1. By Richard F. Garnett, P.E. Prepared for INSY 7056 for Fall 2014
The Bhopal Tragedy
By Richard F. Garnett, P.E.
Prepared for INSY 7056 for Fall 2014
“Those who cannot remember the past are condemned to repeat it.”
- George Santayana
HPDCM 1st Shot
LPDCM 1st Shot

2. Topics Background Sevin Manufacturing Process Drifting Toward Disaster
Union Carbide & UCIL
Sevin Manufacturing Process
Methyl Isocynate (MCI)
Engineering Controls
Drifting Toward Disaster
December 3, 1984
Across the Fence
Health Impact on the Population of Bhopal
References
Richard F. Garnett, P.E.

3. 3rd largest chemical company in the USA(12)
Union Carbide
Union Carbide, 1980(12)
37th largest industrial company in the USA
3rd largest chemical company in the USA(12)
Batteries, industrial gases, uranium enrichment, plastics & agricultural chemicals
International Company
700 chemical plants
35 countries

4. Union Carbide India Limited (UCIL) (12)
Union Carbide in India
Union Carbide India Limited (UCIL) (12)
Carbide earlier investor in India
Union Carbide India Limited (UCIL) established in 1934
Manufactured dry cell batteries
Carbide owned 50.9% of UCIL
Indian investors owned 49.1
Indian Government owned 22%
“… while it should be recognized that participation of foreign capital and enterprise, particularly as regards industrial technique and knowledge, will be of value to the rapid industrialization of the country, it is necessary that the conditions under which they may participate in Indian industry should be carefully regulated in the national interest.”
- Resolution on Industrial Policy, 1948 as quote by M.J. Peterson

5. Plant built on land owned by the Indian Government
Union Carbide in India
Union Carbide asked to build a plant in Madhya Pradesh, in the city of Bhopal (3)
Plant built on land owned by the Indian Government
99 year lease
“In the 1960s and 70s, the rural population of Madhya Pradesh was increasing at a rate of 2% a year. Bhopal was one of the fastest-growing cities in India during the 1960s and 1970s as unemployed people from the surrounding countryside came looking for better opportunities, and the state government was anxious to have an industrial base ” (3)

6. Access to water for the manufacturing process
The Bhopal Site
Bhopal a good site (12):
Good access to rail
Access to water for the manufacturing process
Exploit an emerging agricultural market
“UCC’s Sevin production plant was built in Madhya Pradesh, not to avoid environmental regulations but to exploit the large and growing Indian pesticide market .” (3)

7. Encouraged by Indian government to bring jobs
The Bhopal Site
Bhopal a good site (12)
Encouraged by Indian government to bring jobs
Low level of automation in the plant to maximize jobs (13)
“There was relatively little industry in Bhopal, but both the central government and the state government of Madhya Pradesh, of which Bhopal is the capital, were anxious to bring industry to the area M.J. Peterson(9)

8. The plant was designed to produce “Sevin”
The Bhopal Site
The plant was designed to produce “Sevin”
Carbonyl pesticide, popular in Asia
Facility was original designed as a “blending plant”
Combine components manufactured from other sites
Little chemical technology

9. The Bhopal plant was not a financial success
The Bhopal Site
The Bhopal plant was not a financial success
To improve margins, Union Carbide opted to backward integrate into manufacturing Sevin at Bhopal
Issued a license to manufacture 5,000 tons/day (1975)
More technically challenging & more dangerous.

10. Sevin Manufacturing Process
UC produced Sevin in their plant in Institute, West Virginia
The chemical was manufactured in a three step process:
React carbon monoxide & chlorine to from phosgene
React phosgene and methylamine to form methyl isocynate (MIC)
React MIC with hydrochloric acid to make Sevin

11. Sevin Manufacturing Process
The Process used two highly reactive (& dangerous) chemical intermediates
From Bhopal.ppt - University College Cork

12. Sevin Manufacturing Process
Methyl Isocynate (MIC) (6)
MIC is a colorless liquid with a pungent odor
Boiling point = 39 °C, vapor pressure = 348 mm Hg at 20 °C. Vapors are 2x heavier than air
OSHA PEL is 0.02ppm; IDLH = 2.0ppm
MIC is moderately soluble in water, and hydrolyzes to form carbon dioxide and methylamine.
Reacts exothermically (heat generated) with water.
MIC irritates the skin, eyes, and respiratory mucus membranes.
Decomposes into HCN at temps above 200 °C
It reacts with water to penetrate tissues, including skin and interacts with proteins.

13. Sevin Manufacturing Process
Issues(1)
Carbon steel ($)
Lack of automation
Operability issues
MIC stored in large (oversized) intermediate storage tanks(1)
Three (3) stainless steel tanks (610,611, & 619) of 15,000 gallons each
Continuous/Batch Process

14. Sevin Manufacturing Process
MIC Safety Systems:
MIC stored in three tanks
610, 611, & 619
One empty to allow emergency transfer.
MIC Storage Tanks refrigerated & buried to reduce temp (lower reaction rates)
Dry header design
Pancake blanks
Pressure relief valves discharge to caustic scrubber
Flare stack
Water curtain

15. Drifting Toward Disaster
City of Bhopal- rapid population growth ( ,000 to ,815)
“When UCIL constructed the plant in large portions of the area next to the plant were still uninhabited developments made the area more attractive to newcomers seeking employment, and the fact the state government owned much of the vacant land made the area particularly attractive to squatters . . .”

16. Drifting Toward Disaster
Shanty towns grew around the UCIL plant.
Population density adjacent to plant was 100 persons per acre.
Conflicts between the population and the plant; Noise & smells were an issue. Plant personnel instructed not to sound alarms at night.

17. Drifting Toward Disaster
Backward integration did not stem the losses at Bhopal.
UCIL cut costs to stems the losses
Reduced operating staff, maintenance staff
Minimal maintenance investment
Corrosion issues with CS system
Minimize operating costs
Shutdown tank refrigeration systems
In 1984, UCIL decide to sell the Bhopal plant
Plant operations limited; Using up raw materials

18. Some maintenance operating underway
December 2, 1984
Some maintenance operating underway
Water flushing of some piping, jumpers installed between piping, pancake blanks not installed.
Around 10:00pm operator note the pressure in tank 610 is 10 psig (usually 2 psig)
Water in Tank 610
Around 11:30pm smell of MIC; Operators realize there is a leak in the system; They decide to investigate after tea time. (12)

19. December 3, 1984
Around 12:35 operators inspect the 610 tank, both the temperature & pressure gages are at the top of their scale. The 610 tank is shaking violently:
“There was a tremendous sound, a messy boiling sound, underneath the slab, like a cauldron.” operator Suman Dey(12)
The pressure safety valve on tank 610 opens and dumps MIC into the relief system
Most of the safety systems are shutdown or undergoing maintenance.
Drawing from SACHE presentation on “The Bhopal Disaster” published by AICHE/CCPS & A. Ritchie, “The Bhopal Disaster- A Critical Study”

20. December 3, 1984

21. December 3, 1984
Vapors reach the plant boundaries within minutes and spread across Bhopal.
Fumigating Plume
Cool night, low wind speed
MIC  High vapor density
Low mixing; Slow rate of dilution
Example of a Fumigating Plume
Downloaded 11/7/14

22. Vapors spread over 50 sq km(12)
December 3, 1984
Driven by the exothermic, runaway reaction of water/MIC, 610 tank discharges 27,000 lb/hr of MIC vapor for 1.5 – 2.0 hours
Total Discharge Volume was approx 27 tons of MIC
Vapors spread over 50 sq km(12)

23. Health Impact on the Population of Bhopal
Concentration in the plume 0.12ppm – 85ppm(6)
Estimated mean concentration 27ppm(6)
Note:
PEL= 0.02ppm
IDLH = 2.0ppm
Estimated population
exposed 200,000

24. Across the Fence
Most of the population of Bhopal were asleep “ many thousands woke up only between 12:30 and 1:00 am, by which time the gas was spreading in high concentrations. People woke up coughing violently and with eyes burning By 3:00 am the main thoroughfares were jammed with an unending and uncontrollable stream of humanity. The streets were foul with vomit. Those who fell were trampled by the crowd. The worst affected were the children: unable to walk and breathe, they simply suffocated and died ” (12)

25. Across the Fence
“ At Bhopal’s 1,200-bed Hamidia Hospital, the first patient reported at 1:15 am. Within five minutes, there were a thousand and by 2:30 am there were 4,000, about 25,000 people were crammed into Hamidia Hospital. The floor was splattered with blood and vomit. Said a doctor “I was standing in the pediatric department. There was such a terrible crowd, that there wasn’t even place to keep bodies on the floor. .” (12)
This December 4, 1984 photograph shows blinded victims of the Bhopal tragedy as they sit in the street and wait to be treated at a Bhopal hospital

26. Most deaths were attributed to respiratory toxicity(6)
Across the Fence
It is unclear how many people died at Bhopal
The government of Madhya Pradesh estimated the initial death toll at 3,598
Most deaths were attributed to respiratory toxicity(6)
MIC (soluble in water & propensity to attack mucous membranes) cause injury though out the lung
Autopsies revealed Necrosis in the upper respiratory tract and bronchioles, & alveoli
Severe bronchitis, pneumonia, & hemorrhage
“It was awful, Knock on any door and all you found were bodies.”
-Swaraj Puri, Superintendent of Police

27. Thousands of victims with eye injury
Across the Fence
Thousands of victims with eye injury
Irritation and damage to the cornea
MIC demonstrated sever reproductive toxicity(6)
43% of the pregnancies in the area adjacent to the UCIL plant did not result in a live birth
Of the 466 babies born during the 1st 30 days after the event, 14% died (compared with 3% in the control group.)

28. Health Effect  Decades
Across the Fence
Health Effect  Decades
“15,000 to 20,000 premature deaths in the subsequent decades.” (6)
Lung damage survivors showed decrease lung function ten (10) years after the event(2)

29. Lessons to Learn
“ Massive failures occur from behavior that is considered completely normal, even accepted, as part of a daily routine. These routines give our perspectives tunnel vision and often don't allow us to see the underlying issue. Production goals, scarce resources and pressure on performance causes drift in these routines that slowly erode safe practices. From Drift Into Failure - from hunting broken components to understanding complex systems by Sidney Dekker
Little by little One small, bad decision at a time, in response to stress place on the organization Systems drift into disaster.
“ To place service before profit, the honor & standing of the profession before personal advantage, the public welfare above all other considerations . . .” From the Engineers Creed, 1954

30. Lessons to Learn
“What you don’t have, can’t leak.” Trevor Kletz
Commercial processes existed that did not require the MIC step or at least minimized the volume of MIC on hand to produce Sevin.
From both a safety and industrial hygiene standpoint, it is always better to eliminate a hazard than to design for it. (1)
Principle #1 of Inherently Safer Design
Intensification: Minimize the inventory of hazardous materials(8)

31. Lessons to Learn
We often view accidents as a single event, but exposures to toxic substances can be long lasting, with chronic health effects that effects victims for the rest of their life. And these affects are not confined to the plant, they can “jump the fence” and effect the public.

32. Bibliography
Atherton, J., & Gil, F., (2008), Incidents That Defined Process Safety, Hoboken, John Wiley & Sons, Inc.
Beckett, W. (1998) Persistent Respiratory Effects in Survivors of the Bhopal Disaster, Thorax, Vol 21 pp
Broughton, E. (2005) The Bhopal disaster and its aftermath: a review, Environmental Health: A Global Access Science Source, available from:
Culliman P., (2009) Case Study of the Bhopal Incident, Environmental Toxicology and Human Health- Vol 1, Available
Culliman P., (2009) Bhopal Plant Disaster Appendix A: Chronology, Environmental Toxicology and Human Health- Vol 1, Available
Dhara, R & Dhara, R., (September/October 2002), The Union Carbide Disaster in Bhopal: A Review of Health Effects, Archives of Environmental Health, 57 (No. 5), pp
Hollinagel, E., Woods, D., & Leveson, N., (2006), Resilience Engineering, Burlington, Ashgate
Kletz, T. , (1991) Plant Design for Safety – A User-Friendly Approach, Hemisphere, New York
M.J. Peterson “Bhopal Plant Disaster.” International Dimensions of Ethics Education in Science and Engineering. Available
Sharan, M., McNider, R., Gopalakrishnan, S., & Singh, M. (1995) Bhopal Gas Leak: a Numerical Simulation of Episodic Dispersion, Atmospheric Environment Vol 29, No 16, pp
Shirvastava, R. (2011), Bhopal Gas Disaster: Review on Health Effects of Methyl Isocynate, Research Journal of Environmental Sciences, 5:
The Bhopal Disaster, (n.d.) downloaded 11/4/2014
Ritchie, A. (2003), SACHE presentation “The Bhopal Disaster” published by AICHE/CCPS, New York
“Those who cannot remember the past are condemned to repeat it.”
- George Santayana