Summary
This report provides an overview of the Bhopal Gas disaster which occurred at the Union Carbide pesticide production plant in India in 1984. A large amount of Methyl Isocyanate (MIC) was released from tank 610 within the facility, a failure of safety and alarm systems allowed the gas cloud spread and kill thousands of people resulting in one of historys worst chemical accidents. This paper will first discuss the plants setting and establishment before providing a brief background on the layout of the plant and the chemical process underwent. It will then discuss MIC and pesticide toxicity and the importance of safety systems within the plant and how Union Carbides plant failed to meet such standards. The second major section of the report will describe how the leak propagated and dispersed throughout the city, what emergency procedures were taken to counteract it, and its aftermath and effects both on the local people and the people involved with Union Carbide. The last major part of the report will discuss how such an incident revolutionized chemical process safety and the various conclusions that could be drawn from this situation to prevent similar tragedies from occurring in the future.
1. Introduction
On December 3 1984, in the city of Bhopal, a highly toxic cloud of methyl isocyanate(MIC) vapor burst from the Union Carbide pesticide plant. Of the 800,000 people living in Bhopal at the time, 2,000 died immediately, and as many as 300,000 were injured .MIC was a major component for the production of the pesticide Sevin by the Union Carbide factory at Bhopal. This incident we now refer to as the Bhopal Gas Tragedy is one of the worst commercial industrial disasters in history. It is described as a low probabilityhigh consequence accident. The tumultuous outcome of the accident was a cumulative effect of the following seven reasons. 1. Large release of chemical from the plant. 2. Release of colorless, odorless MIC, which is highly toxic. 3. Heavily populated areas adjacent to the plant. 4. Calm weather conditions, bringing the vapor cloud down 5. Leak occurs at night when people are sleeping. 6. Failure or late warnings 7. Unqualified and unaware people working at the plant Due to the magnitude of the accident, the Bhopal disaster has been the focus of media and an example of lessons to be learnt for industrial safety. This incident which has also been called Hiroshima of the Chemical Industry one of the worst commercial industrial disasters in history3. Table 1 below provides a list of the major industrial accidents that occurred in a period of 65 years (19211986) with their fatalities. After the incidence, over the next few years, numerous studies were conducted, many theories were explored, and the involved parties accused each other. This report will explore the various causes offered for the tragedy and the strategies that Union Carbide Corporation used through the course of the crisis.
2. Background
After the independence of India, in 1947, the first major problem faced by the nation was to cope with food shortage. The government decided to join the Green Revolution initiative started by the United States, aimed at tremendously increasing the production of food grains in underdeveloped countries4. However, the change from traditional to capitalist farming required many inputs including pesticides. Bhopal, the capital of Madhya Pradesh, an agricultural city had few industries.
2.1 Union Carbide India Limited (UCIL)
The UCIL was a 50.9% subsidiary of the Union Carbide Corporation, the third largest chemical manufacturing corporation functioning at the time of the accident. The UCIL was founded in Bhopal and was fully operated by Indian labor. This plant was a packaged transfer where UCC arranged for starting the project, attaining process licenses and all other technicalities. The Chief Minister of Madhya Pradesh, Mr. Arjun Singh was responsible for moving the agricultural office of Union Carbide India Limited (UCIL) from Bombay to Bhopal in 1968 and actual production began in 1979. The manufacture of the pesticide Sevin was undertaken by importing the Sevin Technical Concentrate from the United States and the processing was done at Bhopal. The profit from manufacturing Sevin from UCIL was low due to competition from other pesticide manufacturers nearby. Despite initial expectations of producing 2000 tons of carbaryl, the plant was actually producing much less due to the decreasing demand. However, within four years of the operation of the plant, 30 metric tons of MIC gas leaked out UCIL plant2. This accident proved to be disastrous for Union Carbide, since the loss of thousands of people due to improper safety regulations Union Carbide became a subsidy of Dow Chemical to avoid bankruptcy.
2.2 Union Carbide MIC plant: Layout and Process Chemistry
It has been speculated that the high number of casualties occurred due to the location of residents in close proximity of the ULIC plant. The dense cloud formed from the leak settled over these shanty towns around the plant, most of which were inhabited by factory workers4. It is estimated that about 5000 people died within two days of the accident 3. The Bhopal UCIL plant was located just on the outskirts of the city, a mere 3km away from two major hospitals and just about a l km away from the railway station, despite regulations requiring chemical plants producing pesticides and insecticides to be located within an industrial zone of 25 km away from the nearest city2. The plants location has been questioned by the commissioner and director of Bhopal and many futile attempts have been done to try and relocate it due to the numerous health risks involved. Figure 1 below shows the location of the ULIC plant relative to the city at the time of the leak.
2.2 MIC Toxicity
To understand the toxicity of MIC, the chemistry of isocyanates, which accounted for the high fatality, will be discussed. Isocyanates consists RN=C=O and thus belong to the heterocumelene group. Methyl isocyanate is highly reactive due to the cumulative action from the presence of adjacent double bonds. MIC is more adverse to health when inhaled than ingested, which explains the catastrophic effect caused on that fateful day. Having a boiling point of 39.1C, MIC vaporizes at room temperature and exists as an odorless, colorless gas4. The effects of MIC can be detected by contact, resulting in watering of the eyes and irritation of the throat. According to the Occupational Safety and Health Administration (OSHA) , the exposure limit for MIC has been set s 0.02ppm during an 8 hour period, this is an indication of how serious a risk MIC poses. However, at the time of the Bhopal disaster, only one report stating the toxicity of MIC was present in literature. An appalling prince had to be paid before the fatal effects of MIC were known.
2.3 Process Chemistry of Carbamate Pesticides
The following scenario was used by ULIC to produce carbamate pesticides4: I. 2C + O2 2CO II. CO + Cl2 COCl2 III. PH3 + CH3NH2 CH3NHCOCL + HCL IV. CH3NHCOCL MIC(CH3NCO) + HCL V. MIC + naphthol + CCl4 1naphthyl methylcarbamate MIC reacts with water exothermically, generating heat above its boiling point and thus turns from liquid to vapor. Hence the existence of even a small amount of water can be sufficient to produce enough heat to cause and ruptures and leaks.
2.5 Available safety systems
Investigations after the incident showed that the Bhopal plant was loosely maintained, with serious lapses in the day to day operations of the plant. Over time, more unqualified staff were hired and the mandatory six months training was abandoned. At the time of the tragedy the staff maintaining the plant was reduced to half with only six operators, one supervisor and no full time superintendent. The plant could not detect leaks automatically and many times a leak was identified by its symptoms of throat irritation and watering of eyes among the plant workers. The emergency alarms installed to warn of any leaks were nonoperational and no effective public evacuation scheme was reserved. The primary existing safety systems at the Bhopal MIC plant were the scrubber, water spraying system and flare, all of which were nonfunctional during the time of the leak. The scrubber was capable of neutralizing MIC entering at 90 kg/hr at 35C at 15 psi at its peak performance4. The MIC that escaped that night was 200 times higher in pressure and about 6 to 10 times higher in temperature, which eventually led to the scrubbers failure 4. Likewise, the flare was capable of burning only miscible amounts of MIC and the water curtain system was capable of spraying water only to a height of 15m while the MIC leaked at heights of about 50 m. Figure 3 below is a schematic showing the vent gas scrubber, the flare tower and the MIC storage tank.
3. The Leak
3.1 Leak Timeline
The timeline below gives the most popular account of the events that took place on December 2nd and 3rd at the Bhopal Plant. December 2, 1984: 89 pm: The MIC plant supervisor was ordered to wash out several pipes running from the phosgene system to the scrubber through the MIC storage tanks. The maintenance department is responsible for inserting the slip bind (a solid disk) into the pipe above the water washing inlet. However, the MIC unit workers were not aware that the installation of these slip blinds is a required safety procedure, and the slip bind was not installed. The temperature of MIC in tanks was between 15 and 20 C .
9:30 pm: The water washing begins. One of the bleeder valves (overflow device) was blocked so water did not come out as it was supposed to. It was collected in the pipes. The plant supervisor ordered that the washing continue until it had risen past a leaking isolation valve in the lines being washed and got into the relief valve pipe 20 feet above ground. 11 pm: The operator in the control room noticed pressure gauge connected to Tank E610 had risen from 2 psi to 10 psi. The rise in pressure didnt arouse any concerns to the operator since 10 psi is within the normal 225 psi range. However, the control room lacked monitoring the temperature of the tank. 11.30 pm: The unit workers in the area noticed MICs smell and saw an MIC leak near the scrubber. They also found MIC and dirty water leaking out of one of the relief valve pipes on the downstream side of the safety valve, away from the tank area. The workers then set up a water spray to neutralize the leaking of MIC and the people in the control room were also informed of the situation and their corresponding actions.
December 3, 1984: 12.1512:30 am: The control room operator noticed that control room pressure indicator for Tank E610 reads 2530 psi. About 12.30 am, the control room operator found out that the pressure reading for same tank reached the maximum value of 55 psi. He found out that one of the safety valves popped out and clouds of lethal gas were discharging from the plant stack vent scrubber and spreading rapidly through Bhopal.
12.40 am: The plant supervisor turned on the inplant and external toxic gas sirens. The operators also turned on the fire water sprayer. However, water could not reach the gas cloud formed at the top of the scrubber stack. Moreover, attempts to cool the tank with the refrigeration system failed because the Freon had been drained. 1 am: Plant supervisor realized that the spare tank, E619, was also not empty, so workers failed to reduce the pressure in E610 by transferring any MIC to E619. The gas smell was obvious outside the plant. 1.30 am: Bhopal police chief was informed of the leak; no significant police mobilization was followed. 8 am: Madhya Pradesh governor ordered closure of the plant and arrest of the plant manager and 4 other employees.
3.2 Causes of the Release
A detailed analysis of the accident has shown that safety management was poor at the plant level. The disaster that happened at the plant was a result of poor zoning and industrial sitting procedures, poor emergency management procedures, and poor safety regulatory frameworks.12 The causes of the releases behind the disaster were classified into three errors: hard, human, and system errors. 1. Hard Errors: The workers in the industry were informed to wash the pipelines with water without placing slip blind isolation plates. The washing is normally done after inserting a slip blind near the valve to close off the rest of the system .Slip blinds are mostly used for hydro testing piping. When maintaining equipment or piping, the equipment or piping must be isolated to ensure a safe working environment. Because of this, and of the bad maintenance, the workers consider it possible for water to have accidentally entered the MIC tank. Since MIC polymerizes easily, phosgene is added while storing MIC to avoid the initiation of polymerization. As the water entered the MIC tank, it reacted with phosgene and generated hydrochloric acid, which is a catalyst for the polymerization of MIC.The environment helped the reaction to proceed, as high temperatures, containments and other factors helped to speed the reaction. The reaction took place at 200 C and 180 Psig, which forced the emergency vent scrubber to release a large volume of toxic gases. The reaction increased and accelerated more due to the presence of iron that resulted from corroding nonstainless steel pipelines.10 The ferric ions also catalyze MIC polymerization. Reaction of water with MIC (catalyzed by the presence of ferric ions and hydrochloric acid) initiated the polymerization, which is an exothermic reaction. None of the workers was aware of the runaway reactions that were taking place in the storage tank between water and MIC. Therefore proper emergency steps were not taken. Another important cause was the bad structural design. The design of the vent gas scrubber was constructed to handle a flowrate of 88 Kilograms of MIC per hour. However, the actual flowrate was 20,000 Kg/hr during the time of the accident. Moreover, the storage systems were designed to carry 5 tons on a daily basis. However, during the accident, there were three storage tanks and 55 tons of MIC was stored. Large scale storage without a proper safety system was a major hard error. Most of the safety systems were not functioning and many valves were in poor condition. The pressure control valve for the MIC storage tank (610) had not been working for over a month. The pressure gauge of the MIC relief valve was only reading 10 psi, whereas the actual pressure value exceeded 40 psi.
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The refrigeration unit (30 tons capacity) was used to keep the MIC cool below 5 C. However, it was shut down, and the MIC was kept at ambient temperature.
2. Human Errors: The operator failed to recognize the entry of water into the MIC tank. The process took more than an hour for him to be aware of the reaction in the tank. Moreover, the operator ignored the rise in pressure from 3 psi to 10 psi; he did not consider it to be a serious problem.12 Even when the shift occurred, the previous operator failed to inform the current operator about the rise in pressure; this results in communication error between the workers. 3. System Errors: There was poor examination and follow up in the Union Carbide Industry despite the previous accidents and warnings that took place before this disaster. There were not any systematic procedures made to improve the safety regulations. Moreover, insufficient operational procedure took place in examining the status of the valves when the MIC tank failed to get pressurized. In addition, an empty tank for the evaluation of MIC was not used and the operator failed to switch on the vent gas scrubber
Safety failures at Union Carbides plant: FACTS
Union Carbide lacked a damning number of safety and security measures that a similar US based plant would have considered necessary for operation. Despite Union Carbides claims that the plant was held at the same operational standards as its US equivalents, investigations of the plant proved otherwise. The following are some of the serious failures present at the Bhopal plant.
Operational and safety failures:
The following is a list of equipment failure present at the Union Carbide plant prior to the incident 1. Storage of MIC for a period longer than permissible 2. Chloroform was fully not separated from MIC before storage, this played an important role in the runaway reaction. 3. Non functional and nonexistent detection and warning devices 4. Temperature and pressure gauges at various parts of the plant were extremely faulty and were generally ignored by workers 5. Insufficient and untrained staff a. Faulty pipe washing b. Storage of contaminated MIC 6. Failure of Union Carbide to respond to defects and lapses pointed out earlier 7. Shutdown of MIC refrigeration unit 8. Shutdown of caustic soda spray system 9. Out of order flare towers 10. Excess MIC in the tank 11. Lack of a spare tank for diverting MIC from the main tank, the emergency tank present to hold any excess MIC was being used for something else 12. Misinformation about the toxic effects of MIC and the treatment 13. No valves to prevent water entering the tank 14. Safety devices defective: a. Vent gas scrubber lacked sodium hydroxide for neutralizing the gases; it was also not prepared to handle the high pressures reached during the tragedy. b. Pipe leading to the flare tower had been dismantled for repairs and could not be used to burn escaping gases c. Water curtains around the plant could not be used because they lacked sufficient pressure to reach the height of the release d. Lack of coolant in the MIC tank refrigerator.
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Management failure
1. Union Carbide claimed MIC is merely a mild throat and ear irritant 2. Sloppy safety procedures 3. Management neglect of general plant operations 4. Lack of investment in plant safety 5. Cost cutting: Employee training and factory maintenance were radically cut. Skilled employees were replaced with lower paid workers Stainless valving and pipes were replaced with Carbon Steel 6. No onsite emergency plan 7. Locating the plant in a densely populated area 8. Haphazard urbanization in surrounding areas 9. Indian governments acceptance of the plant for political reasons without any safety analysis 10. Failure of Indian government to identify hazards and mandate safety standards 11. The lack of written reference manuals/instructions for the workers reference 12. Data logging of both technical and general activities was not enforced by management.
Lessons and Observations from Bhopal34
The Bhopal tragedy was a long overdue wake up call to the chemical industry, a tragedy of such magnitude has changed the chemical industry for the better; many lessons were learned from Bhopal which helped raise safety awareness within the chemical industry. Many companies and universities started incorporating process safety into its training curriculum, the United States formed the Chemical Safety board in an attempt to use the lessons learned from such Bhopal and invoke positive change within the industry to prevent future incidents and save lives. Some of the major lessons from Bhopal outlines in Lees Process Safety in the Chemical Industry are: Unlike the Flixborough and Seveso incidents, Bhopal invoked worldwide and intense publicity for a long time. This helped bring chemical process safety to the forefront, both within the chemical industry and to the general public who started perceiving it as unsafe and risky. Siting at major hazard installations was taken lightly before the incident, had the plant been located in a less densely populated area, such a tragedy could have been averted. Bhopal also brought the issue of development control into attention. Despite the area being relatively populated beforehand, the development of densely populated shantytowns which came up to the site boundaries should have been controlled and prevented both by Union Carbide and the Indian Government. The tragedy shed light onto the issue of plant management and how it is important to minimize continuous changes in management and staff within a plant, especially one that needs significant levels of technical familiarity to handle due to both its location and its hazardous product. Furthermore, the issue of prioritizing safety in
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decision making was established, one absolutely cannot afford to cut costs by jeopardizing plant safety. Storage of toxic substances was revolutionized after the tragedy, one cannot be too handled in the chemical industry. Inherent design safety, should be incorporated into facilities handling these materials and dispersion mechanisms should always be present and functional. There should always be a limit to the amount of oxic maerial one can store, process design needs to take into consideration the amount of inventory needed and try to minimize it. Moreover, guidelines on the storage of runaway reactions have been developed. It has established that a safety valve should only open when the pressure rise inside the vessel threatens its integrity but not with any minor pressure deviation. Nevertheless, when the risk of an excessive rise in temperature, such as the case of highly exothermic or runaway reactions, a compromise needs to be made so as when the venting starts. Under no circumstances shall any safety devices be disabled in a plant, it is is crucial to have strict procedures for disabling any safety equipment and to try to keep it to minimum. Regular and effective maintenance is crucial in any plant setting, and immediate action should be taken when anything unusual is detected.
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Conclusion
The Bhopal tragedy sent shockwaves throughout the chemical industry, both the human heartbreak and the utter technical negligence came as a slap across the face for the chemical industry, provoking wide scale changes and highlighting process safety as a crucial and indispensable element at both the technical and managerial levels. Perhaps it is too late as to search for who was behind such a tragedy, as the balance of power between the poor laborers and the major multinational will just carve another chapter into our book of human misery. Nevertheless, it is crucial to analyze the tragedy and try to overcome all the failures that led to it, something the chemical industry has successfully managed to achieve over the past decades.
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References
1. Bhopal Methyl Isocyanate Incident. Investigation Team Report. Union Carbide Corporation, Danbury, CT (1985). 2. Stix G. Bhopal: A Tragedy in Waiting. IEEE Spectrum. 1999. 3. Bowonder B. The Bhopal Accident. Technological Forecasting and Social Change. 1987; 4. CommonDreamsBhopal: The Hiroshima of the Chemical Industry WWW URL: http://www.commondreams.org/headline/2009/07/123 (November, 2009) 5. OSHA. Methyl Isoccyanate WWW URL: http://www.osha.gov/dts/sltc/methods/organic/org054/org054.html (November, 2009)
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