Journal of Loss Prevention in the Process Industries 18 (2005) 205208

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The unfolding of Bhopal disaster

T.R. Chouhan*
Ex-MIC Plant Operator, Union Carbide Plant, Bhopal

Abstract

As an employee of Union Carbide India at the Bhopal plant, I know how the disaster happened. The merciless cost-cutting severely
affecting materials of construction, maintenance, training, manpower and morale resulted in the disaster that was waiting to happen.
Significant differences between the West Virginia, USA plant and the Bhopal, India plant show the callous disregard of the corporation for
the people of the developing countries. The narrative below, if given a proper thought by the management and governments, should help in
significantly reducing industrial accidents.
q 2005 Published by Elsevier Ltd.

Keywords: Bhopal gas tragedy; Safety; Industrial accidents; Methyl isocyanate; MIC

1. The details iron, rust, etc.) entering the storage tank 610 of the Union
Carbide MIC plant. The phosgenes stripping still and the
Since I was an employee of the Union Carbide India quench filters safety valves downstream (four in
before and also when the tragic event took place on the night numbers) were connected to the relief valve vent header
of December 23, 1984 in Bhopal, I am aware of the (RVVH). These lines were badly choked with solid
sequence of events that led to it. I am here today to share my sodium salts deposition. The exercise of washing these
experience with you. filters started at 8:30 PM on 2nd December 1984. Because
To begin with, I would like to state that the disaster was not of the choking of these lines and malfunctioning of
merely an accident! Extensive details are given in (Chouhan, RVVH isolation valve, the water entered the RVVH main
2004). The points that I would highlight subsequently will header (Fig. 1). This header was connected to the MIC
prove how such a big multi-national corporation (like Union storage area. The RVVH header of storage area was also
Carbide) had little concern about the safety and well-being of connected to the process vent header (PVH) with a jumper
people in a developing country like ours. Not just that, even line (Fig. 2 shows where the jumper line was connected. It
the technology they used was unproven and faulty. For was removed when the remainder MIC was utilized on
instance: emergency procedure for MIC storage tanks for December 16, 1984). The blow down valve of the MIC
Bhopal plant as per the MIC operating manual reads: If a leak tank 610 was malfunctioning and was in an open position.
develops in a tank that cannot be stopped or isolated, the (The tank had been unable to maintain pressure when
material in the tank may be pumped to another tank. There pressurized using nitrogen a few days earlier.) The water
will be exceptions to all these guidelines. We will learn along with the catalytic material entered the tank. Other
more and more as we gain actual experience. It implies that MIC storage tanks, numbered 611 and 619, were holding
they did not know the process well enough to advise the pressure so that they were not contaminated.
As the 42 tons of MIC in tank 610 got contaminated with
emergency procedure in many situations.
water and the catalytic material, the exothermic reactions
The toxic gas that leaked into the Bhopal atmosphere
began and within an hour, turned into violent runaway
that night was due to water (along with catalytic material:
reactions resulting in high pressure and temperature in the
tank. The reaction products and the unreacted MIC started
* Corresponding author. Tel.: C91 755 2600732; fax: C91 9302370740. coming out through PVH/Jumper line/RVVH/VGS
E-mail address: [email protected] and finally to the atmosphere through the atmospheric vent
0950-4230/$ - see front matter q 2005 Published by Elsevier Ltd. line and overflow vent line of scrubber, between approxi-
doi:10.1016/j.jlp.2005.07.025 mately 12:15 and 2:30 AM.
206 T.R. Chouhan / Journal of Loss Prevention in the Process Industries 18 (2005) 205208

5. Danger alarm (siren). Installed for warning the

community people, was switched off after 5 min as per
the revised company policy. Thereafter, only the muted
siren for the plant personal was sounded. No plant
person died due to the gas. If the loud alarm for the
community had been sounded for long, many would
have escaped before the gas overpowered them.
6. Evacuation plan. It was only made for the plant
personal, not for the community.

The management had told the workers that the Bhopal

plant was designed and built on the basis of 20 years
experience in making MIC in the West Virginia, USA plant.

Fig. 1. Four quench filters and RVVH isolation valve (with wheel, top right).
Table 1
Comparative designs of Union Carbide MIC production plants in West
The safety equipment provided for the Bhopal plant were Virginia, USA and Bhopal, India
as follows:
West Virginia plant Bhopal plant
1. Vent gas scrubber (VGS, Fig. 3). It was designed to All lines and instruments spread out On one single manhole
neutralize the toxic release material released from over whole tank
various equipment of MIC plant. However, it was not Computerized control No computerized control
PVH and RVVH lines: 304 SS C-Steel (although prohibited due
capable of controlling the runaway reaction. (Further, it to safety considerations)
was not operational that night). Unit storage tank between MIC No such tank
2. Flare tower (Fig. 4). It was designed to burn out excess manufacture and large storage tank
CO and MIC vapors at a controlled rate and was not to check purity
Four Vent Gas Scrubbers (VGS, One vent gas scrubber (no
capable of burning the huge amounts released that night. inbuilt redundancy) redundancy)
(Further, it was under maintenance that night). VGS had no atmospheric vent VGS released gases into air. This
3. MIC storage 30 tons refrigeration system. It was caused the tragedy
installed to keep the storage tank material below 5 8C. Two flare towers (FT, inbuilt One flare tower (no redundancy)
redundancy)
(However, the system had been shutdown in May 1984
Designed for emergency MIC Designed for occasional releases
to save power, approx. $ 20/day). release only
4. Water spray. This could be used to knock out the toxic VGS, FT operational around the Not available when shutdown for
chemical vapor by spraying large amount of water. But, clock due to redundancy repairs
while the toxic gases were released at 30-m (100 ft) Intermediate, non-interactive Direct brine as coolant: could
refrigerant react with MIC in case of leak
above ground, the water spray could not reach that a-Naphthol added through pipe line a-Naphthol added manually from
height and hence could not knock out any gas. jute sacks after opening MIC
reactor manhole. Several other
hazardous operations performed
manually
Pressure, temperature, level instru- Not trustworthy; temperature
ments functioned well indicator worked only the first
few months
PVH and RVVH lines from storage Lines from other equipment also
tank direct to VGS and flare tower joined these lines. Probability of
contamination of MIC high
MIC storage temperature %5 8C !5 8C when drums being filled
to minimise vapor loss.
Refrigeration shutdown since
May 1984. Power saved (w$ 20/
day)Ocost of MIC vapor loss
Operation and maintenance under Not so (training and number
trained, experienced staff, enough in declined)
number
Complete evacuation plan for com- No evacuation plan for commu-
munity in place nity
Hospital, train, road, river transport, No such arrangements existed
police, civic administration
Fig. 2. Jumper line was connected to PVH line (left) and RVVH line (right, informed in an emergency
larger diameter).
 T.R. Chouhan / Journal of Loss Prevention in the Process Industries 18 (2005) 205208 207

16
Operators High School
14
Operators BSC/Diploma
12

Number of Persons
Maintenance Supervisors
10 Shift Spervisors
8 Plant Suptd.

6
4
2
0
1979-80 1981-82 1984 1984 Nov

Fig. 3. Vent Gas Scrubber. MIC came out from the tall pipe left of centre. Fig. 5. MIC plant supervisory/operating staff; declining numbers
19791984.
We felt excited knowing that we were going to work in a
However, it could have warned of the runaway
modern, sophisticated and automatic chemical plant. After
reaction occurring much earlier.
the disaster, I came to know of a lot of differences between
B The refrigeration unit (30 tons capacity) had
the MIC plants in W. Virginia and Bhopal (Table 1). It is
evident from Table 1 that the Bhopal plant was not designed been down for over an year, and was totally
to handle emergencies that the West Virginia plant could shutdown in May 1984. As a result, the MIC tank
have. was at ambient temperature while the MIC
manual had strongly recommended keeping MIC
below 5 8C.
B The vent gas scrubber was not operating at the
2. Causes behind the Bhopal gas disaster
time of the accident.
B The flare tower had been under maintenance since
The order for water washing was given without
November 25, 1984 and maintenance was not
Placing slip blinds completed until the accident. The job could have
Checking related lines been completed within 8 h but for the shortage of staff.
B Manpower was reduced in all categories (Fig. 5)
Disconnecting various lines.
B Sodium hydroxide (NaOH) solution, in the VGS B Fire and rescue squad (emergency squad) members

unit and field storage tanks, was insufficient for were not qualified and trained to handle such an
neutralization of such a large amount of gas. accident.
B The pressure control valve for the MIC storage tank B There was no maintenance supervisor for the night

(610) had not been functioning for over a month. shift.

Water entered through this route. Nobody was aware of such types of runaway reactions in
B The temperature sensor and alarm for the MIC the storage tank and therefore proper emergency steps were
storage tank had not been working for almost 4 not taken.
years. Therefore, regular recording of temperature B MIC plant operating personnel did not have the

in the log sheets was not done. According to the qualifications and training that were necessary.
officers this parameter was not important. Training had been reduced over the years (Figs. 6
and 7).
Training Programme (MONTHS)

20
18
16
14
12
10
8
6
4
2
0
1975 1977 1978 1979 1980-82 1984 1984
Nov-Dec

Fig. 4. Flare tower. Fig. 6. Duration of training programme for operators of UC plant, Bhopal.
208 T.R. Chouhan / Journal of Loss Prevention in the Process Industries 18 (2005) 205208

100 100
90 90
Fully Trained 80
80
% Operating Staff

70

Percentage
70 Transferred
60
60 50
50 40
40 30
30 20
10
20 0
10 1979-81 1982-83 1984 1984
0 Nov- Dec
1980 1981 1982 1983 1984
Year Fig. 8. Relative safety of MIC plant based on its design, operation,
maintenance, number of staff and their training.
Fig. 7. Declining number of trained staff; operators and supervisors at MIC
plant. Transferees from other plants had less training. accident, and then stated that MIC gas was like a tear
gas and the effects would be temporary. No effective
B The agreement between the union and the manage-
antidote was told.
ment was completed in 1983 by-passing the safety
B The civic authorities did not know the treatment since
rules.
they had not been informed of the extremely
B Improper behavior of management with the operating
hazardous nature of the material stored.
personnel.
B Keeping all the above developments in mind, no one
B Incorrect modifications of the relief valve vent header
should be surprised that such a major accident took
(RVVH) and process vent header (PVH) by providing
place. It was waiting to happen (Fig. 8).
interconnection with a jumper line in the MIC storage
area (Fig. 2). My objective in this presentation is to see that such
B The design and technology given by the Union disasters are averted all over the world. I do hope that MNCs
Carbide Corporation was not safe and sufficient for while investing in such projects in developing countries
preventing contamination and controlling runaway would be as concerned and careful of the safety and well-
reaction. being of the recipient country people as they would be of
B The loud siren did not start at the proper time and was their own.
shut down after 5 min since the siren policy had been
modified.
B There was no evacuation plan for the neighboring
area/communities. Even after the accident the References
neighboring communities were not informed.
B The Plant superintendent did not inform outside Chouhan, T.R. (2004), Bhopal - The Inside Story, 2nd edition, Goa, India:
agencies about the accident. Initially, he denied the Other India Press; New York, USA: The Apex Press.