Systematic Risk Bhopal Gas Tragedy


Question: Write a paper on systemetic risk.



Bhopal gas accident was the spillage of the methyl isocyanate or MIC, a toxic substance to the air in major quantities from a pesticide plant. Poor practices of safety management, poor hazard management, a poor early warning system and a lack of perception of associated risk are attributed to the accident. 

Description of the failure

As per the guidelines provided in the manual for safety, there should be an active mode of scrubber, as it requires alkali sprayed while the plant is in operation. Had the scrubber is kept in a passive mode and the refrigerator is shut down, problem would not have occurred. For the maintenance purposes, the plant was closed for two months before the accident has happened and the operations were to be resumed in December. However, on the 26 of November, when the operator pressurized MIC tank 610, in an effort to transfer MIC to the processing unit as tank has  about 42 tons of MIC. Even though there was a transfer of nitrogen into inside, pressure did not developed in the tank, which indicated a leak. Rather than attending on the leak, the management has taken the decision to pressurize the tank that contained about forty tons of MIC. On the 3 of December, the supervisor of MIC plant order the washing of lines of MIC lines in a presumption that there is a blockage in the line. While cleaning, it was found that some of the lines were clogged and the supervisor who was new to this particular unit ordered washing after twenty minutes. Accumulation of water and absence of using a slip bind triggered the event for water entry. Investigations indicated that Union Carbide Corporation or UCC has permitted the Union Carbide India Ltd., to perform modifications of the plant. (Morehouse and Subrahmanian,1986). People In the vicinity of the plant were affected severely by the vapors of MIC and officially deaths were accounted to 2500 due to gas leakage. 

The time line

Evening  of 2 December 1984
Washing of the relief valve lines without isolation
Identifications of blocks in the lines, orders from supervisor to continue washing
Tank 610 fails to get pressurized
Change of shift
Water entry, logging of the pressure by the operator
Detection of first leakage of MIC, high pressure and the leak of MIC were notified to the supervisor.
Supervisor ordered to stop washing
Pressure gauge has over reading, with hot concrete tanks
Operator of MIC reports the escape of MIC gas through the vent line
Alert through alarm was done about the leakage of toxic gas but switched off, police official on patrol reported about the UCIL to police control room and police chief of the city.
Reports from UCIL stated that every thing was normal
Works manager of UCIL was informed by the additional district magistrate about the leak
Between 2.00 to 2.30 am, the safety valve was reseated, but before that, 40-45 tons of MIC escaped into the atmosphere. Nearly 55,000 people were hospitalized in 3-4 December.


The prime cause is the missing of most important aspect, that is emergency planning. The emergency planning comprises of the dry run of the emergency procedure on real, live plant in which all levels of management are actively associated. The occurrence of such regular practices would have provided the deficiencies in plant and operational inefficiencies that would enable a corrective action. The severity of the accident may be attributed to hardware errors, errors related to operations, errors associated with information, and the errors associated with the system.

Errors associated with system

The system-related errors include poor siting procedures, lack of risk assessment, safety audit that is poorly implemented, storage of large scale of toxics, poor level of emergency evaluation procedures, absence  of emergency coordination and medical care. 

Analysis of failure

The errors associated with failure include technical failure, operational failure, failure of management and the failure of government. One view is that disasters initiated by humans can be identified as deficiency in systems management at the corporate level.  However, the assessment and prevention of major accidents these deficiencies are overlooked or addressed in an inadequate manner. (Batstone,1986). Costs associated with hazard management can be lowered if assessment of hazard is conducted along with the decision to locate the project, determination of  requirements of storage, investment on equipment for safety, in addition to man power as well as skilled man power requirements. Hazard assessment can be institutionalized by internalizing the costs associated with damage via an insurance system that is suitable. (Kleindorfer and Junreuther 1986). 


It is important to develop prevent accidents and some prerequisites that can prevent hazards include
• All the steps need to be formalized in such a way that adhoc decisions taken by the operators are minimized. During the emergencies, there will be severe stress to operators and operators’ interference should be minimal at the beginning stages of emergency. In a situation, where there is any unusual happening, all parameters should be logged and monitored including the ones that are considered unnecessary by the operators. The gas tragedy would have been avoided if there is a thorough investigation prior to attempting repressurisation again. (Otway and Misenta ,1980). 
• Beginning from the stage of formulation of project, it is important for the proposers of project to be open to the approach with regard to nature of hazard as well as precautions.  (Kunreuther and Linneroth 1984). In accident systems with low probability, sharing of information greatly helps in the reduction of hazards. In the MIC gas tragedy, the open attitude of corporation to workers of government, public around the plant and the authorities of public health would have lowered the loss of people.
• Conducting a detailed rehearsal emergency on the hazardous facilities in which all levels of management are actively associated in a continuous manner should be mandatory. Inadequacies in the system are evaluated in such a way that a corrective action is initiated. 
• The facilities associated with accident prone hazard causal structure are such that there are more escapes before a disaster. (Lees 1982). The management should investigate the near misses in a detailed manner. Monitoring system in hazardous facilities should such that there is a higher level of unwanted things through duplicated monitoring of instrumentation, reduced intervention of operators through automated warning system. It is necessary to eliminate non formalized intervention of operators that activates the early warning signal system.
• Conventional management structures that are utilized for facilities that are non hazardous are not effective for hazardous management facilities as the safety is considered at somewhat lower level at the facilities that are non hazardous. Safety management status at the corporate level should be higher and the prime objective of the corporation should not be associated with production or financial at the hazardous facilities. A subservient safety system cannot be activate the corporation to get committed for a safety of higher levels.
• It is important to formulate risk assessment at the project feasibility phase in an effort to obtain consent for planning. Internal staff should study a detailed account of hazard operations or hazard analysis that could be used for safety management in operations on a day to day basis. The work related to safety management in operations should be done only by the people who were there during installation and have a detailed knowledge and experience on that particular operation.
• In complex facilities, it is difficult to predict the likelihood of disasters, even then, there is a near certainty as is the case with Bhopal gas tragedy where there were near miss accidents, unidentified safety lapses by the audit in addition to the poor corrective measures. It is essential to make auditing by hazard operators and hazard experts. 


Batstone,R.J.(1986),  Preventing major hazard accidents, paper presented by IAENUNEPNVHO Workshop, World Bank, Washington 
Kleindorfer P and H Kunreuther,(1986)  Insuring and Managing Hazardous Risks (IIASA Laxenburg, 
Kunreuther. H and J Linnerooth,(1984) Low probability acci-, dents", Risk Analysis, 4, pages 143-152. 
Lees, F.P (1982), The hazard warning structure of major hazards, Transactions of the Institute of Chemical Engineering, 60, pages 21 1-221, 
Morehouse.W and A Subramaniam,(1986) The Bhopal Tragedy Council on International and Public Affairs, New York, 
Otway.H. and R Misenta,(1980) Some human performance paradoxes of nuclear operations, futures, 18, pages 340-357, 1980. 

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