[Extra] Bhopal Investigation
Source: https://en.wikipedia.org/wiki/Bhopal_disaster
- Also known as the Bhopal gas tragedy, was a gas leak incident in December 1984
- World’s worst industrial disaster -> over 500 000 people were exposed to methyl isocyanate (MIC) gas
- Immediate death toll = 2 259, rose to 3 787
Two main lines of argument:
- Corporate negligence: combination of under-maintained and decaying facilities, a weak attitude toward safety, culminating in worker actions that inadvertently enabled water the penetrate the tanks in the absence of properly working safeguards
- Worker sabotage: argues that it was not physically possible for the water to enter the tank without concerted human effort. That extensive testimony and engineering analysis leads to a conclusion that water entered the tank when a rogue individual employee hooked a water hose directly to an empty valve on the side of the tank.
This water entry route could not be reproduced despite strenuous efforts by motivated parties. UCC claims that a “disgruntled worker” deliberately connecting a hose to a pressure gauge connection was the real cause.
- Management (some extent, local government) underinvested in safety, which allowed for a dangerous working environment to develop
- Filling of the MIC tanks beyond recommended levels, poor maintenance after the plant ceased MIC production in 1984 -> several safety systems to be inoperable due to poor maintenance, and switching off safety systems to save money (including the MIC tank refrigeration system which could have mitigated the severity of the disaster)
- Undersized safety devices and the dependence on manual operations
- Lack of skilled operators, reduction of safety management, insufficient maintenance and inadequate emergency action plans
- Attempts to reduce expenses, $1.25 million of cuts were placed upon the plant
- Promotions were halted, seriously affecting employee morale
- Workers were forced to use English manuals, even though only a few had a grasp of the language
- Only 6 of the 12 operators were still working with MIC and the number of supervisory personnel had also been halved
- No maintenance supervisor was placed on the night shift and instrument readings were taken every 2 hours instead of every hour
- 70% of the plant’s employees were fined before the disaster for refusing to deviate from the proper safety regulations under pressure from the management
Adequacy of Equipment and Regulations
- Not well equipped to handle the gas created the sudden addition of water to the MIC tank
- MIC tank alarms had not been working for 4 years and there was only one manual back-up system
- The flare tower and several vent gas scrubbers had been out of service for five months before the disaster
- Even the steam boiler, intended to clean the pipes, were not operational for unknown reasons
- Slip-blind platers were not installed and their installation had been omitted from the cleaning checklist
- As MIC is water-soluble, deluge guns were in place to contain escaping gases from the stack -> the water pressure was to weak to spray high enough
- The MIC tank pressure gauge had been malfunctioning for roughly a week
- No action plans had been established to cope with incidents of this magnitude
- Senior officials were aware of - 61 hazards, 30 of them major and 11 minor in the dangerous phosgene/methyl isocyanate units
- Worker performance was below standards
- Sept 1984 Audit warned “a runaway reaction could occur in the MIC until storage tanks, and that the planned response would not be timely or effective enough to prevent catastrophic failure of the tanks.”
Impossibility of the “Negligence”
- Water from work nearby was diverted due to combination of improper maintenance, leaking and clogging, and eventually ended up in the MIC storage tank.
- Not possible because:
1. The pipes were only 1/2 inch and were physically incapable of producing enough hydraulic pressure to raise the water more than the 10 feet necessary to enable “back flow” into the MIC tank
2. A key intermediate value would have had to be open for the Negligence argument to apply. Marked “tagged” closed, meaning that it had been inspected and found to be closed.
3. Would have had to flow through a significant network of pipes ranging from 6 to 8 inches in diameter, before rising ten feet. Water would have remained in the pipes but Indian government investigations revealed the pipes were bone dry.
- Claims that the incident was the result of sabotage, stating that sufficient safety systems were in place and operative to prevent the intrusion of water
- Likely that a single employee secretly and deliberately introduced a large amount of water into the MIC tank by removing a meter and connecting a water hose directly to the tank through the metering port
- UCC claims the plant stand falsified numerous records to distance themselves from the incident and absolve themselves of blame
- The evidence in favour of this point of view includes:
1. A key witness that testified the control room as “tense and quiet”
2. Another witness, noticed that the local pressure indicator on the critical Tank 610 was missing and that he had found a hose lying next to the empty manhead
3. Testimony was corroborated by other witnesses
4. Graphological analysis revealed major attempts to alter log files and destroy log evidence
5. Other log files show that the control team and attempted to purge 1 ton of material out of Tank 610 immediately prior to the disaster. An attempt was then made to cover up this transfer via log alteration.
6. A third witness was told that water had entered through a tube that had been connected to the tank
7. A fourth key witness stated that after the release, two MIC operators had told him that water had entered the tank through a pressure gauge.
