[Reader-list] On Bhopal

anupam chakravartty c.anupam at gmail.com
Wed Jun 9 12:54:12 IST 2010

Before we start probing whether it was a communal attack as highlighted by
Rajendra, some of these facts as stated by an environmental engineer, Sagar

"Here is a detailed account of the Bhopal Gas tragedy -
(Excerpt from an article by Environmental Engineer Sagar Dhara)

Prior to the 1980s, Union Carbide made Sevin, a carbamate group pesticide,
with importing chemicals
and formulating them into the product at their Chembur plant in Mumbai.
Sevin sold well so in the late-
1970s, Carbide2 decided to build a plant to make Sevin in India.

Carbide’s Bhopal plant MIC plant
Carbide used the out-dated industrial location theory to decide where to
locate the plant. The theory
states that all other costs being equal transport cost minimization should
become the rationale for plant
location. Bhopal was chosen to locate the plant as it was close to large
tracts of cotton and paddy fields
in Madhya Pradesh (MP) and Maharashtra, where Sevin sold well.

The genesis of the Bhopal disaster lay not so much in faulty plant design or
operations, but in the many
human errors—both of omission and commission—that occurred before and after
the accident. Some of
the important ones were:

Plant site: Once the plant location was fixed at Bhopal, the plant site was
chosen on the edge of
Bhopal city, close to the heavily populated slums Chola Khenchi and JP Nagar
and Bhopal’s main
railway station and bus stand that have lot of people right around the
clock. Bhopal’s proximity
helped Carbide recruit skilled engineers and workers who invariably prefer
to live in a city.
In the 1980s, the risk that hazardous plants posed was not a public issue.

In response to newspaper articles that likened the Carbide plant to a
ticking time bomb, an MP Minister stated, “The Carbide plant is not some
small pebble that can be picked up and put elsewhere.”

Product choice—profits and plant safety hit: By the time the Bhopal plant
was built, synthetic
pyrethroids, the next generation pesticides, were already pushing the
carbamate group pesticides out
of the Indian market. The Carbide plant that went into production in the
early 1980s never produced
more than 50% of its installed product capacity.

When a product does not make a profit, the first systems to get hit are
those considered dispensable,
ie, environmental and safety. The refrigeration system that kept the methyl
isocynate (MIC, the
highly toxic gas that leaked) at a low-reactive temperature of 5oC was
switched off because it was
winter, and MIC was stored at a more-reactive temperature averaging 17oC.
The pilot flare on the
flare tower that is always kept lit to burn off leaked MIC, was put off to
save some LPG gas. Both
safety systems were turned off to save Rs 1,000 a day, an economy measure
that may not have been
taken if the plant were making profits. Just before the accident, the vent
gas scrubber, a device that
can neutralize leaking MIC was hooked offline from the system. One of the
two alarms in the plant
had stopped working, and to save a bit of money, was never replaced.

While considering the grant of consent for operations for a facility,
regulatory authorities, neither
then nor now, consider the impact of monetary loss of an enterprise on its
safety and environmental

Ironically, a little before the accident occurred, Carbide decided that it
would be more profitable to
dismantle the Bhopal plant and set it up in Indonesia that had a growing
carbamate market.

Process choice—cheaper and riskier: Bhopal’s Carbide plant was designed to
make MIC, store it,
and then use it later to make Sevin. The reaction process is:
CO + Cl2 = COCl2 (phosgene)
COCl2 + Monomethyl amine (MMA) = CH3NCO (MIC)
CH3NCO + Naphthol = Carbaryl (Sevin)

Other manufacturers built plants to make the same product, but that
eliminated the risk-prone MIC
storage step by making and using MIC immediately in-situ. The US Senate’s
Waxman report notes
that Carbide chose the former route for making MIC against the advice of
Indian engineers, as plant
construction cost using the former process was cheaper.

Safety standards diluted: Chauhan, a plant operator in Carbide’s Bhopal
plant at the time of the
accident, indicts his management for gradually diluting safety standards
after the plant went online.
Minor leaks of highly toxic carbon tetrachloride, alpha naphthol, phosgene
and MIC began to be
tolerated as being normal. Mercury and alpha naphthol venting into the
atmosphere was done on a
large scale as it was more expensive to recover these chemicals than to vent

When the plant was spanking new, process parameters were monitored every
hour. Subsequently,
this was revised to once in two hours, and before the accident, this was
again altered to taking just
one reading at the end of each shift. Process deviation could now not be
detected except at the shiftend.

And this is exactly what happened at the time of the MIC leak. The 10.30 pm
instrument readings done at 10.12 pm indicated that everything was normal.
The MIC leak
commenced an hour into the next shift, when no fresh readings were available
to indicate that
something was amiss.

Diluting administrative control systems in safety led to a series of
accidents before the big one in
December 1984 (see box) in Bhopal plant. Warning signs that were never

· In 1981, a worker was splashed with phosgene. He ripped off his mask in
panic, inhaling a large
amount of phosgene gas. He died 72 hours later.
· In January 1982, 24 workers exposed to phosgene were hospitalized. None of
the workers had
been ordered to wear protective masks.
· In February 1982, an MIC leak affected 18 workers.
· In August 1982, an engineer came into contact with liquid MIC, resulting
in burns over 30
percent of his body.
· In October 1982, there was a leak of MIC, methylcarbaryl chloride,
chloroform and hydrochloric
acid. In attempting to stop the leak, the MIC supervisor suffered intensive
chemical burns and
two other workers were severely exposed to the gases.
· During 1983 and 1984, leaks of the following substances regularly took
place in the MIC plant:
MIC, chlorine, monomethylamine, phosgene, and carbon tetrachloride,
sometimes in
· Reports issued by scientists within the Union Carbide Corporation months
before the Dec.2
incident warned of the possibility of an accident almost identical to that
which occurred in
Bhopal. The reports were ignored and never reached senior staff.

· Union Carbide was warned by American experts who visited the plant after
1981 of the potential
of a "runaway reaction” in the MIC storage tank; local Indian authorities
warned the company of
problems on several occasions from 1979 onwards. Again, these warnings were
not heeded.

Manpower quality deterioration:

When the Carbide plant was setup, plant operators recruited had a science
degree or an engineering diploma. They were put through long training
periods. As plant profits declined, many of the best employees left the
company. By 1982, 30% of the plant operators did not have requisite training
levels. By 1984, this figure jumped to 70%.

When the plant was new, each shift had a maintenance and instruments
supervisor. By November
1984, a month before the accident, these supervisors were available only
during the general shift,
and night shifts had only two maintenance fitters.

Poor information dissemination: Except for some senior Carbide managers,
others knew little
about the highly toxic properties of MIC. People living in JP Nagar and
Chola Khenchi were under
the impression that the Carbide plant made harmless fertilizers. Even plant
workers were unaware of
the toxic properties of the chemicals they were handling and the high risk
their plant posed. The law
prior to 1986 did not require material safety data sheets to be prepared or
submitted to regulatory
authorities; hence this was never done by Carbide.

The accident
Carbide’s MIC Plant supervisor ordered water washing of some clogged
pipelines in the plant, but as no
water was available immediately, the washing was begun in the next shift at
10 pm on 2 Dec 1984 night.
Slip blinds were not inserted to isolate the pipelines being washed, a
standard practice for lines carrying
hazardous substances. The supervisor believed that the closed valves at the
end of the pipelines were
secure. His faith was belied, the consequences of which were tragic and
enormous. Wash water seeped
through one of the closed valves and got into MIC Tank 610, triggering a
runaway reaction that ruptured the tank and leaked 42 tons of MIC into the
atmosphere at 11.30 pm. A toxic gas cloud formed and drifted slowly with the
wind towards JP Nagar, Chola Khenchi slums and areas further south. Being
heavier than air, the cloud hugged the ground, and the low wind speeds kept
the gas concentrations high.

The loud alarm was sounded at 00.50 am, but was turned off after 10 minutes,
to be sounded again only
after an hour. In a trice, Bhopal’s unsuspecting population was hit in the
stealth of the night by a killer
gas. Most of the people ran with the wind and remained in the gas cloud. And
the more they ran; they
injured their lungs more as MIC is a highly corrosive gas that causes edema
in the lungs. The first lot of
the gassed people reached Hamidia hospital, a government hospital located
close to the affected area,
with symptoms of visual impairment and blindness, respiratory distress,
frothing at the mouth and
vomiting. Soon the numbers of those arriving at the hospital turned into a
torrent; many being brought
dying or dead.

The official death toll immediately after the accident was put at 2,259.
Journalists who estimated the
death toll from the number of shrouds (for Muslims) made immediately after
the accident; put the
immediate death toll at 7,500-10,000. Over 2,000 animal carcasses were
disposed. Government of
India now admits that the cumulative number of deaths due to the gas
exposure is 20,000. Those
exposed with some health effects is now estimated at 5 lakh persons.

Of the many heroic tales of that night and the horrific week to follow, the
one that is worth re-telling is
the supreme sacrifice made by the Bhopal railway station master. As the
toxic gas cloud spread, he
realized the danger and ordered trains standing at Bhopal station to move
out, and stopped incoming
trains at the outer signals outside the city; saving hundreds of people from
sure death. The station
master died soon after due to high gas concentration exposure.

Presence of mind and better training of the plant supervisor could have
reduced the MIC leak. After
discovering the source of the leak, it would have been possible to pump some
of the MIC from the
leaking Tank 610 into the half empty tanks 611 and 619.

On 16 December, a fortnight after the accident, the Indian Government
launched Operation Faith to
empty tanks 611 and 619. Fearing another MIC spill, over half of Bhopal’s
population (~5 lakhs)
evacuated the city spontaneously.

After the accident

If a swath were to be cut through the layers of confusing facts surrounding
the accident, four issues
stand out for what needed to have been done, but remained as grossly
unfinished tasks: restoring
people’s health, rehabilitating people, conducting a site cleanup and fixing
the responsibility and
culpability for causing the accident.

Restoring people’s health: The foremost task immediately after the disaster
was to restore people’s
shattered health to the nearest to normal that was possible. No system
anywhere in the world could have coped with the deluge of the dying and
injured that poured into Hamidia hospital from early morning on 3 December.

For the next few weeks, Bhopal’s medical fraternity heroically battled to
save the dying
and provide succor for the injured, and with no help from Carbide. Instead
of providing information that
was useful in dealing with the medical emergency, Carbide made statements
that were worthless,
contradictory and solely motivated to protect itself from liability (details
provided later in this article).
In the absence of proper toxemic information from Carbide and elsewhere, gas
affected victims were
treated symptomatically, and that continues even to this day.

The primary health impacts were on the respiratory, ocular and reproductive
systems, genetic and
immune functions, and psychological effects

Respiratory: Dyspnea, chest pain, pneumonitis, Pulmonary fibrosis,
persistent cough
respiratory distress, pulmonary edema & dyspnea, chronic bronchitis
Ocular Intense lacrimation, eye redness, photo- Persistent eye watering,
phobia, chemosis, corneal ulcers opacities, chronic conjunctivitis,
tear secretion deficiencies, cataracts

Reproductive: Increased pregnancy loss (43% of pregnancies did not lead to
birth), increased
infant mortality (14% of infants died within 30 days of birth compared to 3%
preceding 2 years—Varma, 1987), increased rate of spontaneous abortions,
alteration of menstrual cycle (MFC, 1986)

Genetic, immune Genetic functions—increased chromosomal aberrations,
increased sister
functions chromatid exchanges, cell cycle delay (Deo, 1987, Saxena, 1988);
functions—decreased T cells populations & phygocytic activity, decreased
response to T&B cell mitogens, transient MIC specific antibodies (Karol &
Kamat, 1987)

Psychological Post-traumatic stress—anxiety, sleeplessness, restlessness,
sleep disorders
effects associated with event recall, pathological grief, emotional reaction
to physical
problems, and exacerbation of pre-existing problems

To treat the gas victims satisfactorily, three specific medical programmes
were required:

Developing a proper medical perspective:

To develop an effective line of treatment, it was
essential to know what the exposure was. With Carbide revealing almost
nothing about the
constituents of the leak, but hinting at possible cyanide exposure, it was
left to the Varadarajan
Committee to figure that out. They detected 12 chemicals in the exploded
Tank 610, but not
cyanides. MIC is known to produce 3% hydrogen cyanide at 200oC and 20% at

Unable to deny the lethal effects of MIC as they were so patently visible,
Carbide built-up an
explanation for the health effects. This came to be known as the Exclusive
Pulmonary Pathology
Theory (EPPT), which stated that: The emissions were constituted by MIC
only, which is rapidly
rendered harmless when it comes into contact with water in the body, eg,
eyes, lungs. MIC does
not enter the bloodstream so cannot cause systemic poisoning. At high
concentrations, it causes
injury at the point of contact, eg, eyes, and also death or chronic
suffering. The multi-systemic
injury reported by victims can be explained by secondary effects of hypoxia
(oxygen deficiency
in body) resulting from irreparable damage to lungs. There is no need for
Symptomatic treatment is adequate.

Dr Heeresh Chandra, Director, Medico Legal Institute, Bhopal, observed in
the autopsies he
conducted that: the colour of venous blood and of various organs was cherry
red; early setting of
rigor mortis; coagulated blood in veins and cerebral edema—all telltale
marks of cyanide
poisoning. Later, he even detected cyanide in victims’ blood. In a Double
Blind Control Trial
(DBCT) that the Indian Council for Medical Research (ICMR) conducted, they
found that gas
exposed victims excreted 2-3 times higher amounts of thiocyanate in urine,
and on
administration of sodium thiosulphate (NaTS), it increased 8-10 fold.
Cyanide is neutralized by
NaTS to form the relatively harmless thiocyanate. In the absence of
literature on chronic
persistence of cyanide after a single exposure, ICMR scientists came up with
the Enlarged
Cyanogen Pool Theory (ECPT) to explain the persistence of cyanide-like
compounds in the
human body.

Based on its findings, ICMR recommended mass detoxification with NaTS.
However, this line
of treatment did not find favour with the medical establishment, and was not
followed, even
though it was well known that NaTS had no side effects. A golden opportunity
was thus lost to
mass detoxify the gas victims.

Continuous medical monitoring of the victims and their offsprings:

This needed to be done for two reasons—
a) To assess whether health effects continued to exist on date,
b) To facilitate medical treatment of the victims.

Some initial effort was made to fulfill the first objective. The Medical
monitoring of the gas
victims was started by ICMR in 1985. An internal report concluded that:
there was sustained
and increased morbidity, respiratory illness and high spontaneous abortion
rates in the exposed
population in 1989-90 as compared to the unexposed population. The
monitoring was shut down
six years after it began. The reports were not made public till 2003. In
1985, the Medico Friends
Circle made a survey of health effects in the affected areas. In 1993, the
Commission on Bhopal, attempted to understand the health status. Since
longitudinal studies
were not done, their worth was limited to knowing the health status of the
exposed population at
the time they were done.

The second objective was never fulfilled. Systematic documentation of the
health status of each
victim was virtually non-existent. The health care delivery system in Bhopal
was not geared for
this. If any of the victims had retained their medical papers, they were the
only record of their
health status.

Gearing the health care delivery system to offer the best available
treatment at the victims’
doorstep: Health care of the victims can be said to be patchy at best.
Government focused on
providing hospital-based services, and did increase bed strength for
inpatients. However, what
was required was health care at the victims’ doorstep.

On the Supreme Court’s directive,Carbide funded a 350 bed hospital with
eight outreach centres. Non governmental organizations (NGOs) set up a
clinic in the affected area soon after the accident, and another one later.

In the absence of a detoxification programme, the gas victims’ treatment was
symptomatic rather
than systemic. And when their suffering was not mitigated by the treatment
offered by any of the
health care delivery systems, they switched from hospitals to private
doctors, counted their tablets
not in numbers but by weight, lost money but did not regain their health.
Their health continues to
remain shattered even to this day.

Economic rehabilitation:

One aspect of living in dignity is to be able to earn one’s livelihood.
Most of the Bhopal gas victims faced a double jeopardy. To begin with, a
vast majority of them
come from an economically depressed class. Then the gas exposure ravaged
their bodies and minds.
Most of the exposed could never work as they did earlier, and felt fatigued
even after a bit of work.
Home makers could no longer stay at home or look after children, and many of
those who worked in
jobs lost them to fitter persons. Children’s school performance suffered.

Food, ration cards and an ex-gratia payment of Rs 1,500 per family were
distributed immediately
after the accident. However compensation claimants had to be medically
assessed before they got
any money; and this took an inordinately long time and some expense,
delaying payments.
Little was done to rehabilitate the gas victims economically. An assessment
of impairment of the
ability to work or available jobs was not done.

Thirty three of the 50 planned worksheds were opened immediately after the
accident, but were shutdown by 1992. In 1986, the MP Government built 152
out of a planned 200 worksheds in a special industrial area meant for gas

By 2000, only 16 of these worksheds were working partially. Of the estimated
50,000 persons who
needed jobs, less than 100 gas victims found them under various government
Little can be done to ease the burden of housework unless better housing,
water and sanitation
facilities are provided. About 2,500 flats were built in the Widow’s colony
outside Bhopal. But
water did not reach the upper stories and there were no buses and schools
available for a very long

Gas exposed children required special attention like an
individually-tailored learning pace, and
community support programmes that give them a sense of security. Government
can do little here
except provide infrastructure. But even this was lacking.

Site cleanup:

The Carbide plant shut down after the accident, but continued to carry large
inventories of toxic chemicals—naphthol, naphthalene, Sevin, mercury,
chromium and other heavy
metals, organochlorines, hexachloroethane, etc. Over time, these chemicals
have leached into the
soil and groundwater around the Carbide plant. Even in 1982, tubewells
around the plant had to be
abandoned for this reason. In 1989, Carbide’s laboratory tested soil and
water samples from inside
the plant and surroundings and found them to be toxic to fish.

A recent study done by Centre for Science and Environment (CSE) confirms
that soil and
groundwater around the Carbide plant are excessively contaminated. All
eleven groundwater
samples collected from colonies around the plant were found to be
contaminated with chlorinate
hydrocarbons. Based on this, CSE believes that immediately after the
accident the issue was of
acute toxicity, but now it has been transformed to a chronic toxicity

There is a dire need to cleanup the contaminated soil and water around the
plant site.

Fixing responsibility for the accident:

In the last 25 years, court battles have taken just about every twist and
turn. Four months after the accident, the Bhopal Gas leak Act was passed,
allowing Government of India to act as the legal representative for victims.
Civil cases were filed in Indian and US courts for seeking remedy in torts
against Carbide.

In the US, all cases were consolidated in
Judge John F Keenan’s court in the Southern District Court of New York, who
delayed ruling on
where the case should be heard—in the US or in India, in the hope that the
parties may compromise.
After months of negotiations, Carbide offered $ 350 million, a sum equal to
what Carbide’s insurers
were willing to pay, which the Indian Government rejected. In May 1986,
Keenan finally threw the
case out of his court on grounds that most of the evidence and witnesses
were in India, and this was
affirmed by a US Court of Appeals in January 1987. In 1993, the US Supreme
Court refused to hear
appeals against the lower court orders, effectively shutting the door to the
victims seeking damages
in the US. Other petitions still pending in US courts seeking damages for
personal injury, medical
monitoring, and cleanup of contamination have yielded no result till date.
Carbide wanted precise
this, ie, for US courts not to hear the case, as Indian Courts take longer
to decide cases and award
significantly lower compensation amounts.

Soon after US Appeals Court passed its order, the scene of legal action was
back in India. In mid-
1987, Judge M W Deo, presiding over a Bhopal Court, revived the settlement
proposal as he felt that
quick relief would serve the victims’ interest best. It was rumoured that
Carbide had nearly doubled
its initial offer of $ 350 million, only to be rejected by the Indian
Government. In December 1987,
Deo passed an interim order directing Carbide’s parent company, Union
Carbide Corporation (UCC)
to deposit Rs 350 crores5 ($ 270 million) as interim relief with the court
to make payments to victims
and meet medical and rehabilitation costs, without prejudice to admission of
Carbide’s liability.
UCC appealed to the MP High Court stating that it had lost faith in Deo’s
impartiality as he had prejudged
the case by awarding “damages” when their liability was yet to be
established, and therefore
exceeded his jurisdiction.

The MP High Court upheld UCC’s contention against Deo’s order, yet
ordered Carbide to pay Rs 250 crores ($ 193 million), not as interim relief,
but as interim payment.
The MP High Court explained this apparent paradox by arguing that UCC’s
liability was already
established and that the corporate veil between UCC and its Indian
subsidiary Union Carbide India
Ltd (UCIL) was lifted and that UCC’s direct complicity in the affair was
established beyond doubt.

In 1988, the Supreme Court of India stepped in and asked Carbide and the
Government of India to
come to a settlement, which they did in 1989 for $ 470 million, which was
the equivalent of the
insurance amount plus accrued interest, a sum that was 15% of the $ 3
billion that the Indian
Government had originally asked for. For the next one year, the Supreme
Court heard appeals
against the agreement, but upheld the figure. However, it set aside the
quashing of the criminal
proceedings against Carbide officials that was part of the original
settlement between the two parties.
In 2007, of the 10 lakh cases were registered and decided, 574,304 persons
were award a total
compensation of Rs 1,547 crores. The average amount awarded for personal
injury, including
interim relief was Rs 25,000 ($ 830), and for death Rs 62,000 ($ 2,060).
Because the compensation amounts were small, Rs 1,000 crores would have been
left over after all claims were settled.

These amounts compare rather unfavourably with compensation amounts obtained
in the US. Ten
years ago, W R Grace, a US company, paid an average settlement of a million
dollars to each of
eight leukemia patients because it had dumped trichloroethylene into
drinking water of Woburn, a
small town near Boston, ie, 500 times more than what was paid to the Bhopal
victims (even if PPP
prices are used, US compensation payments would be 100 times the Bhopal
ones). Each of the
10,000 asbestosis-related deaths reported annually in the US is also settled
for similar amounts. In
10 years, this amount would have increased to more than $ 1 million.

Four days after the accident, Warren Anderson, Carbide’s Chairman, was
arrested in Bhopal for
culpable homicide and other charges, and released immediately on bail.
Anderson retired in 1986
and went into “hiding” in New York State. Journalists and Greenpeace
activists have visited him
and found him living in luxury, but the long arm of the Indian and US laws
have not been able to
“find” him in the last 25 years.

In 2002, the Central Bureau of Investigations (CBI) attempted to dilute the
charges against
Anderson, but the Bhopal magistrate declined to allow this. In 2003, the
Ministry of External
Affairs reluctantly requested the US Government to extradite Anderson to
India to face charges,
which the US Government refused to do on minor technical grounds.

In July 2009, the Bhopal Court again ordered the CBI to produce Anderson.
Given the reluctance of
both governments to comply with this order, it is highly unlikely that
Anderson, now 88 years old,
will ever set foot on Indian soil again.

Though Carbide is primarily culpable for the accident, the MP Factories
Inspectorate must also be
rapped on its knuckles for not ensuring that the Bhopal plant was being
operated safely.

In 1994, UCC sold its Indian subsidiary UCIL to Eveready Industries India
Ltd, and in 2001, Dow Chemical Company bought UCC. Attempts to make Dow
accept liability for the Bhopal accident has failed. Dow maintains that it
has bought UCC minus its Bhopal liabilities.

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