University: MSTU

Date: March 2012

Introduction to PETROCHEMIC !S and I"DUSTRI ! PO!#MERI$ TIO" %ro& Re'inin( to Po)y&ers and P)astics

MiniPro*ect M +OR CCIDE"T " !#SIS

Imagine that you work for a petrochemical company. Through a recent discussion with colleagues, your big boss has learned about a catastrophe that occurred some years ago in a different company and he would like to know more about it. He has asked his assistant to search the literature for some pieces of information about:

,rou- . / The Seveso Disaster

However, after looking at what his assistant has quickly gathered from Internet, he realizes that he does not have the time necessary to (o throu(h a)) this in'or&ation you can also find other pieces of information by yourself!0 e)i&inate the non/re)evant docu&ents0 'ind out 1hat occurred0 sort out the &ost si(ni'icant 'acts0 ana)y2e the root causes o' the accident0 and dra1 the &a*or )essons 1hich cou)d 3e use'u) 'or his o1n co&-any4 "o, because he is the boss, he si&-)y as5ed your (rou- to do the *o3 'or hi& . #nd because he is the big boss, you had better do that, and do it well$ %lease, &ointly prepare a %ower%oint document which will summarize the results of your work and be ready to collectively present it to your boss, with some complementary oral comments. 'ou know that your big boss is always in a hurry. "o your %ower%oint document should be short: &a6i&u& 7 s)ides. 'ou should strive to give only the most important pieces of information and not to bother your boss with non(significant details. If you have to present in front of him, do not read the slides: this makes your boss very, very nervous and unhappy$ He is a fast reader and goes through your slide much faster than you can read it aloud. #lso, he has the disagreeable habit of asking surprise questions to anyone in the group) so all members of your group should be prepared to give a collective answer at anytime during the presentation, on any part of it. If you have diverging views within the group, no problem$ 'ou simply need to *agree to disagree*. +ut your boss should clearly feel that you have worked collectively. P)ease0 hand out a -a-er co-y 8 an e)ectronic version 9on a c)ean US: 5ey;< o' your (rou-=s Po1erPoint -resentation 'or Thursday March 17 a'ternoon4 Se)ected tea&s 1i)) &a5e a 17 &inute ora) -resentation on %riday March 1> &ornin(4 ,ood )uc5; ,%

Seveso disaster
-rom .ikipedia, the free encyclopedia The Seveso disaster was an industrial accident that occurred around /0:12 pm 3uly /4, /526, in a small chemical manufacturing plant appro7imately 08 km north of 9ilan in the :ombardy region in Italy. It resulted in the highest known e7posure to 0,1,2,;(tetrachlorodibenzo(p(dio7in T<==! in residential populations>/? which gave rise to numerous scientific studies and standardized industrial safety regulations. The @A industrial safety regulations are known as the "eveso II =irective. Contents >hide? ?edit@ The accident ?edit@ !ocation The "eveso disaster was so named because "eveso was the community most affected. "eveso is a small town with the population of /2,444 in /526, other affected neighbourhood communities were 9eda /5,444!, =esio 11,444!, <esano 9aderno 1B,444! and to a lesser e7tent +arlassina 6,444! and +ovisio(9asciago //,444!.>0? The industrial plant was close by 9eda, owned by the company I<9@"# Industrie Chimiche Meda Societ!, a subsidiary of Civaudan which in turn was a subsidiary of Hoffmann(:a ,oche ,oche Croup!. The factory building was built many years ago and the local population did not perceive it as a potential source of danger. 9oreover although several industrial accidents involving dio7ins had occurred before they were of a more limited scale with the e7ception of the use of #gent Drange as a herbicidal warfare agent during the Eietnam .ar. ?edit@ Che&ica) events The accident occurred in building B where 0,B,8 T 0,B,8 trichloropheno7yacetic acid!, a herbicide, was being produced from /,0,B,8(tetrachlorobenzene by the nucleophilic aromatic substitution reaction with sodium hydro7ide. It is thought that some /,0,B,8(tetrachlorobenzene had formed a solid cake on the upper parts of the reaction vessel. #s the temperature increased this melted and entered the sodium hydro7ide containing mi7ture. The addition of more /,0,B,8(tetrachlorobenzene increased the rate of heat production. It is likely that the dio7in formed by either an Allmann condensation ether synthesis this requires a metal catalyst! or by a simple pair of nucleophilic attacks on the aromatic ring. The 0,B,8(trichlorophenol was intended for use as an intermediate in the production of he7achlorophene, a medical disinfectant. #n unintended byproduct of the manufacture of T<% is T<== in trace amounts, measured in ppm parts per million!. =ue to human error, around mid(noon on a "aturday, an uncontrolled reaction thermal runaway! occurred bursting the security disk of the chemical reactor and an aerosol cloud containing sodium hydro7ide, ethylene glycol, sodium trichlorophenate, and somewhere between a few hundred grams and up to a few kilograms of T<==>1? was released over an /; kmF area. ?edit@ I&&ediate e''ects

/ The accident o /./ :ocation o /.0 <hemical events 0 Immediate effects 1 <leanup operations o 1./ .aste from the cleanup o 1.0 <riminal court case B <onclusions 8 ,eferences 6 @7ternal links

The affected area was split into 2ones 0 : and R in decreasing order of surface soil concentrations of T<==. $one was further split into 2 sub(zones. The local population was advised not to touch or eat locally grown fruits or vegetables. $one had a T<== soil concentration of G 84 micrograms per square metre HgImF!, it had 216 residents.

$one : had a T<== soil concentration of between 8 and 84 HgImF, it had about B244 residents. $one R had negligible or a T<== soil concentration of J 8 HgImF, it had 1/,;44 residents.

.ithin days a total of 1144 animals were found dead, mostly poultry and rabbits. @mergency slaughtering commensed to prevent T<== from entering the food chain, by /52; over ;4,444 animals had been slaughtered. /8 children were quickly hospitalised with skin inflammation. +y the end of #ugust $one had been completely evacuated and fenced, /644 people of all ages had been e7amined and BB2 were found to suffer from skin lesions or chloracne. #n advice center was set up for pregnant women of which several opted for an abortion, which was legal in special cases, after consultation. Herwig von Kwehl ( the Technical =irector of Icmesa, and =r. %aolo %aoletti ( director of production at Icmesa, were arrested. Then two government commissions were established to thrash out a plan for quarantining and decontaminating the area and finally the Italian government diverted B4 billion liras from its coffers, this amount would be tripled two years later. ?edit@ C)eanu- o-erations In 3anuary /522, an action plan consisting of scientific analysis, economic aid, medical monitoring and restorationIdecontamination was completed. "hortly after Icmesa began to pay the first compensations to those affected. :ater that spring decontamination operations were initiated and in 3une a system epidemiological health monitoring for 004,444 people was launched. In "eptember The International Steering Committee was created, staffed with *renowned e7perts from all over the world*, in order to assess the scientific data generated. In -ebruary, /5;B The International "teering <ommittee released its final report stating that *with the e7ception of chloracne, no ill effects can be attributed to T<==*. In 3une /52;, the Italian government raised its special loan from B4 to //8 billion liras. +y the end of the year most individual compensation claims had been settled >out of court?. Dn -ebruary 0, /5;4 %aolo %aoletti ( the =irector of %roduction at Icmesa ( was shot and killed in 9onza by a member of the Italian radical left(wing terrorist organization %rima :inea. Dn =ecember /5, /5;4 representatives of the ,egion of :ombardyIItalian ,epublic and CivaudanIIcmesa signed a compensation agreement in the presence of the prime minister of Italy, #rnaldo -orlani. The total amount would reach 04 billion liras L /4.1 million!. ?edit@ Aaste 'ro& the c)eanuThe waste from the clean up of the plant was a mi7ture of protective clothing and chemical residues from the plant. This waste was packed into waste drums which had been designed for the storage of nuclear waste. It was agreed that the waste would be disposed of in a legal manner. To this end, in spring /5;0, the firm 9annesmann Italiana was contracted to dispose of the contaminated chemicals from $one . 9annesmann Italiana made it a condition that Civaudan would not be notified of the disposal site which prompted Civaudan to insist that a notary public certify the disposal. Dn "eptember 5 B/ barrels of to7ic waste left the Icmesa premises. Dn =ecember /1, the notary gave a sworn statement that the barrels had been disposed of in an approved way. However, in -ebruary /5;1, the programme *# bon entendeur* on TMlMvision "uisse ,omande, a -rench language "wiss TE channel, followed the route of the barrels to "aint(Nuentin in northern -rance where they disappeared. # public debate ensued in which numerous theories were put forward when it was found out that 9annesmann Italiana hired two subcontractors to get rid of the to7ic waste. Dn 9ay /5 the B/ barrels were found in an unused abattoir in #nguilcourt(le("art, a village in northern -rance. -rom there they were transferred to a -rench military base near "issonne. The ,oche Croup parent firm of Civaudan! took it upon itself to properly dispose of the waste. Dn Oovember 08, over nine years after the disaster, the ,oche Croup issued a public statement that the to7ic waste consisting of B0 barrels / was added earlier that year! had all been incinerated in "witzerland. #ccording to Oew "cientist it was thought that the high chlorine content of the waste might cause damage to the high temperature

incinerator used by ,oche, but ,oche stated that they would burn the waste in the incinerator and repair it afterwards if it were damaged. They stated that they wanted to take responsibility for the safe destruction of the waste. ?edit@ Cri&ina) court case In "eptember, the <riminal <ourt of 9onza sentenced five former employees of Icmesa or its parent company Civaudan, respectively, to prison sentences ranging from 0P years to 8 years. They all appealed. In 9ay /5;8, the <ourt of #ppeal in 9ilan finds three of the five accused not guilty, the two still facing prosecution appealed to the "upreme <ourt in ,ome. Dn 9ay 01, /5;6, the "upreme <ourt in ,ome confirmed the &udgment against the two remaining even though the prosecuting attorney had called for their acquittal. ?edit@ Conc)usions The safety operations handled by the companyQs directors and local government were badly coordinated and to some e7tent incompetent. #t least a week passed before it was publicly stated that dio7in had been emitted and another week passed before evacuation began. -ew scientific studies had confirmed the level of danger T<== posed and there were scant industrial regulations to be followed. #s a result the local population was caught unaware when the accident happened and in such an insecure situation became very frightened. <onfrontation with an invisible poison possibly e7tremely hazardous to human health was a very traumatic e7perience for small rural communities. *In the conte7t of such heightened tensions, "eveso became a microcosm where all the e7isting conflicts within society political, institutional, religious, industrial! were reflected. However, within a relatively short time such conflicts abated and the recovery of the community proceeded. -or, in "eveso, blame was never at issue: the responsible party was known from the outset and soon offered reparation. 9oreover, the eventual disappearance of the offending factory itself and the physical e7portation of the to7ic substances and polluted soil enabled the community to feel cleansed. The resolution of the emotional after(effects of the trauma, so necessary for the recovery of a community, was facilitated by these favourable circumstances.* >B? Industrial safety regulations were passed in the @uropean <ommunity in /5;0 called the "eveso =irective>8? which imposed much harsher industrial regulations. The "eveso =irective was updated in /555, amended again in 0448 and is currently referred to as the "eveso II =irective or <D9#H ,egulations in the Anited Ringdom!. Treatment of the soil in the affected areas was so complete that it now has a dio7in level below what would normally be found. The whole site has been turned into a public park, "eveso Dak -orest park. "ome say that "eveso is now the least polluted place in Italy. >citation needed? It could be argued that "eveso is a disaster that has not yet produced identifiable disastrous consequences. "everal studies have been completed on the health of the population of surrounding communities. It has been established that people from "eveso e7posed to T<== are more susceptible to rare cancers but when all types of cancers are grouped into one category, no statistical significant e7cess has yet been observed. @pidemiological monitoring programmes established as follows with termination dates!: abortions /5;0!) malformations /5;0!) tumours /552!) deaths /552!. Health monitoring of workers at I<9@"# and on decontamination pro&ects, and chloracne sufferers /5;8!. The "eveso disaster gives valuable comparative insight into the effects of #gent Drange on >flora and fauna? in Eietnam, not to mention Eietnamese people as T<== was an active chemical element in #gent Drange. >6? The documentary *Cambit* is about 3oerg "ambeth, the technical director of Icmesa who was sentenced to five years in the first trial and whose sentence was reduced to two years and paroled on appeal. >2? ?edit@ Re'erences

/.

0. 1. B. 8. 6. 2.

B +renda @skenazi) %aolo 9ocarelli, 9arcella .arner, :arry Oeedham, =onald C. %atterson, 3r., "teven "amuels, .ayman Turner, %ier 9ario Certhou7, and %aolo +rambilla. *,elationship of "erum T<== <oncentrations and #ge at @7posure of -emale ,esidents of "eveso, Italy*. Environmental Health Perspectives 112 /!. B +. =e 9archi) ". -untowicz, and 3. ,avetz. B "eveso: # parado7ical classic disaster. Anited Oations Aniversity. B "eveso SS 14 'ears #fter: # chronology of events B +. =e 9archi) ". -untowicz, and 3. ,avetz. <onclusion: *"eveso* ( # parado7ical symbol. Anited Oations Aniversity. B Driginal "eveso =irective ;0I84/I@@< T"eveso IU! pdf!. B Eietnam #gent Drange <ampaign ( +ackground. B *Ich war absolut dumm* Cerman!.

-uller, 3ohn C.>%oison That -ell from the "ky.? Oew 'ork, Oew 'ork: +erkley +ooks, /525. :ater %rinting.

?edit@ E6terna) )in5s Oational %ollutant Inventory ( =io7in -act "heet =io7in: "eveso disaster testament to effects of dio7in, article by 9ick <orliss, 9ay 6, /555. Icmesa chemical company, "eveso, Italy. 3uly 5, /526 +ritish Health V "afety @7ecutive <D9#H information page on the "eveso =isaster. #ssesment of the Health ,isks of =io7ins, a /55; report by the .orld Health Drganisation. ,oche ( /568 ( /52; pdf History timeline at the homepage of Hoffmann(:a,oche.

,etrieved from *http:IIen.wikipedia.orgIwikiI"evesoWdisaster*

=io7in: "eveso disaster testament to effects of dio7in

9ay 6, /555 =io7in: "eveso disaster testament to effects of dio7in Third in a series +y 9I<R <D,:I"" "taff writer 9I:#O, Italy(( Today, birds chatter in the trees and people take "unday strolls along the paths of +osco delle Nuerce, or "eveso Dak -orest park. Dne would not suspect that beneath the lush green carpet and vegetation lurk the poisonous remains of a chemical disaster nearly 01 years ago. The origin of the park, roughly /8 km north of 9ilan in ItalyQs :ombardy region, can be traced back to the afternoon of 3uly /4, /526. # little after noon that "aturday, a valve broke at the Industrie <himiche 9eda "ocieta #zionaria chemical plant in 9eda, releasing a cloud of chemicals containing dio7in that wafted an estimated 84 meters into the sky. <arried southeast by the wind, the to7ic cloud enshrouded the municipality of "eveso and other communities in the area. #bout 1,444 kg of chemicals were released into the air, according to some researchers. #mong them was 0,B,8 trichlorophenol, used in the manufacture of herbicides, and anywhere from about /44 grams to 04 kg of dio7in, said =r. %aolo 9ocarelli of the Hospital of =esio. The accident was not immediately noticed. Oo one was at the plant when it happened and I<9@"# (( the company responsible (( failed to swiftly address the event. The first sign of health problems, burn(like skin lesions, appeared on children a few hours after the accident. +eginning in "eptember of that year, chloracne, a severe skin disorder usually associated with dio7in, broke out on some of the people most e7posed to the cloud. #uthorities began an investigation five days after the accident, when animals such as rabbits began to die en masse. Oearly two weeks later, a chemist deduced that the cause was dio7in. #nd within three weeks, some 216 people living closest to the plant were evacuated. #bout 12,444 people are believed to have been e7posed to the chemicals, according to researchers familiar with the case. #ppro7imately B percent of local farm animals died, and those that didnQt (( roughly ;4,444 animals (( were killed to prevent contamination from filtering up the food chain. The affected areas were divided and subdivided based on soil contamination levels. Kone # (( the most contaminated area, covering //4 hectares (( was completely evacuated and was later turned into the park it is today, "eveso Dak -orest. In Kones + and ,, the ne7t(most contaminated areas, farming as well as consumption of local agricultural goods and meats were strictly prohibited.

Oot only did e7posure to one of the most to7ic chemicals known to humanity change the lay of the land and the lives of local people, it also altered the life of =r. 9ocarelli. 9ocarelli was put in charge of a laboratory set up two weeks after the accident to test people for health problems. The first day on the &ob, he initiated a series of tests that today have surpassed / million, he said. #t the time of the accident, the technical knowhow for testing dio7in concentrations in people did not e7ist, so 9ocarelliQs lab ran neurological, obstetric and other tests on those believed to have been e7posed. *I got the inspiration to save one sample of blood from each person!.* * "amples! like this more or less,* he says holding his hand in front of his face and indicating the fingernail of his pinkie to show an amount of roughly / milliliter. *3ust in case it would be possible to measure T<== dio7in! someday.* -ortunately, this became possible in /5;2, the doctor said. Oow the nearly 14,444 samples 9ocarelli put in the refrigerator following the accident are paying research dividends as he works with the A.". <enters for =isease <ontrol and %revention, headquartered in #tlanta, to unravel the accident and its implications more than two decades later. The "eveso accident is likely the most systematically studied dio7in contamination incident in history and, in 9ocarelliQs words, a chance e7periment on human beings. The chance e7periment has shed light on the threat dio7in poses. *%robably the strongest effect is on reproduction,* 9ocarelli said. In the first seven years after the accident, an incredibly high proportion of females were born to parents who were e7posed to the chemical cloud: B6 females compared to only 0; males. Asually, the proportion is roughly equal. This was the first time a chemical had been observed to change the se7 ratio, 9ocarelli said. *There is no other molecule known to induce change in the se7 ratio,* he said, adding that this implicates dio7in as a hormone disrupter. Eictims of the "eveso accident also reported symptoms of other afflictions (( immune system and neurological disorders as well as spontaneous abortions (( but studies found no link to dio7in. 9inor increases in some forms of cancer were found in one e7posed group. "tudies have suggested a link between dio7in and cancer. The lessons of "eveso may offer clues to how dio7in might signal its presence in 3apan. "uch telltale signs might include a shift in the se7 ratio in areas suspected of contamination, or an appearance of chloracne or skin disorders, such as those found in former employees of a waste incinerator in Oose, Dsaka %refecture. The blood(dio7in contamination level of one former Oose worker was almost twice the average of the most contaminated group surveyed in "eveso, although far below the most contaminated. In addition, research using the "eveso samples taken over the last two decades may help determine what dio7in levels are dangerous, and help in making more accurate risk assessments in other nations.

Today, 9ocarelli and his team are conducting research on the children of victims of the incident, as well as on dio7inQs long(term carcinogenic properties. These studies will likely help enrich debate on the topic around the world as well as in 3apan, which is now in the throes of its own reassessment of the chemicalQs effects. #part from monitoring victims of the accident, another type of monitoring continues as well. +eneath "eveso Dak -orestQs grassy undulations are two massive concrete tanks (( the resting place of the top B4 cm of soil removed after the e7plosion. It is also the final resting place of the contaminated animals that were slaughtered, the factory (( taken apart brick by brick by workers in protective suits (( as well as other buildings coated by the fallout. .ater seeps from the two giant tombs that lie &ust below the parkQs surface into another container where the dio7in is treated. The facilities, overseen by the park service, are constantly monitored for leaks. Ironically, today the soil here *has lower dio7in levels than in average areas,* according to park administrator #ntonio 9ambriani. # desolate chunk of land after the accident and until reclamation was completed in the /5;4s, the area is now a place where families gather on "undays. #nimals have returned to the park and ad&acent /1(hectare nature reserve. *In /5;B, this place was a desert. Oow, you see it is covered with trees,* 9ambriani said. *If anything good came of dio7in, it was probably this park and the green it gave "eveso.* #nother gift of the incident has been the data on the effects of dio7in. ,econstruction of the event using samples taken over time have helped clarify how long dio7in stays in the human body, as well as the different effects it has on children and adults. #fter 04 years of work to decipher the lessons of "eveso, 9ocarelli has simple advice to offer. *I think this accident teaches us that it is better to take care of the environment before these things happen. Oot after.* To? Sy&-to&s o' Pesticide Poisonin( @ ? Pesticide rtic)es Site Ma- @ C Pesticide In*ury Pa(e C ,et Set Site Ma- C

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D7ford 3ournals 9edicine #nnals of Dccupational Hygiene Eolume 00, Oumber B %p. 102(124

Oe7t #rticle
Ann. occup. H g., Eol. 00, Oo. B, pp. 102(124, /525 X /525 +ritish Dccupational Hygiene "ociety %ublished by D7ford Aniversity %ress

research/artic)e

THE SEDESO CCIDE"T: ITS " TURE0 EETE"T "D CO"SEFUE"CES

E4 HOM:ER,ERG0 ,4 RE,,I "I 0 +4 S M:ETHG and H4 H4 AIP%G
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Civaudan ,esearch <ompany :td -. Hoffmann(:a ,oche V <o. :td

The accident which occurred during the production of T<% at "eveso. Italy, was possibly caused by an unforeseeable e7othermic reaction with increase of temperature, slow decomposition of the reaction mass, formation of gas and rise in pressure. The nature of the reaction is still unknown and will be investigated further. The detection and measurement of T<== by the <ompanyQs analysts on material collected at the site of the accident have guided

measures for the protection of the population and the land and for the prevention of further damage. <hloracne, the skin lesion indicating a T<== e7posure, appearing mainly in a small segment of the population, has been generally of mild degree and inclined to rapid and complete healing. Incidence or severity of adolescent acne and of the current skin pathology have not been affected. Hepatoto7icity, neurological findings or deranged porphyrin metabolism have not been observed in the chloracne cases. %regnancy, foetal development, growth of the new( born, immunoresponse, rate of chromosome aberrations, functions of the neurological system, haematological and hepatic conditions, morbidity and mortality have been surveyed in the e7posed population. "o far the pathology related to these parameters has remained within the range which is current for the population of this region and could not be correlated to the e7posure to T<==. -our per cent of the domestic animals living in the contaminated zones died spontaneously, 55.6BZ of these being small animals. The remaining animals 22,2/6! were slaughtered as a preventive measure to protect the food chain. The analysis of T<== tissue levels revealed that the rather large amount did not necessarily correspond to anatomical or functional lesions. The elimination of T<== from the body in small as well as large animals indicated that, if T<== is removed from the diet, all animals can be reintroduced into the food chain after a suitable recovery period. #s regards the crops and the land, the deposited chemicals had practically no effect on the flora. #bout ;4Z of the T<== adhered to foliage, grass and crops for several weeks until it was transferred to the soil by the rain. -ield and greenhouse trials have shown that T<== does not leach significantly beyond a depth of 04 cm in the soil and that its 84Z breakdown in the "eveso soil takes between 5 and /0 months. Dnly fractions of the T<== in the soil can be found in the vegetation and fruit growing in the contaminated area. =econtamination could have been rapidly achieved immediately after the accident either by collecting and disposing of the vegetation or by the spraying of an H donor. Today the area which is still fenced(in could be made accessible by removing the contaminated soil layers and burying them in a concrete pit. The natural course of the breakdown would take at least 6S; yr.
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This artic)e has 3een cited 3y other artic)es:

T. OGDEN Annals of &ccupational % "iene at /olume 012 Man Achie!ements) a Few Mista3es) and an ,nterestin" Future Ann. Hyg., November 1, 200 ! "0#$%& '"1 ( ' ). *Abstra+t, *-.// Te0t, *1D-,

Ic&esa che&ica) co&-any0 Seveso0 Ita)y4 Ith +u)y 1IJ>

ccident su&&ary
#t appro7imately /0:12 on "aturday 5th 3uly /526 a bursting disc on a chemical reactor ruptured. 9aintenance staff heard a whistling sound and a cloud of vapour was seen to issue from a vent on the roof. # dense white cloud, of considerable altitude drifted offsite. The release lasted for some twenty minutes. #bout an hour after the release the operators were able to admit cooling water to the reactor. #mong the substances of the white cloud released was a small deposit of T<<=, a highly to7ic material. The nearby town of "eveso, located /8 miles from 9ilan, had some /2,444 inhabitants. Dver the ne7t few days following the release there was much confusion due to the lack of communication between the company and the authorities in dealing with this type of situation. Oo human deaths were attributed to T<<= but many individuals fell ill. # number of pregnant women who had been e7posed to the release had abortions. In the contaminated area many animals died.

%ai)in(s in technica) &easures

The production cycle was interrupted, without any agitation or cooling, allowing a prolonged holding of the reaction mass. #lso, the conduct of the final batch involved a series of failures to adhere to the operating procedures. The original method of distillation patent specified that the charge was acidified before distillation. However, in the plant procedures the order of these steps was reversed. Dperating %rocedures: safe operating procedures The bursting disc was set at 1.8 bar, and was to guard against e7cessive pressure in the compressed air that was used to transfer the materials to the reactor. Had a bursting disc with a lower set pressure been installed, venting would have occurred at a lower and less hazardous temperature. ,elief "ystems I Eent "ystems: venting of e7cessive pressures, sizing of vents for e7othermic reactions The reactor control systems were inadequate both in terms of the measuring equipment for a number of fundamental parameters and also in the absence of any automatic control system. <ontrol "ystems: sensors #larms I Trips I Interlocks: loss of cooling, agitator failure The company was aware of the hazardous characteristics of the principal e7otherm. However, studies showed that weaker e7otherms e7isted that could lead to a runaway reaction. ,eaction I %roduct Testing: calorimetry methods, thermal stability There was no device to collect or destroy the to7ic materials as they vented. The manufacturer of the bursting disc recommended the use of a second receiver to recover to7ic materials. Oo such vessel was fitted. =esign <odes ( %lant: nature of hazardous releases

"econdary <ontainment: catchpots Information on the chemicals released and their associated hazards was not available from the company. <ommunication was poor and failed both between the company and the local authorities and within the regulatory authorities. @mergency ,esponse I "pill <ontrol: safety management system, site emergency plan

Re'erences
:ees, -.%., \:oss %revention in the %rocess Industries S Hazard Identification, #ssessment and <ontrol], Eolume 1, #ppendi7 1, +utterworth Heinemann, I"+O 4 2846 /8B2 ;, /556.

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Seveso:

-arado6ica) c)assic disaster

+. =e 9archi, ". -untowicz, and 3. ,avetz

Introduction Overvie1 The Euro-ean Co&&unity=s institutiona) res-onse to Seveso The )essons o' Seveso Conc)usion: KSevesoK / -arado6ica) sy&3o) c5no1)ed(e&ents Chrono)o(y "otes Re'erences

Introduction -or some people the name "eveso is tied to the e7perience of a seriously mismanaged to7ic chemical release <onti /522) Hay /5;0) %occhiari, "ilano, and Kapponi /5;2!) for others it is firmly and positively linked with a set of innovative public policies for managing industrial disasters. These contradictory characterizations make the interpretation of this industrial disaster both parado7ical and ambiguous. The "eveso e7perience illustrates many different types of uncertainty that are mobilized by industrial disasters and suggests a new interpretive model. Overvie1

The chemical release Dioxin The Seveso Directive

The chemical release #round midday on "aturday /4 3uly /526, an e7plosion occurred in a T<% 0,B,8(trichlorophenol! reactor of the I<9@"# chemical plant on the outskirts of 9eda, a small town about 04 kilometres north of 9ilan, Italy. / # to7ic cloud containing T<== 0,1,2,;(tetrachlorodibenzo(p(dio7in!, then widely believed to be one of the most to7ic man(made chemicals 9ocarelli et al. /55/!, was accidentally released into the atmosphere. The dio7in cloud contaminated a densely populated area about si7 kilometres long and one kilometre wide, lying downwind from the site fig. B./!. This event became internationally known as the "eveso disaster, after the name of a neighbouring municipality that was most severely affected Hay /5;0) %occhiari, "ilano, and Kapponi /5;2!. %i(4 .41 rea a''ected 3y the Seveso dio6in re)ease 9Source: Roche Ma(a2in 1IL>< @leven communities in the rolling countryside between 9ilan and :ake <omo were directly involved in the to7ic release and its aftermath. The four most impacted municipalities included "eveso /526 population /2,444!, 9eda /5,444!, =esio 11,444!, and <esano 9aderno 1B,444!. Two other municipalities were sub&ect to postaccident restrictions: +arlassina 6,444! and +ovisio 9asciago //,444!. Health monitoring was e7tended to a further five municipalities. The entire affected area is part of the +rianza, a prosperous district of :ombardy, itself one of the wealthiest and most industrialized regions of Italy fig. B.0!. Though originally agricultural, the economy of this area depended on a cluster of small workshops and industries, mainly engaged in manufacturing furniture.

The "eveso disaster had a particularly traumatic effect on e7posed local populations because its seriousness was recognized only gradually. The community was divided by rancorous conflicts. %eople in other countries also e7perienced much heightened concern about industrial risks and the need for tighter regulation of hazardous chemical installations. In these respects "eveso resembled +hopal /5;B! and <hernobyl /5;6!, which have both come to be regarded as international symbols of industrial pathology. %i(4 .42 !ocation o' Seveso +ut as we shall see, "eveso is a parado7ical symbol, because human health effects of the disaster have been obscure and the process of recovery has been unusual. Eictims have been compensated, workers have been redeployed, a substantial programme of long(term health monitoring is in operation, and the site itself has been made into a park. Though initially slow and conflicted, responses to the accident may eventually have showed high(technology society working at its best. ,ecovery was therefore a process of overcoming initial traumas e.g. chloracne, fear of genetic impairments, evacuation, animal deaths! and re(establishing customary patterns of societal, economic, and institutional life. -or some, the main lesson of "eveso might be that a reasonably prompt, effective, and generous response by public and private agencies is the key to community recovery. +ut, to a significant degree, local recovery was achieved by e!porting parts of the problem. "eriously contaminated materials were disposed of abroad in an atmosphere of confusion and scandal) their ultimate fate is still unravelling Cambino, Cumpel, and Oovelli /551) see also <hronology items =ecember /550 and Oovember /551!. This, too, is part of the style of high( technology industry: consumer satisfaction is often sustained by *e7ternalizing* environmental costs and attendant social problems. In other words, the burdens of technology are often transferred away from producers and immediate consumers into a universally shared but unprotected natural environment or into specific poor communities local or overseas! that are treated as sweatshops and dumps.0 "io!in The "eveso e7perience was essentially about dread ( an emotion mobilized by involvement of the chemical dio7in. =io7in first came to widespread public notice during the Eiet Oam .ar, when it was identified as a component of the defoliant #gent Drange Hay /5;0!. %reviously, campaigns on behalf of agricultural and forestry workers had been mounted to have T<% banned because of its alleged to7ic effects on humans. These frequently met with scientific disapproval, partly because the evidence was only *anecdotal.* The Anited RingdomQs regulatory system was particularly unsympathetic to such claims .ynne /5;5!. +efore the "eveso release, several industrial accidents involving T<% were known to have occurred. #mong others, these affected the following firms and countries: ^ /5B5 9onsanto A"#!) ^ /581 +#"- Cermany!) ^ /564 =ow <hemical A"#!) ^ /561 %hillips =uphar Oetherlands!) ^ /56; <oalite <hemical %roductions AR!. These accidents precipitated acute illness among affected workers and added to the burden of e7isting chronic sickness caused by prolonged e7posure to the same chemicals under unsanitary conditions Hay /5;0: /1;/B4!. #fter the +#"- accident, production of T<% was stopped at that site. The same occurred at %hillips =uphar, where the plant was closed and subsequently dismantled) its pieces were swathed in concrete and dumped in the #tlantic Dcean. "imilar procedures were adopted at the <oalite site near +olsover. #fter the =ow <hemical accident, new installations were constructed there. The reactor was enclosed by a supplemental safety vessel, whose purpose was to collect and cool any to7ic material that might leak if reactor valves ruptured Dtway and #mendola /5;5!. "imilar *containment vessels* have been widely employed in nuclear power stations that house pressurized water(cooled reactors. Had there been such a vessel at I<9@"#, there would probably have been no "eveso disaster. =io7in was known to be an e7tremely dangerous substance, partly because of these industrial e7periences and partly because e7perimental evidence indicated that it was unprecedentedly to7ic to some species of laboratory animals. In many ways the image of dio7in was similar to that of radioactivity: it was invisible, it poisoned at

microscopic dose levels, and it was implicated in war. 9oreover, because dio7in was carried by people and things, it took on the appearance of a dread disease ( a plague. In particular, it was the sense of being gravely contaminated that increased personal, social, and economic distress among the affected population. %roducts of dio7in(impacted areas were re&ected because of feared contamination, thus imposing a stigma on whole communities. The Seveso "irective The best(known consequence of the "eveso disaster was the impulse that it gave to the creation of the @uropean <ommunityQs "eveso =irective, a new system of industrial regulation. .ithin the @<, each country previously followed its own rules for managing industrial safety. Argent discussions about a new @<(wide regulatory framework for ensuring the safety of hazardous installations started after an e7plosion of cyclohe7ane in the Oypro :td. plant at -li7borough Anited Ringdom, /52B!.1 =uring the ne7t two years, three additional serious chemical accidents occurred within the @uropean <ommunity: these were at +eek the Oetherlands /528!, 9anfredonia Italy /526!, and finally "eveso Dtway and #mendola /5;5) =rogaris /55/!. Dne of the most remarkable features of the "eveso e7perience was that neither the residents nor the local and regional authorities suspected that the I<9@"# plant was a source of risk. They did not even know much about the type of production processes and chemical substances that occurred there. #s the 9ayor reported ,occa /550, personal communication!, the factory had been in e7istence for 14 years and the only occasional complaints from nearby residents concerned some unpleasant smells. 9oreover, at "eveso as well as -li7borough, *changes had been made in plant or processes which compromised the safety of the facilities but were not communicated to authorities responsible for public health and safety* Dtway and #mendola /5;5: 842!. In light of these disastrous accidents it was clear that new legislation was needed to improve the safety of industrial sites, to plan for off(site emergencies, and to cope with broader regional and transboundary aspects of industrial safety. The "eveso =irective, adopted by the <ouncil of 9inisters of the @uropean <ommunities in 3une /5;0 =irective ;0I84/I@@<!, is the result of those efforts. # central part of the =irective is a requirement for public information about ma&or industrial hazards and appropriate safety measures in the event of an accident. It is based on recognition that industrial workers and the general public need to know about hazards that threaten them and about safety procedures. This is the first time that the principle of *need to know* has been enshrined in @uropean <ommunity legislation. The *need to know* principle is not as strong as the *right to know* principle that is widely applied in the Anited "tates. The status of *need* is determined by the authorities) it is not a right of citizens +aram /55/) ,oyal "ociety "tudy Croup /550!. #lthough the "eveso =irective grew out of deficiencies in the e7isting system of industrial regulation, it is not simply intended to provide protection against hazards: it is also designed to equalize the burden of regulation on industry. The creation of a single hazardous industry code ensures a *level playing field* for trade within the @uropean <ommunity by depriving unscrupulous industrial operators of competitive advantages that might flow from e7ploiting differences among varied national regulations. 9oreover, adoption of the *need to know* principle increases the political equity of decision(making and adds a valuable new tool to the regulatory process. The ne7t section e7amines this institutional response in greater detail. The Euro-ean Co&&unity=s institutiona) res-onse to Seveso

The Directive and its annexes Other institutional effects of the Seveso Directive

=irectives are one type of legislation issued by the @uropean <ommunity. Dthers include regulations, decisions, recommendations, and opinions. "ome of these are binding on the /0 @uropean states that make up the <ommunity, B while others are not. "everal different units of the <ommunity are involved in the process of legislating a directive table B./!. Ta3)e .41 Units o' the Euro-ean Co&&unity invo)ved in )e(is)atin( a directive

Euro-ean Co&&unity Unit <ommission <ouncil @uropean %arliament @uropean <ourt of 3ustice @conomic and "ocial <ommittee

Characteristics "eventeen members appointed by /0 9ember "tate governments for four years. Twelve representatives, one from each 9ember "tate government) presidency rotates among countries every si7 months. @lected by peoples of the @< for five(year term according to each 9ember "tateQs electoral system 8/; members in /550!. Thirteen &udges appointed by agreement among 9ember "tate governments for si7(year terms. #ssisted by si7 advocates(general. #ssists the <ouncil and the <ommission with @uropean @conomic <ommunity and @uropean #tomic @nergy <ommunity matters) /;5 members from various economic and social sectors.

The path for adopting a directive is as follows.8 The <ommission presents a proposal to the <ouncil. #fter consultation with the @uropean %arliament and the @conomic and "ocial <ommittee whose opinions must be heard even if they are not strictly binding!, the <ouncil may formally adopt the proposal. #fter adoption, an @< directive is not immediately applicable to a 9ember "tate. Individual states must incorporate the directive into national legislation and take all the necessary measures for compliance within a specified period. "uch a procedure allows for effective implementation, while respecting different &uridical and administrative traditions. If a 9ember "tate fails to comply, the <ommission may bring a case before the @uropean <ourt of 3ustice. In practice, the process of arriving at the directive on ma&or accident hazards was long and comple7. Technical and political problems required e7tended consultations among different parties and institutions. # proposal was finally presented by the <ommission to the <ouncil in 3uly /525. The required opinions of the @uropean %arliament and the @conomic and "ocial <ommittee were e7pressed in /5;4 and it took two more years of further consulting and discussion before a directive was finally adopted, on 0B 3une /5;0, ; 3anuary /5;B being the anticipated deadline for implementation by the /4 @< 9ember "tates of that time. =irective ;0I84/I@@< soon became known as the "eveso =irective, despite opposition from "eveso residents, who formally complained to @< authorities in +russels about what they perceived as an implied insult. +efore the "eveso =irective, manufacturers in different 9ember "tates were sub&ect to obligations of varying stringency. -or e7ample, the submission of a safety report by the manufacturer responsible for a hazardous installation was not mandatory in all countries. Therefore, the =irectiveQs main purpose was to ensure harmonization of regulations among different countries. This was achieved by establishing minimal @< requirements and permitting 9ember "tates to enforce stricter regulations. "uch a general purpose is consistent with the overall @< policy on environmental health and safety matters. It is instructive to review the =irectiveQs ma&or components. The "irective and its anne!es The "eveso =irective is addressed to @< 9ember "tates, and holds them responsible for ensuring that the relevant national institutions accomplish what is required for adequate risk management. The entire =irective is also shaped by a concern for prevention, even those parts that relate to post(accident activities. The first article defines relevant terms such as *industrial activity, manufacturer, ma&or accident, and dangerous substances.* It also makes reference to four anne7es that identify types of production, operations, and storage activities that are sub&ect to regulation, and dangers that are anticipated. #rticles 1 and B require 9ember "tates to ensure that manufacturers identify e7isting ma&or accident hazards and adopt all appropriate safety measures, including information, training, and equipment for workers. They must also provide competent authorities with a notification containing detailed and updated information on safety precautions and other matters #rticle 8!. 9oreover, 9ember "tates must set up competent authorities that will take responsibility for receiving such a notification, e7amining the information provided, organizing inspections or other measures of control, and ensuring that off(site emergency plans are prepared #rticle 2!. -urthermore, 9ember "tates are held responsible for assuring that *persons liable to be affected by a ma&or accident... are

informed in an appropriate manner of the safety measures and of the correct behaviour to adopt in the event of an accident* #rticle ;!. #rticle ; is a very innovative feature in safety legislation. -or the first time in @urope, the safety of people outside hazardous installations is taken into account) previously, only workers might have the right to be informed. The publicQs right to know was recognized on both pragmatic and ethical grounds. Oot surprisingly, this article met with strong resistance and was sub&ect to long delays in implementation .ynne /5;2) =e 9archi /55/a, /55/b!. =espite these initial difficulties, the =irective proved to be a watershed event. 9atters that had previously been considered suitable *for e7perts alone* were now opened to inspection by ( and input from ( the general public. #rticle /4 requires that 9ember "tates shall take the necessary measures to ensure that the manufacturer immediately provides full and detailed information about an accident to the competent authorities) they must in turn ensure that all necessary measures are taken and that full analysis of the accident is accomplished whenever possible. It is a specific obligation of 9ember "tates, to report any accident to the @< <ommission #rticle //!. The <ommission is in charge of setting up a register containing a summary of ma&or accidents that occur within the @<, including an analysis of causes, e7perience gained, and measures taken to enable 9ember "tates to use this information for prevention purposes #rticle /0!. #nne7 EI to the =irective lists the items of information that the 9ember "tates must report to the <ommission in the event of a ma&or accident. The =irective includes provisions for ensuring effective implementation and for updating in light of technological change. #rticle /8 provides for the creation of a committee composed of representatives of the 9ember "tates and chaired by a representative of the <ommission. The 9ember "tates and the <ommission are e7pected to e7change information about the e7periences acquired regarding the prevention of ma&or accidents and the limitation of their consequences. "uch information covers the operation of measures stipulated in the =irective #rticle /;!. 9oreover, the <ommission is required to make proposals for revising the technical anne7es as new technologies are adopted. %rocedures for updating and revision include regular meetings of the <ommittee of <ompetent #uthorities. "uch meetings have produced two amendments to the original =irective that grew out of e7perience with ma&or industrial disasters in +hopal, 9e7ico <ity, and +asle during the early /5;4s. The first amendment, =irective ;2I0/6I@@<, adopted by the <ouncil on /5 9arch /5;2, modifies #nne7es I, II, and III by lowering the threshold quantities of certain substances and including additional industrial activities in the category that requires notification under #rticle 8. =uring the revision process, between /525 and /5;2, there was a continuous e7change of correspondence between the "pecial +ureau for "eveso Afficio "peciale!, which had been set up by the :ombardy ,egion in 3une /522 see <hronology!, and various institutions of the @< ,egione :ombardia /550!. In /5;B, a report was prepared by the Afficio "peciale for a meeting of a committee of the @uropean %arliament which was held in "eveso 9eazza /550, personal communication!. The second amendment, =irective ;;I6/4I@@< issued by the <ouncil on 0B Oovember /5;;, further revised #nne7 II to include more types of storage activities. It also substantially revised #rticle ;, stating that information shall be made publicly available as well as actively provided in an appropriate manner. "uch information shall be periodically repeated and updated as necessary. # new anne7, #nne7 EII, was added, which specifies the information that shall be provided to the public.6 The official deadline for compliance of 9ember "tates with =irective ;;I6/4I@@< was / 3une /554. 9eetings of the <ompetent #uthorities have continued after the adoption of the second amendment, and further revision of the "eveso =irective is being discussed. #ther institutional e$$ects o$ the Seveso "irective In order to meet the "eveso =irectiveQs requirements, the 9a&or #ccident ,eporting "ystem 9#,"! data bank has been established to store and retrieve accident information reported by the 9ember "tates =rogaris /551!. It is located at the <ommissionQs 3oint ,esearch <entre, Institute of "ystems @ngineering and Informatics in Ispra, Italy. To promote safety(related knowledge further, a <ommunity =ocumentation <entre on Industrial ,isk <=<I,! has also been established at the same site. This <entre collects, classifies, and reviews materials relevant to industrial risks and safety.

The effects of the "eveso =irective were not confined to improvements in the management of industrial accidents. The =irective also opened the floodgates for similar initiatives on a variety of other issues, particularly in the fields of environmental management and public health. #mong these are the following: =irective ;5I15/I@@<, which mandates the introduction of measures to encourage improvements in occupational safety and health) =irective ;5I68BI@@<, which addresses minimum safety and health requirements for the workplace) =irective 54I0/5I@@<, which relates to biotechnology) =irective 54I1/1I@@<, on the freedom of access to environmental information) and =irective ;5I6/;I@uratom, which concerns public information about radioactive emergencies. The @uropean "ingle #ct and the 9aastricht Treaty also call for greater participation of citizens in @< decision(making and this has e7panded the scope of public information programmes. Indeed, recent reluctance by =anish voters and others to approve the 9aastricht Treaty has led to further broadening of the commitment to provide information in support of public policy within the @<. +eyond the @uropean <ommunity, the =irective has relevance for many international organizations. Those that are concerned with industrial hazards include the .orld +ank, the Anited Oations @nvironment %rogramme, the <ouncil of @urope, the International #tomic @nergy #gency I#@#!, the Dffice of the AO =isaster ,elief <o( ordinator AO=,D!, the .orld Health Drganization .HD!, and the International :abour Drganization I:D!. In particular, the D@<= Drganisation for @conomic <o(operation and =evelopment! has devoted much attention to accident prevention and response and has published a number of recommendations, some of which are specifically addressed to public information and public participation in decision(making D@<= /5;5, /554, /550!. The )essons o' Seveso

A model for managing uncertainty Modelling the Seveso disaster Modelling the Seveso Directive Modelling the Karin B incident A moral paradox A scientific paradox Industrial accidents, industrial society, and recovery

A model $or managing uncertaint 9any students of disaster have concluded that uncertainty and communication are key factors in the management of emergencies. =uring emergencies, uncertainty increases and formerly dominant consensual views of problems and solutions often break down) different parties tend to evaluate the same evidence differently and, at times, tend to perceive different sorts of evidence. "uch divergent interpretations create antagonisms and mistrust, which persist after the acute phase of an emergency has ended and complicate the tasks of recovery Nuarantelli /5;;) Dtway and .ynne /5;5!. Dur study of "eveso and other disasters =e 9archi, -untowicz, and ,avetz /551! suggests that there are si7 basic types of uncertainty table B.0! and eight distinctive strategies for managing the communication of uncertainty table B.1!. Together, these two sets of variables provide the basis for a model of uncertainty management that has broad applicability. Ta3)e .42 Ty-es o' uncertainty Ty-e "ituational :egalImoral "ocietal Institutional Descri-tion Inadequacy of available information in relation to necessary decisions %ossibility of future liability or guilt for actions or inactions #bsence or scarcity of integration of publics and institutions .ithholding of information by agencies for bureaucratic reasons

%roprietary "cientific

<ontested rights to know, to warn, or to conceal =ifficulty of risk assessment or of forecasts of emergencies

Ta3)e .4M Strate(ies 'or co&&unication o' uncertainty Inter-retations Po)icies "uppression =iscounting ,ecognition #mplification "ecrecy <onfidentiality %ublicity "haring

Situational uncertainty involves a poor match between the decisions that must be taken and the information at hand. It is normally the most salient type of uncertainty because information is central to decision(making. It is also a very common type of uncertainty because complete highquality information about ma&or hazards is usually lacking. 9oreover, interagency collaboration in decision(making is usually required and knowledge about the capabilities of such agencies is often incomplete. In an ideal world, legal%moral uncertainty would not be salient because decisions would always be made in the public interest with due consideration of social &ustice) decision makers would be held free of liability. +ut few public decisions about industrial hazards meet these e7acting criteria, so decision makers cannot ignore the possibility that they will be sub&ect to legal action or moral censure. <oncern about legalImoral uncertainty often leads to indecisiveness and defensiveness about the release of information. Societal uncertainty occurs when institutions and the publics that they are intended to serve are not well integrated. =ecisions that are sub&ect to high degrees of legalImoral uncertainty also tend to be affected by societal uncertainty. "uch uncertainty is most marked where every action is scrutinized by lawyers who represent other stakeholders. +ut societal uncertainty can be manifested in other ways. -or e7ample, respect for government agencies may be low, or individualism may be carried to e7tremes, either among the public or among leaders in ma&or institutions. Institutional uncertainty is brought about when agencies withhold information for bureaucratic reasons. It is most likely to be high in circumstances where there are difficulties about informal communication, acquaintance, and trust among personnel of agencies with different traditions and missions. This ensures that the necessary channels of understanding and confidence are absent during a crisis. Institutional uncertainty can be high even in relatively consensual societies, if there happens to be a tradition of bureaucratic secrecy. .hen the parameters of confidentiality are strained, proprietar uncertainty becomes salient. Thus, in the midst of an emergency there may be a debate about the rights of persons to know, to warn, or to conceal. Scienti$ic uncertainty is the last but by no means the least important! type of uncertainty. It is mobilized at various phases of hazard including before, during, and after emergencies. -or e7ample, scientific! risk assessments that are undertaken well in advance of a crisis may employ long(established techniques to evaluate industrial plants and equipment but may have to depend on less(seasoned methodologies to analyse the transport of environmental pollutants -untowicz and ,avetz /554!. .hen a hazard is in the acute emergency! phase, the possibility of effective forecasting may be either good or poor, depending on the circumstances which themselves cannot always be predicted!. Thus, scientific uncertainty can vary from low to very high. Two sets of strategies table B.1! are available for communication of uncertainty, one of which is an attribute of people or agencies that make decisions) the other refers to the way in which communication is accomplished. "ome people may decide to suppress information about uncertainty entirely, even from themselves. This may translate into a refusal to admit that uncertainty e7ists or a failure to notice it. It is an e7treme form of discounting. Drdinary discounting will recognize a possibility but as with many events in the distant future! will assign such a low value to its salience that it can be neglected for policy purposes. &ecognition of an uncertain

contingency is a balanced appreciation. +y contrast, ampli$ication is an emphasis ( perhaps even an overemphasis ( of the significance of uncertainty. <orresponding to the interpretations are the policies concerning communication of uncertainties. #t one e7treme lies secrec , the e7treme case of con$identialit ) then comes publicit , with its own e7treme form ( sharing. There are many variations and nuances in any practical policy of communication. The utility of these classification schema can be illustrated with reference to the "eveso disaster, the "eveso =irective, and the 'arin B incident. Modelling the Seveso disaster #t the time of the "eveso disaster, the comple7ity of communication problems under conditions of severe uncertainty was recognized, if not fully managed. +efore the gas release, no one outside the plant neither residents nor political or health authorities ( had any idea that there was a hazard of such magnitude. The e7plosion and release were greeted by incredulity, followed by alarm and dismay. The firmQs initial behaviour led to subsequent suspicion about their motives) various instructions for precautionary measures were issued almost immediately, but the firm denied knowledge of the to7ic substances involved ,occa /5;4) ,occa /550, personal communication!. Ten days passed before the firm confirmed that dio7in had been released %occhiari, "ilano, and Kapponi /5;2!. Dnly then did the governmental authorities and the public learn that there was a grave risk. @ven so, it was impossible to assess the danger with any precision. There was an onset of genuine dread, about illness in general and about malformed babies in particular. The widespread illness and deaths of animals of many species was an ominous sign. The authorities had their own severe problems of decision( making under uncertainty, including the definition of different polluted zones, programmes of evacuation of endangered residents, and disposal of contaminated material. -rom the very beginning of the disaster, situational uncertainty was salient) decisions had to be taken, sometimes under conditions of great urgencyQ in the nearly complete absence of information that might guide actions. "cientific uncertainty was salient, as shown by the fact that local investigating magistrates closed off the site within eight days of the accident. "ocietal uncertainty was severe because there had been no previous institutional preparation or consultation for the accident. :egalImoral uncertainty was also severe. -or e7ample, the "wiss! Technical =irector of I<9@"# found himself under arrest when he attended a works meeting /0 days after the accident the =irector of %roduction was also placed under arrest at that time, and was assassinated by terrorists four years later!. Dne of the few relatively straightforward aspects of the accident was the low level of proprietary uncertainty. #lthough the provision of relevant information did not proceed as quickly or smoothly as desired by all, at least there was no need for the government authorities to use legal means to force the firm to divulge information. The fact that the I<9@"# factory was already sequestered would have made it highly imprudent for its owners to withhold information about the contaminants, and it was noted at the time that the dio7in threat had already been publicized by the media before it was officially confirmed. :ater, and off the "eveso site, proprietary uncertainty was not as low, particularly in connection with the disposal of barrels containing to7ic materials. -rom /5;0 onwards, stories of concealment and blunders began to circulate and these have not yet ended see <hronology!. Modelling the Seveso "irective Dur model of uncertainty management is also reflected in the regulations of the "eveso =irective. The main concern here is with communication: Member States shall ensure that in$ormation on sa$et measures and on the correct behaviour to adopt in the case o$ an accident is supplied in an appropriate manner( and )ithout their having to re*uest it( to persons liable to be a$$ected b the ma+or accident originating in a noti$ied industrial activit )ithin the meaning o$ Article ,. The in$ormation should be repeated and updated at appropriate intervals. It shall also be made publicl available. Such in$ormation shall contain that laid do)n in Anne! -II. .Article / o$ "irective //%012%EEC( amending "irective /3%,21%EEC4 This portion of the =irective reflects concerns about several sorts of uncertainty. -irst, there is an attempt to institute progressive reduction of scientific uncertainty via updating requirements. "econd, the various phrases that call for effective implementation of the publicQs right to know show clear awareness of the need to confront problems of institutional uncertainty and proprietary uncertainty. 9oreover, the very e7istence of the =irective,

particularly #rticle ;, underscores heightened awareness of legalImoral uncertainty, for the "eveso event showed that simple *accidents,* or *acts of Cod,* are not the most important problems affecting the safety of industrial installations and surrounding communities. .hen we consider the implementation of the hazard communication requirements of #rticle ;, we find that the model illuminates practice. -irst, actual @< regulations seem to assume that societal and institutional uncertainties are not salient or severe. Oor do they deal with the possibility of situational uncertainty i.e. less than complete competence of available official e7pertise for prediction, prevention, or control!. The contrast between @uropean and #merican practice is noteworthy. In the Anited "tates, provision is often made for the inclusion of alternative e7pertise via environmental legislation that permits the use of public funds for the incorporation of local citizensQ knowledge into the policy discourse on the grounds of due process or fairness. Modelling the 'arin B incident -inally, the model can also be applied to the 'arin B incident. "ome /0 years after the "eveso gas release, a shipload of Italian industrial to7ic wastes was first dumped in Oigeria and then reloaded after protests. In the full glare of publicity and widespread public dread, the regions of @milia(,omagna and Tuscany undertook the final task of disposal, in the process showing how a large quantity of mi7ed to7ic wastes could be managed, with full satisfaction of technical requirements and local concerns. +etween the time that the 'arin B was discovered to be carrying a to7ic cargo and the eventual agreement on destruction of the wastes, all uncertainties were effectively out of control. .hoever knew about such shipments had previously kept them secret) when they were discovered, therefore, all the issues of knowledge, uncertainty, and responsibility came into play simultaneously. However, when the regional authorities of @milia,omagna and Tuscany together with several local authorities ( finally took physical possession of the wastes, the change was dramatic. #cting in cooperation with each other and with the media, and creating opportunities for the participation of interested communities, they were able to reduce salient uncertainties, starting with the scientific ones and then proceeding to others, such as institutional uncertainties. The societal uncertainties became less severe and less salient, and the clean(up operation proceeded peacefully to a successful conclusion in all respects <entro Informativo Rarin + /550) @gidi /551!.

@,,I"

Environmental Risk Reportin and !n"ormation System

In July 1976, a runaway reaction occurred in the trichlorophenol synthesis essel of a che!ical plant near Se eso, Italy. "n uncontrolla#le sur$e in te!perature and pressure caused the rupture of a safety al e, resultin$ in release into the air of a fluid !i%ture of che!icals. &his to%ic cloud containin$ &'(( )2,*,7,+,tetrachlorodi#en-o,p,dio%in., then widely #elie ed to #e one of the !ost to%ic !an,!ade che!icals, conta!inated a densely populated area a#out si% /ilo!etres lon$ and one /ilo!etre wide, lyin$ downwind fro! the site. &his e ent #eca!e internationally /nown as the Se eso disaster, after the na!e of a nei$h#orin$ !unicipality that was !ost se erely affected. 0ore than 711 people were e acuated, and restrictions were applied to another *1,111.

&he I!pact
"lthou$h no i!!ediate fatalities were reported, the full horror of the incident slowly e!er$ed o er the followin$ days, !onths and years. 0ore than 211 people ha e #een treated for dio%in poisonin$ and countless thousands of ani!als died, or /illed to pre ent further i!pact alon$ the food chain. 0ore than fi e s2uare !iles of land and e$etation were conta!inated. " !onitorin$ pro$ra! was initiated for en iron!ental syste!s and !edia to deter!ine the le el of e%posure, the e%tent of conta!ination, and the #eha ior and fate of &'(( released into the en iron!ent. Infor!ation a#out e%posures was also o#tained fro! si$ns3sy!pto!s. 4lood sa!ples were collected and analy-ed for &'(( and #lood che!istry. &he early screenin$ of thousands of children re ealed chloracne as the !ain health effect.

Lon$,ter! effects studies of !ortality and cancer incidence were desi$ned usin$ the populations fro! four conta!inated and se en unconta!inated towns, who were resident at the ti!e of the incident and for the followin$ ei$ht years. &he ten,year !ortality study re ealed an increased occurrence of cardio ascular diseases that !i$ht ha e #een related to stressors caused #y the disaster. 5esults fro! the cancer incidence study showed an increased ris/ of hepato#iliary cancer in so!e su#6ects, particularly those residin$ for !ore than fi e years. So!e !en had an increased ris/ of leu/e!ia, and wo!en e%hi#ited an increase in !ultiple !yelo!a and !yeloid leu/e!ia. In another -one, su#6ects e%perienced an ele ated incidence of soft,tissue sarco!as. &he researchers clai!ed that these findin$s were consistent with pre ious /nowled$e of &'((7s effects on ani!als and hu!ans. &he !ortality and cancer incidence in esti$ations were planned to continue for at least 21 years after the release. 'ase8control studies ha e #een initiated to in esti$ate the possi#le role for !ar/ers of suscepti#ility to &'((.

Cancer incidence in Seveso

'ancer incidence at Se eso, ten years after the accident9 " era$e dio%in found in $round e%pressed in !icro$ra! I,&:; per s2uare !eter. " era$e dio%in found in #lood e%pressed in parts per trillion )ppt..

5ecently, the <=> has declared the Se eso type dio%in )2,*,7,+ &'((. as a hu!an carcino$en, #ased on the conse2uences of se ere accidents in se eral che!ical wor/s, where wor/ers recei ed e%tre!e hi$h le els of this dio%in type )tenthousends of ti!es hi$her than #ac/$round?.. &he rise of cancer incidences in a life ti!e was app. @1A for the hi$hest e%posed people. &hat has to #e co!pared with a 21 ti!es )or 2,111A. rise in cancer incidence for s!o/ers...

&he other 219 types of chlorinated dio%ins and furans are not classified until now, #ecause of lac/ of relia#le data.

&he Se eso (irecti e

Bations downstrea! fro! other nations will always #e threatened #y en iron!ental spills and accidents caused #y upstrea! nations. =un$ary, with 9C percent of its surface waters ori$inatin$ a#road, is particularly ulnera#le.

Dor this reason, international treaties and laws $o ernin$ trans#oundary pollution are crucial for pre entin$ disasters. &hey are needed to resol e issues related to lia#ility and co!pensation. &hey are also needed to protect countries fro! do!estic disasters caused #y

the carelessness or e%ploitati e acti ities of forei$n co!panies.

Bu!erous treaties and laws do now e%ist. So!e include =un$ary and 5o!ania as Econtractin$ partiesE Le$islation ai!ed at the pre ention and control of accidents in ol in$ dan$erous su#stances in the :U was si$nificantly pro!pted #y one particular disaster fro! the past. &he disaster at Se eso, Italy resulted in releasin$ lar$e a!ounts of poisonous dio%ins into the air, conta!inatin$ ten s2uare !iles of land and e$etation. > er 611 people were e acuated with as !any as 2,111 treated for dio%in poisonin$.

"s a result, in 19+2, the Se eso (irecti e )'ouncil (irecti e +23C113::'. on the !a6or accident ha-ards of certain industrial acti ities was adopted, later a!ended in li$ht of two other !a6or accidents. &he first was the 19+@ che!ical disaster at the Union 'ar#ide factory in 4hopal, India, where o er 2,C11 people died. &he second was the 19+6 catastrophe at the Sando- warehouse in 4asel, Swit-erland, where a !a6or che!ical lea/ laden with !ercury led to the !assi e pollution of the 5hine 5i er and the death of half a !illion fish.

In 1996, the Se eso (irecti e II )'ouncil (irecti e 963+23:'. replaced its predecessor. Still in effect, it ai!s to pre ent !a6or accidents in ol in$ dan$erous su#stances and to li!it their conse2uences for hu!ans and the en iron!ent. It co ers industrial acti ities and the stora$e of dan$erous che!icals, e%pands the pu#licFs ri$ht to access infor!ation and re2uires $o ern!ental authorities to carry out re$ular inspections.

Se eso (irecti e, as fallout to the disaster

&here was no professional en$ineer in the plant at the ti!e of the accident. &he te!porary !odification was constructed #y people who did not /now to desi$n lar$e pipes e2uipped with #ellows. &he Dli%#orou$h plant contained appro%. @11 0& of in entory of which @1 or C10& escaped. &he in entory was lar$e #ecause the con ersion was low and !ost of the !aterial had to #e reco ered and recycled. &he !ost i!portant lesson that Dli%#orou$h tau$ht is the need to !ini!i-e in entories of ha-ardous !aterials.

&he disaster led to a widespread pu#lic outcry o er industrial plant safety, and si$nificant ti$htenin$ of the UG $o ern!entFs re$ulations co erin$ ha-ardous industrial processes. "ll refineries and related petroche!ical industries were shoc/ed fro! the accident, althou$h they were aware of the ris/ of plant !odifications and i!!ediately i!pro ed their procedures and chec/lists in order to appro e plant !odifications. &e!porary !odifications were e en e%cluded in so!e cases or appro ed after thorou$h e%a!ination. "lthou$h !any !odification accidents occurred, Dli%#orou$h is still the stoc/ e%a!ple, the !ost disastrous of the! all.

&he Lessons Learnt fro! the (isaster

"t the ti!e of the Se eso disaster, the co!ple%ity of co!!unication pro#le!s under conditions of se ere uncertainty was reco$ni-ed, if not fully !ana$ed. 4efore the $as release, no one outside the plant neither residents nor political or health authorities , had any idea that there was a ha-ard of such !a$nitude. &he e%plosion and release were $reeted #y incredulity, followed #y alar! and dis!ay. &he fir!Fs initial #eha ior led to su#se2uent suspicion a#out their !oti esH arious instructions for precautionary !easures were issued al!ost i!!ediately, #ut the fir! denied /nowled$e of the to%ic su#stances in ol ed. &en days passed #efore the fir! confir!ed that dio%in had #een released. >nly then did the $o ern!ental authorities and the pu#lic learn that there was a $ra e ris/. : en so, it was i!possi#le to assess the dan$er with any precision. &here was an onset of $enuine dread, a#out illness in $eneral and a#out !alfor!ed #a#ies in particular. &he widespread illness and deaths of ani!als of !any species was an o!inous si$n. &he authorities had their own se ere pro#le!s of decision,!a/in$ under uncertainty, includin$ the definition of different polluted -ones, pro$ra!!es of e acuation of endan$ered residents, and disposal of conta!inated !aterial.

Dro! the ery #e$innin$ of the disaster, situational uncertainty was salientH decisions had to #e ta/en, so!eti!es under conditions of $reat ur$encyF in the nearly co!plete a#sence of infor!ation that !i$ht $uide actions. Scientific uncertainty was salient local in esti$atin$ !a$istrates closed off the site within ei$ht days of the accident. Societal uncertainty was se ere #ecause there had #een no pre ious institutional preparation or consultation for the accident. Le$al3!oral uncertainty was also se ere >ne of the few relati ely strai$htforward aspects of the accident was the low le el of proprietary.

4earnin" from Major Accidents