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Director’s Note: Lessons Learned from Bhopal

DIRECTOR’S NOTE:  In the early morning hours of 3 December 1984, a large amount of toxic methyl isocyanate (MIC) gas was released from a Union Carbide India Limited (UCIL) pesticide plant, which swept over a large, densely populated area south of the plant.  Thousands of people were killed including some at the railway station 2 km away. 

I was an employee of Union Carbide Corp. (UCC), the US parent company of UCIL at the time of the accident.  There is a great deal that we will never know about the accident.  It is difficult to investigate a catastrophe of this magnitude.  Most investigations focused on the technical story.  We know that, although significant safeguards were designed into the plant to prevent an MIC release, or at least to minimize its impact, all of the safeguards were bypassed, out-of-service, or otherwise rendered ineffective. 

But there is a social story that is just as important.  Four social drivers form the backdrop to the tragedy:  (1) the appeal of socialism in India, (2) an extreme anti-expatriate legal system, (3) general national poverty with abject localized poverty near the plant, and (4) the lack of a safety culture.  All of these made it difficult to operate a plant of this sort in India at that time.

Financial factors were important as well; the plant was not making money.  UCIL had decided to permanently shut it down, thereby significantly affecting operator morale and exacerbating maintenance deficiencies.  The plant was in its last production run at the time of the accident, working off the last batch of MIC.

Much has changed in the process industries as a result of Bhopal including many things that we take for granted, such as hazard and operability analysis, management of change, permit to work, and dispersion modeling.  There is an important lesson that we have not learned – effective use of SOPs.  The oil and gas industry needs to catch up with the airline and space exploration industries to instill an effective safety culture and to make following SOPs an absolute priority. 

I am frequently struck by how little people know about this accident.   I think it is important to not only remember those killed and injured in the accident but also to resolve that nothing like it will ever happen again. 

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