ‘The accident showed that site was close enough to areas populated before the plant was built to present a hazard ‘when used for the production of a chemical as toxic as MIC. If the manufacture of such a chemical was envisaged from the start, the problem may be regarded as one of siting. If not. it may be viewed as one of intensification of the hazard on the site Management of major hazard installations ‘The plant at Bhopal was by any standards a major hhazard and needed to be operated by a suitable competent management. The standards of operation and maintenance do not give confidence that this was so, There had been recent changes in the responsibilty for the plant which suggest that the new management may not have been familiar with the exigencies of major hhazards operation. However, many of the problems on the plant appear to have antedated these changes Highly toxic substances MIC is a highly toxic substance, much more toxic that substances such as chlorine which are routinely handled in the chemical industry. The hazard from such highly toxic substances has perhaps been insufficiently appre- ciated. ‘This hazard will only be realized if there is a mechanism for dispersion. At Bhopal this mechanism was the occurrence of exothermic reactions in the storage tank: Runaway reaction in storage ‘The hazard of a runaway reaction in a chemical reactor is well understood, but that of such a reaction in a Storage tank had received litle very attention, At Bhopal this occurred due to ingress of water. Where such a reaction could act as the mechanism of dispersion for a large inventory of a hazardous substance, the possibilty of ils occurrence should be carefully reviewed, Water hazard in plants In general terms the hazard of water ingress into plants is well known. In particular, water may contact hot oil and vaporize with explosive force or may cause a rothover, it may corrode the equipment and it may cause a blockage by freezing. Bhopal illustrates the hazard of an exothermic reaction between a process fluid and water Relative hazard of materials in process and in storage ‘There has been a tendency to argue that the risks from materials in storage are less than from materials in process, since, although usually the inventories storage are larger, the probability of a release is much less. The release at Bhopal was from a storage tank, albeit from one associated with a process ‘The relative hazard of materials in process and in storage is discussed Chapter 22, Relative priority of safety and production ‘The features which led to. the accident have been described above. As indicated, the Union Carbide Report itself refers to a number of these,APPENDIX 5/10 BHOPAL ‘The ICFTUICEF report states that at the time of the accident the plant was losing money and lists a number measures which had been taken, apparently to cut costs, ‘These include the manning culs and the cessation of refrigeration. Limitation of inventory in the plant ‘The hazard at Bhopal was the large inventory of highly toxic MIC. The process was the same as that used at UCC’s West Virginia plant. UCIL had stated that it regarded this inventory as undesirable, but was overruled by the parent company, which wished to operate the same process at both plants Processes are available for the manufacture of MIC which require only small inventories of the material Moreover, carbaryl can be made by a route which does not involve MIC, The alternatives to the use of MIC are discussed by Kletz (1988h) Set pressure of relief devices I is desirable from the operational viewpoint for the set pressure of a relief valve to be such that the valve opens when the pressure rise threatens the integrity of the vessel but not when normal minor operating pressure deviations occur, Where the cause of potential pressure rise is a runaway reaction, however, there is a penalty in setting a high set pressure in that this may allow the reaction to reach a higher temperature and to proceed ‘more rapidly before venting starts, so that there is a need to balance these two factors, Disabling of protective systems It was evidently not appreciated that the flare system was 2 critical component for the protection of the plant, since it was allowed to remain out of commission for the three ‘months prior to the accident. It is essential that there be strict procedures for the disabling of any item which is cnitical for protection and that the time for which the item is out of action be kept to a minimum. Maintenance of plant equipment and instrumentation The 1982 UCC safety team drew attention to the problems ia the maintenance of the plant. The Union Carbide Report gives several examples of poor mainte nance of plant equipment and instrumentation and the ICFTUICEF report gives further details. Workers stated that leaking valves and malfunctioning instruments were common throughout the plant. Maintenance wat also very slow. The flare system, which was a critical protective system, had been out of commission for three months before the accident Isolation procedures for maintenance ‘A particular deficiency in the maintenance procedures ‘was the failure to isolate properly the section of plant being flushed out by positive isolation using a slip plate or equivalent means. The fact that the water may not hhave entered in this way does not detract from this lesson, Control of plant and process modifications A principal hypothesis to explain the entry of water into ‘Tank 610 is that the water passed through the jumper line. The installation of this jumper line was 2 plant modification Company procedures called for plant modifications to be checked by the main office engi- neers, bat were evidently disregarded. ‘There was also a process modification which more certainly contributed to the accident, This is the decommissioning of the relrigeration system, so thal the temperature in Tank 610 was higher than the °C for which the system was designed. Information for authorities and public UCIL had not provided full information on the sub- stances on site to the authorities, emergency services, workers or members of the public exposed to the ‘hazards. Many workers interviewed said they had had no information or training about the chemicals. Planning for emergencies ‘The response of the company and the authorities to the emergency suggests that there was no efiective emer- ency plan Within the works defects revealed by the emergency include the hesitation about the use of the siren system and the lack of escape routes. ‘The preliminary condition for emergency planning to protect the public outside the works is provision to the authorities of full information about the hazards, This vwas not done. In consequence the people exposed did not know what the siren meant or what action to take the hospitals did not know what they might be called on to handle, and so on, Likewise, the essential action in an actual emergency is to inform the authorities what has happened and what the hazards are. On the morning of the accident the hospitals were in the dark about the nature and eifects of the toxic chemical whose victims they were trying to teat. ‘AS.10.2 An accident model ‘An accident model for Bhopal given by Kletz (1988h) is shown in Figure A5.6,BHOPAL APPENDIX 5/11 Event Recommendations for prevention/mitigation tattayer Immediate tecrnical -ecommendatons Ene tayer Avovoing the hazard 3rd layer: Improving the management system Pubic concern ‘compoliod ore companies to improve stangards Provide information b-— risks in perspective, 1at wil help public Keep Emergoney not handles well | ______ Promue and pracise emergeray plans, About 2600 yevple wiled Control building near major hazards. SSorubber not i Hull ‘working order Fate slack out of use Both may have been 120 smal { Keep protect ve equperent in working order Size (or ‘oreseeasle condrions, Disehznge from relel vawe 1 Relrige-ation systerr putot use Kear protective equipment in use even trough — plant is stut down Ruraway ‘eaction 1 | ise in temaeratire ‘Train operators not to Ignore unusual readings Wate: entered MIC tank Carry out hazcps on new designs Ba not atiow meter near MIC Decision 1 store over 109 toares MIC Aicumize 5 Ks of hazardcus matscais, Decision to use MIC rove ~ Avord use of hazardous materias Jont veoture astavished | ______ agree who is responsible for satety. To acheve the above Train chemical engineers in loss prevention Figur AS.8 An accident model or Bhopal showing etca events an recommendations (Katz, 1988h (Courtesy of Butterworths)