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Yousuf S A Follow. Web developer. Bhopal Gas Tragedy case study. In the early s, the demand for pesticides had fallen, but production continued, leading to buildup of stores of unused MIC. In , the two trade unions reacted because of pollution within the plant. While, in , a worker got splashed with phosgene. In panic, he ripped off his mask, thus inhaling a large amount of phosgene gas which resulted in his death 72 hours later..
Again in January , there was a phosgene leak, when 24 workers were exposed and had to be admitted to hospital. None of the workers had been ordered to wear protective masks. A similar incident occurred in February , when an MIC leak affected 18 workers.. In August , a chemical engineer came into contact with liquid MIC, resulting in burns over 30 percent of his body..
Later, in October , 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 and , leaks of the following substances regularly took place in the MIC plant: MIC, chlorine, monomethylamine, phosgene, and carbon tetrachloride, sometimes in combination. Reports issued months before the incident by UCC engineers warned of the possibility of an incident almost identical to that which occurred in Bhopal. However, the reports never reached UCC's senior management.
UCC was warned by American experts who visited the plant after of the potential of a "runaway reaction" in the MIC storage tank. Local Indian authorities warned the company of the problems on several occasions from onward but constructive actions were not undertaken by the UCC.
Kurzman argues that "cuts. A pipe leaked? Don't replace it, employees said they were told. MIC workers needed more training?
They could do with less. Promotions were halted, seriously affecting employee morale and driving some of the most skilled Workers were forced to use English manuals, even though only a few had a grasp of the language.
By , only six of the original twelve operators were still working with MIC and the number of supervisory personnel was also halved. No maintenance supervisor was placed on the night shift and instrument readings were taken every two hours, rather than the previous and required one-hour readings. Workers made complaints about the cuts through their union but were ignored.
One employee was fired after going on a day hunger strike. In addition, some observers, such as those writing in the Trade Environmental Database TED Case Studies as part of the Mandala Project from American University, have pointed to "serious communication problems and management gaps between Union Carbide and its Indian operation", characterized by "the parent companies [sic] hands-off approach to its overseas operation" and "cross-cultural barriers".
The flare tower and several vent gas scrubbers had been out of service for five months before the disaster. Only one gas scrubber was operating: it could not treat such a large amount of MIC with sodium hydroxide caustic soda , which would have brought the concentration down to a safe level.
The flare tower could only handle a quarter of the gas that leaked in , and moreover it was out of order at the time of the incident. To reduce energy costs, the refrigeration system was idle.
The MIC was kept at 20 degrees Celsius, not the 4. Even the steam boiler, intended to clean the pipes, was in operational for unknown reasons. Slip-blind plates that would have prevented water from pipes being cleaned from leaking into the MIC tanks through faulty valves were not installed and their installation had been omitted from the cleaning checklist..
The water pressure was too weak to spray the escaping gases from the stack. They could not spray high enough to reduce the concentration of escaping gas.
In addition to it, carbon steel valves were used at the factory, even though they were known to corrode when exposed to acid. According to the operators, the MIC tank pressure gauge had been malfunctioning for roughly a week. Other tanks were used, rather than repairing the gauge. The build-up in temperature and pressure is believed to have affected the magnitude of the gas release.
UCC admitted in their own investigation report that most of the safety systems were not functioning on the night of 3 December The design of the MIC plant, following government guidelines, was "Indianized" by UCIL engineers to maximize the use of indigenous materials and products.
Mumbai-based Humphreys and Glasgow Consultants Pvt. In , during civil action suits in India, it emerged that the plant was not prepared for problems. No action plans had been established to cope with incidents of this magnitude. This included not informing local authorities of the quantities or dangers of chemicals used and manufactured at Bhopal.. An investigation of the piping on the spot in indicated that a saboteur must have had intimate knowledge of piping into and out of the tank as well as act extremely fast and exact.
In November , most of the safety systems were not functioning and many valves and lines were in poor condition. In addition to this, several vent gas scrubbers had been out of service as well as the steam boiler, intended to clean the pipes was nonoperational. Other issue was that, Tank contained 42 tons of MIC which was much more than what safety rules allowed.
A runaway reaction started, which was accelerated by contaminants, high temperatures and other factors. The reaction was sped up by the presence of iron from corroding non-stainless steel pipelines.
The resulting exothermic reaction increased the temperature inside the tank to over C F and raised the pressure. This forced the emergency venting of pressure from the MIC holding tank, releasing a large volume of toxic gases. About 30 metric tons of methyl isocyanate MIC escaped from the tank into the atmosphere in 45 to 60 minutes.
Apart from MIC, the gas cloud may have contained phosgene, hydrogen cyanide, carbon monoxide, hydrogen chloride, oxides of nitrogen, monomethyl amine MMA and carbon dioxide, either produced in the storage tank or in the atmosphere. The gas cloud was composed mainly of materials denser than the surrounding air, stayed close to the ground and spread outwards through the surrounding community. The nature of the cloud is still discussed.
The chemical reactions would have produced a liquid or solid aerosol with high density. The concentrations at ground level would have been much higher than earlier published. The closing of the plant to outsiders including UCC by the Indian government and the failure to make data public contributed to the confusion. Theories differ as to how the water entered the tank. At the time, workers were cleaning out a clogged pipe with water about feet from the tank. They claimed that they were not told to isolate the tank with a pipe slip-blind plate.
The operators assumed that owing to bad maintenance and leaking valves, it was possible for the water to leak into the tank. However, this water entry route could not be reproduced.
UCC maintains that this route was not possible, but instead alleges water was introduced directly into the tank as an act of sabotage by a disgruntled worker via a connection to a missing pressure gauge on the top of the tank. Early the next morning, a UCIL manager asked the instrument engineer to replace the gauge.
UCIL's investigation team found no evidence of the necessary connection; however, the investigation was totally controlled by the government, denying UCC investigators access to the tank or interviews with the operators. UCC believed that a "disgruntled worker" deliberately connected a hose to a pressure gauge connection and was the real cause. People awakened by these symptoms fled away from the plant. Those who ran inhaled more than those who had a vehicle to ride.
Owing to their height, children and other people of shorter stature inhaled higher concentrations. Many people were trampled trying to escape. Thousands of people had succumbed by the morning hours. There were mass funerals and mass cremations. Bodies were dumped into the Narmada River, less than km from Bhopal. Within a few days, leaves on trees yellowed and fell off. Supplies, including food, became scarce owing to suppliers' safety fears. Fishing was prohibited causing further supply shortages.
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