The Report of the ICFTU-ICEF Mission to study the causes
and Effects of the Methyl Isocyanate Gas Leak at the Union Carbide Pesticide
Plant in Bhopal, India, on December 2nd/3rd 1984
International Confederation of Free Trade Unions
International Federation of Chemical, Energy, and General Workers Unions.
This report, based over an onsite study by a 12 member Fact finding committee,
is the most accurate and detailed analysis we are likely to have of what
happened in Union Carbide's Bhopal Plant and how it came about.
It establishes that while some wrong decisions were made by local plant
management, Union Carbide Corp. also bears a major share of responsibility
for the catastrophe.
As for the lesson to be learned here at home, none of the conditions which
led to the disaster would have been violations of specific standards or
regulations of the occupational Safety and Health Administration or the
Environmental Protection Agency
On an International basis, the ratification and implementation by many governments
and employers of International Labour Organization (ILO) conventions on
occupational safety and health could prevent such horrible accidents.
of this report is to Prevent Future Bhopals.
Many People in the developed countries have viewed the Bhopal Tragedy as
an isolated event in a far away land that resulted from conditions
and factors endemic to developing countries. Statements have been made by
governments and the chemical industry that such as accident could not occur
in the industrialized western countries. Some have even suggested that accidents
like Bhopal are to be expected in developing countries and are the price
that must be paid for technological development.
The investigation by our mission does not support these views.
Our investigation revealed, and our report outlines the fact that none of
the factors that caused or contributed to the Bhopal accident were unique
to the Union Carbide Plant in Bhopal, India Indeed the causes we identified
are common to many chemical manufacturing and other industrial Processes
through out the world. These conditions were not the inevitable result of
technological Progress. But discrete and well-recognized Problems that could
have been controlled.
Dr. Nagu. we
also met several representatives of the two trade unions, Which representatives
of the Union carbide indian LTD.(UCIL) Bhopal Pesticides Plant,
as well as reprsentatives of Health institutions and community groups.
Mission consisted of :
O.Aro , Mission leader, Deputy Secretary General ,ICEF
Carlsen, mission secretary, ICFTU
Rice, Occupational Health and Safety Officers , ICEF
Seminario , Associate Director, Department of Occupational Health and
Safety, AFLCIO, U.S.A.
J. Wright , Director of occupational Health and Safety, United steelworkers
of America, U.S.A.
McClelland, Assistant to the Secretary General, Trade Union Advisory
Committee (TUAC) to the organization for economic cooperation
and development (OECD)
Vidal, members of the chemical industry federation of the french Confederation
of Democratic Trade unions (CFDT-FUC), and employee of La Littorale,
UCC Plant at Beziers , France.
- Raja Kulkarni
, President, Indian National Chemical Workers' Federation(INTUC)
- R.K. Yadav,
General Secretary, Union Carbide Karmachari sangh (Nominated to the
mission by HMS)
Secretary, Madhya Pradesh HMS
ICFTU Asian and Pacific Regional Organisation(APRO)
- In Delhi,
the mission was joined by its indian members on march 31,1985. We visited
the offices of both ICFTU affiliates in india ,namely the
indian National Trade union Congress (INTUC) and Hindi Mazdoor
Sangh(HMS). where we met Mr.Gopeshwar and Mr.Toofan,Respectivly.
- We also
had audiences with the minister of the Labour. Mr.. T. Anjaiah and the
minister of Petroleum. Mr. Nawal Kishore Sharma .We also
had meetings with several trade unionisis, Government authorities. representative
of research institutes and the Press.
- In Bhopal
, we met the present Chief Minister of the state of Madhya
Pradesh , Mr.Vora and the Director of Health Ser vices of
the State of Madhya Pradesh ,
The Trade unions of the chemical workers have for years raised issues Pertaining
to the Safety conditions of this industry. None of the issue involved is
new or unknown. There are ways of Preventing accidents or contributed
to it.. We discuss the implications of the issues arising from accident
and its aftermath.
At the end of this report we make recommendation to governments .Chemical
Industry companies. International Organization like the ILO and the
WHO and the trade unions for measures to improve the safety of workers
and the environment.
Bhopal and Some other recent accidents have created a new level of
awareness about hazardous substances and the Potential danger they
Present Several developments are taking place to increase information
on these questions and to diminish the risks. As an appendix you will find
a resolution which was presented by our members and adopted by the
ILO's annual conference in June , The international free trade union
movements is committed to do its part. We hope this document contributes
to the formulation of that policy.
A very important aspect which needs urgent consideration is the fate of
the former workers of the Bhopal Plant . The plant has been shut down since
the accident. The company has announced that it will not be opened again
.At the moment, there are very few concrete measures being taken to restore
employment to these people .The ongoing trials have to do with the gas victims,
not with the people who lost their jobs. The international trade union movements
has to support the effects of the Indian union's to combat this problem.
At the moment of the writing there are various investigations taking place.
The most important one is a one man inquiry commission appointed
by the state government of Madhya-pradesh . It will take at
least months to be completed and the union's will watch
closely the deliberation and the outcome . Among other things, it is a test
of the integrity of the Indian authorities.
this report, the mission relied on several sources of Information
. Including news accounts from Indian, European and American publications;
articles from technical journals; Union Carbide technical
manuals and reports ; documents compiled by the U.S. Congress ; materials
Published by Indian Community and scientific organization : and
Correspondence between the unions representing Bhopal
workers, The Company , and the government. In addition, the delegation interviewed
more then thirty Union Carbide Worker, Including Several who were on duty
on the night of the release, as well as leader of the local and national
Union's . Victims of the disaster, medical personnel, present and
former government officials and community activists working on behalf
of are sometimes contradictory .A clearer picture emerges from the Union
Carbide Workers. Based on the Information available to us , the mission
has reached the following conclusion about the causes of the
- 1. The
disaster was caused by insufficient attention to safety in the
process design, dangerous operating Procedures, Lack of Proper
maintenance, faulty equipment, and deep cuts in manning levels, crew
sizes, worker training and skilled supervision, Smaller
releases of toxic , and skilled supervision. Smaller releases
of toxic chemicals had occurred in the past., Leading to one death
and numerous injuries . Little was done to correct these Problems.
despite vigorous protests by the Union representing Bhopal
- 2. The
accident was Probably triggered by a runaway reaction occurring when
water entered methyl Isocyanate (MIC) storage tank . A likely
Source of the water was a faulty maintenance Procedure on
the evening of December 2, 1984.
- 3. The
operating and maintenance errors which led to the MIC release
were made by management of the Bhopal plant and Union
Carbide India limited (UCIL). However, responsibility for the
disaster also rests with UCIL' S parent multinational, the U.S-based
Union Carbide Corporation (UCC).UCC insisted on a process
design requiring, large MIC storage tanks, over the objections of UCIL
, engineers, in addition , a 1982 corporate inspection report
demonstrates that UCC knew the Bhopal plant had major safety
Problems. But the company did not take sufficient action to correct
- 4. The
government of Indian and the state of Madhya Pradesh did not cause,
and are not directly responsible for. the gas release .However
, stronger worker safety and environment regulations , and stricter
enforcement . Could have prevented it.
- 5. Chemical
accidents are rarely identical , and it is unlikely that an equivalent
accident involving MIC will happen again in
the limited number of plants still using it. However
, the process design , equipment , operating , maintenance , manning
, training , and supervisory Problems that caused
the Bhopal disaster are not unique to Union
Carbide , India , or developing countries. Highly dangerous
chemicals are produced , used , stored transported
and spilled - throughout the world . Bhopal was not
the first chemical disaster . In the absence of strong
national and international regulations. rigorously enforced
, the next such tragedy is only a matter of time.
CARBIDE IN BHOPAL
Carbide has a long history in India, beginning in 1905 when the company
began selling products manufactured elsewhere. In 1924, a plant
was opened in Calcutta to assemble battery components made in Britain.
By 1983, Union Carbide was operating 14 Indian plants manufacturing
pesticides, chemicals batteries, industrial carbon, and other products.
Carbide's Indian interests are held by Union Carbide India interests
are held by Union Carbide India Limited, Which is 50.9% owned by the
parent multinational, and 49.1% by Indian investors. India's 1973 Foreign
Exchange Regulation Act generally limits foreign investors to minority
ownership, but UCC persuaded the Indian government to waive the requirement
in its case, on the basis of the technological sophistication of its
plants, and the offsetting factor of exports. UCC exercise managerial
control through its Eastern Division headquarters
in Hong Kong. Bhopal workers and national union officials maintain that
even minor production and maintenance decision were made by Hong Kong.
Bhopal plant opened in 1969. At First . UCIL Bhopal only formulated
carbamate pesticides from concentrates imported from U.S. , but
in 1975 UCIL was licensed by the Indian government
to produce its own carbary1 (trade name"sevin") Methyl
isocyanate (MIC) is a chemical intermediate in the sevin manufacturing
process chosen by UCC. For a time, the Bhopal plant depended on MIC
imported from Union Carbide's plant in Institute ,
West Virginia . However, UCIL added an MIC production
unit to the Bhopal plant in 1979. The unit was
approved and designed by UCC in the United States.
licensed registered capacity of the plant was
5,250 tonnes in 1983, falling to 1,657 tonnes in 1983. The
decline was Primarily due to mistaken market estimates, exacerbated
by growing impact of competing pesticides like synthetic
pyrethroids as a result, the plant was losing
money, and UCIL - with UCC's permission - may well
have been looking for a buyer.
Carbaryl process in use in Bhopal began with chlorine, brought
in by tank truck, and carbon monoxide, produced on site from coke, which
were reacted to form phosgene - which was used as a lethal
gas in World War I - and killed one Bhopal worker
in a 1981 accident. Purified Phosgene was sent to
a reactor Vessel and pyrolysis unit to
combine with monomethylamine, ultimately forming MIC.
Chloroform was used as a solvent in this process.
The Bhopal plant stored refined MIC until needed in
two underground 15,000 gallon tanks, designated 610 and
611 . A third tank, 619 . was available as a backup . Eventually,
the MIC was reacted with alpha -naphtol to form sevin.
Bhopal plaint's MIC production unit was shut down for maintenance and
to reduce inventories in mid -October 1984, with more then 185,000 Ibs.
(23, 125 gal.) of MIC stored in the underground tanks. Some of the MIC
in the second storage tank, tank 611, was converted to Carbaryl after
November 24, Ordinarily, the MIC in tank 610 Would have been used first,
but the operators had been unable to pressurize the tank with
nitrogen, which is used to transfer MIC to the Sevin unit . As
a result, tank 610 contained more than 11,290 gal, of MIC on the night
of December 2.
MIC is highly
reactive, unstable, flammable, volatile, and toxic. It reacts with acids,
alkalies , water, and a variety of organic chemicals. It can even react
with itself. Most of these reactions are exothermic (they give off heat);
some are violent . The flash point of MIC is -18 c, and a concentration
of only 6% in air is explosive . MIC boils at 39.1 C. The threshold
limit value set by the American conference of Government Industrial
Hygienist is 0.02 ppm. among the lowest for any substance.
Union Carbide's material safety data sheet states: "Methyl
isocyanate can undergo a 'run-away' reaction if contaminated. A
vapor cloud constitutes from the standpoint of ignition
(a 'fire-ball' could result) and toxicity."
Such a chemical deserves respect, and the Bhopal MIC plant contained several
safety systems. MIC reacts more violently when warm, So the storage
tanks included a refrigeration system. The tanks were protected
from overpressure by safety valves and rupture disks. The system
was designed to vent escaping gases to a vent gas scrubber,
to be neutralized with caustic soda, and then to a flare tower.
The events of December 2-3, 1984 have been described by a number of publications,
and by Union Carbide in its "Bhopal Methyl Isocyanate incident
Investigation Team Report," published on March 20, 1985. Our
primary sources were the workers them-selves . The most complete
journalistic account, and the one that most closely agrees with
the workers, was written by Bhart Bhushan and Arun Subramaniam
for the February 25 issue of Business India( see Diagrams
1 and 2).
Unfortunately, the mission was not permitted to enter the plant, due to
an ongoing investigation by the Indian Central Bureau of investigation.
While we had access to the 1978 Union Carbide Bhopal MIC unit operating
Manual, along with the piping, process, and control diagrams because
they were made after the plant began operating. As a result, we were unable
to check important technical aspects of the accident, which will have
to await more complete information..
The Union Carbide report states that the reaction in the tank
610 which released the gas was triggered by 1000-2000 lbs of water (120-240
gallons) entering the tank. UCC claims not to know the source of
water, and goes so far as to speculate that it
may have been introduced deliberately. During the press conference UCC
held when it released the report, Ronald van Mynen, UCC'S corporate safety
and health director, hypothesized that the water may have come from
a nearby utility station which supplied water and nitrogen to
the area: "If someone had connected a tubing to the water line
instead of the nitrogen line, either deliberately or intending to introduce
nitrogen into the tank, this could account for the presence of the water......"
The Workers disputed this account, insisting that no such connection was
made on the night of December 2. During the press conference, Van Mynen
admitted that the company's investigation team found no evidence
for a connection. Nor is it clear why someone would wish to hook up a
nitrogen tube when it could easily be introduced into the tank through
permanent fixed lines. Although Van Myna' s hypothesis in our view is
unlikely, the company's admission that such a mistake is even possible
is in an example of unsafe plant design. Given the lethal natural of the
water MIC reaction, UCC should have used incompatible fitting on the water
and nitrogen system to prevent their interconnection.
The Bhopal worker we interviewed provided an explanation of the water
in tank 610 which is, in our view, much more credible and consistent with
what is known about the plant. Their account follows:
Sometime on December 2, the production superintendent ordered the MIC
plant supervisors to flush out several lines leading from the phosgene
area to the vent gas scrubber, This operation involves connecting a water
line, closing upstream isolation valves. The work was begun at about 9:30
p.m. on the second shift. Ordinarily, the lines are isolated by
a slip blind (a physical barrier, inserted into a pipe
or fitting, which prevents material from passing). Line washing is the
duty of an MIC operator, while installing the slip blind is
the responsibility of maintenance. However, according to the workers,
the second shift maintenance supervisor position had been eliminated several
days earlier, and no worker was told to insert the slip blind. The operator
could not see the slip blind holder from his location, and had no way
of way of knowing that it was not present and in place.
Unfortunately, the downstream bleeder lines were partially clogged, so
water began to accumulate in the pipes. Many of the valves in the plant
were leaking, including the isolation valve, so water rose past the valve
into the relief valve vent header, a line connecting various pieces of
equipment to the pressure relief system. When the operator noticed that
no water was coming out of the bleeder lines, he shut off the flow, but
the MIC plant supervisor ordered him to resume.
The relief value vent header is about 20 feet (7 meters) off the
ground at its highest point. From it, the water flowed downhill into the
tank through a series of valves. The first two are part of a jumper line
between the relief valve vent header and the process line for the three
tanks. The jumper is not shown on the diagram published by UCC in
its March 20 report, but they described it in our interviews. The
workers stated that, since the jumper constituted a design change,
standard procedures would have dictated its approval
by UCC in Hong Kong or the USA.
Part of the process vent header was being repaired at the time of
the accident, so the valves at each end of the jumper were open. As a
result, water flowed from the relief value vent header. From
there, the water flowed to the main isolation valve for the process
vent header, which is normally open, to a diaphragm motor valve which
should have been closed. However, that valve is part of the system used
to pressurize the tank with nitrogen, and since the tank could
not be presurized in the days preceding the accident, the valve
may well have been faulty. It is also possible that the valve was inadvertently
left open, or had not seated properly - since the valve was routinely
opened and motor valve - the water flowed down past the main tank isolation
valve, which was almost always kept open, into the tank itself.
Eventually, the clogged bleeders were freed and water stopped entering
the process vent header . By that time, the water in the tank 610 had
begun to react with the MIC. The reaction was slow at first, but
when the third shift reported for work at 10:45 p.m., they began
to suffer throat and eye irritation from an MIC leak close
to the area where the lines were being washed. The exact source
of the small leak was never determined, since the workers
were soon overwhelmed by the much larger MIC release, but the MIC
was probably escaping back along the same route by which the water previously
From that point on, the UCC report and the worker's account agree. At
11:00 p.m., the control room operator noted that the pressure in tank
610 had risen from 2 to 10 psig. The MIC water reaction proceeds much
more rapidly if it is catalyzed by iron. UCC'S March 20 report theorizes
that the MIC in tank 610 was contaminated by chloroform, which begun
to release chloride ions as the heat and the
pressure in the tank increased. Others have speculated that
the chloride came from phosgene, which also could have contaminated
the MIC. What ever its source, the chloride attacked the walls of
the tank, leaching out iron. Catalyzed, the reaction's intensity increased
rapidly, creating still more heat and pressure, releasing still
more chloride and more iron, intensifying the reaction still more.
At 12:15 a.m. the operator checked the tank pressure again. It was 30
psig and rising rapidly. Seconds later, the reading was off the scale.
The rupture disk/safety valve system is designed to give way at 40
psig, and when it did, the contents of tank 610 rushed through the lines
at a least 720 lbs per minute. At the height of the reaction, the pressure
in the the tank was probably above 200 psig, the temperature
above 200 C.
The escaping gas went first to the vent gas scrubber. It is not yet clear
whether the scrubber functioned on the night of the release. The pump
had been shut off, and the instrument panel in the control room
indicated that they could not be restarted. On the other hand, the caustic
soda in the scrubber was found to be hot the next morning, indicating
that some reaction had taken place. In any event, from the information
published in the Bhopal operating manual and press reports after the accident,
it appears that the scrubber did not have the capacity to handle the massive
From the scrubber, the gas should have gone to the flare tower, but the
unit was out of service. The pipe leading to it had been removed for maintenance
weeks earlier. So the gas was vented directly to the atmosphere. Several
workers made a last ditch effort to spray the escaping gas with water
to neutralize it. Wearing full face respirators and rapidly running
out of air, they struggled with poorly maintained valves to turn
on the water spray, only to find that the pressure was not sufficient
to reach the gas. One worker kept trying even after he had run out
of air. choking from the gas, he finally tried to escape over the
wall, but passed out, falling to the ground where he was rescued by others.
One supervisor tried to climb the MIC structure to plug the gas leak,
although that would have been stupid. By 1:00 a.m. on December 3, a lethal
cloud was drifting over the unsuspecting neighborhoods of Bhopal, where
it would kill at least 2,500 people and injure more than 200,000.
OF THE RELEASE
Large volumes of MIC were stored in the Bhopal plant.
Reports on the volume of MIC in tank 610 at the time of the accident vary
from 11,290 gallons( 75% capacity) to 13,000 gallons (87% capacity). The
low figure is contained in the Union Carbide report, which also maintains
that such a volume is "well below the maximum operating level."
However , Union Carbide's technical manual on MIC suggests a limit of
50%. Bhopal workers confirmed that all their MIC storage tanks were frequently
filled above the recommended level.
According to calculations based on data in the Union Carbide report, tank
611 contained 11,565 gallons of MIC until November 24, after which it was
slowly drawn down for production to 5,620 gallons on the night of
the accident . Tank 619 also contained a small amount of contaminated
MIC, despite the fact that Union Carbide's 1978 Bhopal MIC unit operating
manual states that one tank is always to be kept empty in case of emergencies.
This long-term storage of large amounts of MIC was a direct causes of the
accident . The accident would not have occurred if the MIC in tank 610 and
611 had been promptly converted to sevin after the MIC unit was shut
down. If either tank 611 and 619 had been empty, it could have been
used as a surge tank to contain some of the reacting MIC on the night
of the accident, thus giving operators more time to regain control of the
reaction. In fact, operators wee not even sure how much MIC was
in tanks 611 and 619, since many of the gauges in the plant were unreliable
and not trusted by the workers. As a result, workers where afraid to open
the line to tanks 611 and 619. Since they did not know the causes of the
reaction in the tank 610, they feared spreading the problems to the adjacent
Indeed, it was never necessary to store more than minor amounts of MIC in
Bhopal. When the plant was first designed, Edward A. Munoz, the managing
director of Union Carbide Ltd,. took the position that large volume storage
of MIC was contrary to safety and economic considerations. In a sworn
affidavit to the Judicial Panel on Multidistrict Litigation
considering of the Bhopal case, Mr. Munoz said that he had recommended,
on behalf of UCIL, that the preliminary design of the Bhopal MIC facility
be altered to involve only token storage in small individual containers,
instead of large bulk storage tanks. However , UCIL was overruled
by the parent corporation, which insisted on a design similar to UCC's Institute,
West Virginia plant. Other UCC facilities which use MIC (but do not
produce it) store the chemical in small containers. Such storage is considered
safer, owing to much smaller quantity in each container.
In fact, Union carbide could have produced Sevin in Bhopal without any MIC
storage. Since MIC is a chemical intermediate, the process could have
been designed in a such a way that MIC was consumed immediately after
it was produced. DuPont is currently building such a plant in Laporte, Texas.
Dupont has stated that no more than 20 pounds of MIC will be in the system
at any one time. A similar process is currently used by Mitsubishi
It should also be noted that Carbaryl, the pesticide produced at Bhopal
under the trade name sevin, can be made without MIC. Although that
process, like the chemical, UCC may have chosen the MIC process on economic
grounds. MIC is a chemical intermediate for a number of pesticides,
and before the accident Union Carbide's Institute plant sold large
amounts of it to other companies. UCC probably had similar plans for
the Bhopal plant when it was designed.
The Bhopal plant had four major safety systems designed to prevent or
neutralize an uncontrolled MIC reaction:
- (1) A
30 ton refrigeration unit to cool stored MIC, in order to prevent it
from vaporizing or reacting;
- (2) A
vent gas scrubber (VGS) to neutralize toxic gases with caustic soda
in the event of a release;
- (3) A
flare tower to burn vented gases from the MIC storage tanks and other
- (4) A
water spray system to knock down escaping vapors.
At the time
of the accident, according to the workers, three of these systems were
The 30 ton refrigeration unit had been shut down since June 1984. There
were no mechanical problems with the system; it was taken out of service
to save money. The Freon refrigerant had been drained out
for use elsewhere in the plant . The shutdown was in violation of established
The vent gas scrubber (VGS) was turned off in October, 1984, apparently
because the supervisors thought it was not necessary when MIC was only
being stored and not produced. In addition, the caustic flow indicator
was malfunctioning, so it would have been difficult to verify whether
the unit was operating or not.
The flare had also been out of service since mid-October. A section
of corroded pipe leading to it had been removed even though replacement
pipe was not ready. The workers stated that the replacement pipe
could have been prepared in the plant, and should have taken only
four hours to install. However, as of December 2, the pipe had not
been replaced, and the escaping gas could not be directed
to the tower. In addition, the company had compromised the reliability
of the flare tower even before it was disconnected. The tower was originally
built with a backup set to fuel gas cylinders to ensure that the pilot
light stayed on. However, the backup system was discontinued to save money.
In spite of all of this, even if the systems had been operating, it does
not appear that they could have contained the massive realease of MIC
There is some controversy over whether the vent gas scrubber operated
at the time of the accident . But if the figures released by Union Carbide
are correct, the gas escaped at rate of 400-800 lbs/ minute, at a pressure
and temperature approaching 200 psig and 200 C. Union Carbide's 1978 Bhopal
operating Manual gives the "maximum allowable working pressure"
of the VGS as 15 psig at 120 C, and the "nominal feed rate"
as 3.2 lbs/minute. Indeed the manual lists "high pressure in the
vent scrubber" as a process "upset", for which the remedy
is check for the source of release and rectify. "Similarly, "toxic
gas release to the atmosphere" from the VGS is also considered
as an"upset", caused by "high release of the toxic streams
from the process," for which the remedy is "check the source
of the release and normalize." In short, the VGs was never dasigned
to handle the kind of release which occurred reduced the severity of the
accident, even if it had operated.
The MIC unit operating manual does not contain the details of the flare
tower, and it is unclear whether it was capable of safety flaring MIC
at the rate it was being release However, some workers believe
that had the flare tower been put into operation during the
release, the enormous MIC cloud near the tower would have exploded, destroying
piping systems in the plant and releasing even more MIC.
According to worker interviewed, the water spray shroud which was activated
the night of the accident did not reach the level of the gas release,
and was therefore useless. In 1982, Union Carbide Corporation, after
inspecting the Bhopal facility, had recommended a new, larger water
spray system, but it was never installed.
Inadequate maintenance was a longstanding complaint at the Bhopal plant.
The poor maintenance of the major safety systems has already been described.
These problems extended to production equipment.
According to the workers, leaking valves and malfunctioning gauges were
common throughout the facility. A 1982 Union Carbide Corporation
inspection of the plant by U.S. safety personnel noted such problems,
and resulted in the replacement of valves in the MIC unit; but at the
time of the accident, valves and pipes had again corroded and leaking
valves were a serious problem. Leaking valves probably allowed water
to enter the tank. Broken gauges made it hard for MIC operators to understand
what was happening. In particular, the pressure indicator/ control, temperature
indicator and the level indicator for the MIC storage tanks had
been malfunctioning for more than a year.
At the time of the accident, the Bhopal plant, including the MIC facility,
was operating with reduced manpower. According to the workers and published
reports, the plant had been losing money, and in 1983 and 1984 there were
more personnel reductions in order to cut costs. Some worker were laid
off and 150 permanent worker were pooled and assigned to jobs as needed.
The workers we interviewed said that employees were often assigned
to jobs they were not qualified to do. This practice was also noted by
Union Carbide corporation in its 1982 inspection report. If the workers
refused to do the job which they were assigned on grounds they were not
trained, their salaries were reduced.
In the MIC facility the production crew had been cut from 12 (11 operators,
1 supervisor) to 6 (5 operators.1 supervisor), and the maintenance crew
reduced from 6 to 2. According to the workers, the maintenance supervisor
position on the second and third shifts had been cut on November 26, less
than a week before accident. With reference to maintenance work and giving
instructions for the job, the workers indicated that it would have been
the responsibility of the maintenance supervisor to prepare the
pipe which was being flushed with water the night of December 2, 1984,
including to prevent the entry of water into the pipes leading to tank
When the post of maintenance supervisor was eliminated , these responsibilities
apparently shifted to the production supervisor. But according to the
workers, the production supervisor on duty the night of December 2 had
been transferred from a Union Carbide battery plant one month before
and was not fully familiar with either operating or maintenance procedures.
Traning was a major problem at the Bhopal plant. At the
time the MIC facility was opened in 1980, 25 people were sent to the United
States for training. But due to high turnover - 80% in the MIC plant from
1982-1984 by the workers estimate - few of the people originally trained
in the MIC operation in the U.S. remained in Bhopal
The worker said that they had been given little or no training about the
safety and health hazards of MIC or other toxic substances in the plant;
they thought the worst effect of MIC was irritation of the eyes.
Even a maintenance worker who had been assigned to the MIC facility
since it first began operation in 1980, stated that he had been given
virually no training about the safety and health hazards of MIC.
Language also may have contributed to the lack of understanding about
MIC and other hazards . All sings and operating Procedures were
written in English. even though many of the workers spoke only Hindi.
Workers stated that if they wrote in the log books in
Hindi, they were reprimanded.
Insufficient Corporate Attention to Safety
In May of 1982, a three man team from Union Carbide corporation in
the USA inspected the Bhopal plant. In its report, the team found a number
of "Concerns" which they classified as "Major" or
"less serious ." with major concerns being those that represented
"either a higher potential for a serious incident or more serious
consequences if an incident should occur."
The team listed 10 major concerns. Among them were;
3. Potentials for release of toxic materials in the phosgene /MIC
unit and storage areas, either due to equipment failure, operating
problems, or maintenance problems.
4. Lack of fixed water spray protection in several areas of
7. Deficiences in safety valve and instrument maintence
8. Deficiences in Master Tag/ Lockout procedure application.
10. Problems created by high personnnel turnover at the plant, particularly
Problems like these led to the catastrophic MIC release two-and-half years
later. But while the team classified these items as "major"
in relation to the other "less serious " concerns, the overall
message UCC sent its Indian subsidiary was at best confusing . The report's
opening summary states:
The team was very favorably impressed with the number and
quality of operating and maintenance procedures that had been developed
and implement in the past 1-2 years . These procedures together
with the job safety Analyses detailed for most operations, constitute
a major step for all concerned...No situation involving imminent
danger or requiring immediate correction were during the course of the
In accord with corporate procedures, UCIL prepared an action plan in response
to the 1982 inspection and sent periodic progress reports to the United States
until June 1984. But UCC never sent a follow-up team to Bhopal in the
two-and-half years between the inspection and the accident. The workers
report that UCIL did temporarily fix many of the items cited in the 1982
report, but by the time of the accident, conditions had again deteriorated.
Labor Relations and Management Disputes
The Bhopal plant was plagued by labor relations problems and internal
management disputes. In India there can be more than one union representing
workers as a plant. At Union Carbide Bhopal there had been conflicts between
a union affiliated with the Indian National trades union congress (INTUC)
and an independent union over who represented the majority of workers
in the plant. Even at the moment of this writing there is a court
case pending on representation rights. According to workers, management
tried to use this inter-union rivalry to its advantage in contract negotiations
to reduce manning levels and in other labor relations matters.
It also appears that there were internal management disputes in the company.
The management structure of UCIL changed before the accident, and the
Bhopal Pesticides plant was put under the direction of the Union
Carbide battery division in India. According to the workers, this resulted
in management conflicts within UCIL and the transfer of managers to Bhopal
from the battery operation who were not fully trained about the hazards
and appropriate operating procedures for the pesticides plant.
Failure to Respond to Previous Accident and workers warnings
2-3 1984, MIC release was not the first accident at the Bhopal plant.
Published reports and interviews with worker we spoke with
indicate that there were at least five chemical accidents
in the plant between 1981 and 1984.
In December 1981 a phosgene leak injured three workers; one of the workers
died the next day. Two weeks later in January 1982, 24 workers were overcome
by another phosgene leak. In February 1982 an MIC leak affected 18 people.
In August 1982 a chemical engineer came into contact with liquid MIC resulting
in burns over 30% of his body. And in October 1982 a combined MIC, hydrochloric
acid and chloroform leak injured three workers in the plant and affected
a number of residents of the surrounding neighborhoods.
Since 1976 the two unions representing Bhopal workers had frequently complained
to Union Carbide management and the Madhya Pradesh authorities, including
the Factory Inspectorate, about safety and health hazards in the plant.
Correspondence obtained from the local INTUC affiliated union, and our
interviews in Bhopal, demonstrate that both Unions consistently raised
health and safety issues with management and the government, and warned
of grave dangers if the conditions were not corrected.
In a July 1976 letter to the General Manager of the Bhopal plant,
the Union listed five serious accidents, including one case of chemical
burns and one of blindness resulting from separate incidents. The letter
On reviewing the above incidents one can conclude that the safety measures
are inadequate. Despite the instructions from the government before commencement
of production that the worker safety should be given top priority, we
feel that you have neglected this aspect.
In an April 13, 1982, letter to the Minister of Labour or
Madhya Pradesh, the Union wrote:
Our unit is going to celebrate the safety week from the 14th of April,
1982. But the workers would like to inform you that this function
is merely a window-display... we would also like point out that our unit
is manufacturing dangerous chemicals like phosgene , carbon monoxide,
methyl iscocyanate, BHC, naphtha and temik.
After the October 1982 combined release of MIC.hydrochloric acid and chloroform.
Which spread into the community, the Union printed hundreds of posters
(in Hindi) which they distributed throughout the community, warning:
of Fatal Accidents
thousands of workers and citizens in danger because of poisonous gas.
Spurt of accidents in the factory, safey measures deficient.
But despite these constant warnings by the union, little was done to correct
these problems and prevent a potential disaster.
to the direct causes described above, several other factors indirectly
contributed to the accident and increased its severity . These include
Failure to inform workers and the public
The Bhopal plant produced, used, stored and transported a number of
toxic and hazardous pesticides, feedstocks and chemical intermediates
that posed a risk to UCIL workers and the public. However, UCIL never
provided complete information about these chemicals to workers, government
authorities, or community residents. Most of the workers we spoke with
said they had received no training or information about the hazards of
MIC or other toxic chemicals in the plant. Residents of J. P. Nager and
other neighborhoods in Bhopal had little idea what UCIL produced; many
residents thought the plant was making "medicine" for crops.
City and state authorities were provided no information on the identites
and hazards of the chemicals present in the plant; none of the officials
we spoke with had been told before the accident how MIC was produced or
Even after the accident, UCC and UCIL failed to provide adequate information
on MIC and its hazards. On December 3rd, as thousands of people lay dead
or dying in the streets, the medical director of the Bhopal plant continued
to insist that methyl isocyanate was only an irritant and not life threatening.
A worker who was overcome by MIC the night of the accident, and went to
the UCIL medical dispensary the next morning, was told by the same company
doctor not to worry, given a shot of medication and sent home. The workers
soon developed delayed pulmonary edema and was rushed to the hospital
in critical condition.
Medical authorities stated that they received little if any information
on the diagnosis and treatment of MIC injuries from either UCIL or UCC.
A hospital, directors told us that he finally found out that the chemical
was MIC from a newspaper report on the evening of December 3rd; the state
health director finally received solid information on the chemical from
the World Health Organization several days the accident .Indeed, the first
communication from UCC in the U.S. appears to have been a telex
received December 5, which briefly outlined possible treatment, but did
not fully describe the possible toxic effects of MIC.
Inadequate Action by Government Authorities
In India , work place safety and healthy conditions are governed by
the 1948 Factory Act. While the legislation is federal, inspection of
health and safety conditions is the responsibility of state authorities,
in this case the state of Madhya Pradesh. For the Bhopal area, the state
employed two factors. Both inspectors were mechanical engineers with neither
the training nor equipment to assess potential hazards posed by chemicals.
However, the factory inspectorate had long been aware of health and safety
problems in the Bhopal plant. Union leaders had frequently complained
to authorities about safety problems in the plant and the risk of a major
gas release. The state factory inspectorate had conducted
inspections following the fatal gas leak in 1981 and a subsequent leak
a 1982. According to union officials and workers no action was taken by
the government. While the authorities did not cause the Bhopal accident,
it is clear that they failed to take the necessary action that could have
prevented the accident from occurring.
The Bhopal plant was located in a heavily populated area. Some of
the residential growth in the immediate vicinity, including the establishment
of the J.P.Nager shanty town directly across the street, took place after
the plant was first opened in 1967. These settlement were not originally
authorized, but in 1984 the government gave the squatters ownership rights
to the land to avoid forcing them out of their homes.
However, even in the absence of the recent settlements, the plant was
built dangerously close to the core of the city and was only a mile (less
than two Kilometers ) upwind from the Bhopal train station where hundreds
of people slept at the time of the accident. Some of the neighborhoods
most effected by the gas had been inhabited for more than 100 years.
The problem was not that people decided to live near the plant. but that
the company built the plant near pre-existing residential areas.
The 1975 Bhopal Development plan, a kind of municipal zoning ordinance,
specifically called for the siting of obnoxious and hazardous facilities
at the far end of the city, Where prevailing winds would disperse releases
away from dense population zones. But the plan was ignored in the case
of Union Carbide . If the 1975 plan had been followed, it is likely that
the impact of the accident would have been significantly reduced.
Lack of Disaster planning
Union Carbide was aware that the chemicals produced and used in the
Bhopal plant posed a risk to workers and the community at large. Leaks
of toxic chemicals from the plant had affected both workers and the public.
However, a disaster plan for warning and evacuating the community in the
event of a leak had never been developed . The plant is reported
to have had two sirens, one to warn the public. However, it is not clear
when the alarm was sounded - people affected by the gas had no idea what
was happening, or which way they should flee.
The emergency plans for workers in the plant were only marginally better.
Workers informed us that in the event of a leak they had been instructed
to check the wind indicators and run into the wind, away from the directions
of the gas dispersion. However, most escape routes from the plant were
blocked. The plant is surrounded by an 8 foot (2.5 meters) concrete wall
topped with barbed wire; with only one gate, workers were forced to scale
the wall and squeeze through the barbed wire to escape.
there are several factors which can be ruled out as causes of the Bhopal
disaster, in particular, the notion of sabotage. After much public criticism,
Union Carbide has backed away from its March 20 suggestion that
water was "deliberately" introduced into tank 610. There was
never any evidence for such an act, a fact the company now admits.
Others have suggested that the workers were some how responsible,
by failing to take proper precautions, or by running away when the
leak began. But the major design, operating, and maintenance decisions
which led to the release were made by UCC and UCIL management. The line
washing procedure which we believe allowed water to enter the tank 610
was ordered by management. The worker ordered to wash the line had no
way of knowing that the slip blind was not in place, Since it was not
his job to instal it, and he could not see it from his location. Of course,
Bhopal workers were not responsible for the decision to store large quantities
of MIC in Bhopal, or to discontinue refrigerating the MIC tanks, or to
disconnect the flare tower.
It is true that some workers ran form the area during the release. That
is what they had always been told to do by UCIL management. Since gas
leaks had occurred several times in the past, it is not surprising that
they feared for their lives. In any event, there is nothing they could
have done. The reaction could not have been stopped after the safety valve
on tank 610 blew open. But many workers stayed in the plant and tried.
Several were injured in the attempt.
Nor can the cause be located in a lack of worker concern for safety. The
letter and poster campaigns of the two plant unions, and their frequent
complaints to management and the government, have already been described.
The unions were as active in pressing health and safety concerns as any
other union with which we are familiar in developed or developing countries.
Some have suggested that India and other developing nations are incapable
of handling modern technology, However, chemical disasters similar in
cause to the Bhopal tragedy have also occurred in highly developed countries,
most notably, the large dioxin release in Seveso, Italy, on July 10, 1976,
and the chemical plant explosion in Flixborough, United Kingdom which
killed 28 people and injured 89 on June 1, 1974. While we were in Bhopal,
the mission visited a large electrical equjipment plant (Bharat Heavy
Electrical Limited) owned by the Indian government. Most industrial plants
have some safety and health problems, but the ventilation systems and
other engineering controls for toxic substances at BHEL Bhopal were at
least as good as in similar plants in the United States.
Some have suggested that accidents like the Bhopal tragedy are an inevitable
consequence of progress. One commentator even stated that half the people
who died in the accident would not have been alive in the first place
had it not been for the rise in agricultural productivity resulting from
pesticides like the ones produced in the plant. However, faulty design,
dangerous operating procedures, lack of proper maintenance and inadequate
training are not inevitable or inherent in modern technology.
The Bhopal disaster could have been prevented.
nature of the gas leaked at Bhopal and considering that a substantial
section of the population was also exposed to non-lethal doses, the effects
of which could manifest over long periods of time, it is very difficult
to arrive at definite estimate of the number of casualties.
The Indian Government estimates that approximately 1,700 people died.
Most of the more reliable news accounts put the figure around 2,600. The
true number will never be known, because in the chaotic situation during
the first days after the accident, bodies were buried and burned without
proper identification or even count. But it is likely that both of the
above mentioned numbers are too small. There are still thousands of people
registered as missing. Another reason why we do not trust there low figures
is that the government death toll only includes those bodies registered
at the mortuaries.
Dr. Nagu, the Director of Health Services of the state of Madhya Pradesh
said that the Bhopal hospitals treated at least 130,000 patients for problems
- mainly of the eyes and lungs. In addition, over 40,000 patients were
treated in the other 22 districts of the state. These were to a large
extent people who fled from Bhopal by whatever means, they had. According
to him, 12,000 of the 170,000 patients were in a very critical condition
when they were brought to hospitals and wards, 484 of them died, and he
estimated the total number of dead at 2,000.
Dr. K.V. Pandya, the chief medical officer of Kasturba Hospital (BHEL)
told us that his hospital treated over 15,000 patients, most of them outside
on the hospital grounds: 95-98% of the victims also had eye problems.
Almost 100% of the victims also had lung problems-pulmonary edema. Vomitting
was also a very common complaint. No official line of treatment was, however,
forth-coming mainly because doctors in charge had no idea of the cause
of the accident and this in turn because Union Carbide provided practically
no medial information to the authorities. In fact, on December 3, the
company was still claiming that MIC was not lethal, but that it causes
only eye irritation.
Because no information was forthcoming from UCC, initial treatment was
essentially supportive-oxygen, bronchodilators, diuretics, corticosteroids
to reduce inflammatory conditions. Control of blindness was already well-established
in the state so cortisone drops and sulfa drugs were readily available
and used to relieve eye problems. Most of the eye problems subsided.
Lung damage on the other hand was much more serious and lasted longer.
The strong irritant effects of MIC caused massive build up of fluid in
the lungs (edema) as a result of large scale tissue damage and this probably
accounted for the majority of deaths.
Although initial treatment was supported by the WHO representative, Dr.
Jaeger, who arrived on December 8, in the midst of the great confusion
of the first days there arose a strong dispute between medical experts
on the methods of treatment. Autopsies carried out by Dr. Heeresh Chandra
of the Forensic Medicine Dept, on the morning of December 3 showed that
all the classic textbook symptoms of cyanide poisoning were present. These
included cherry-red blood, also in the heart and brain, softening of brain
tissue and early rigor mortis. His conclusion was that cyanide poisoning
was present and that thiosulphate as an antidote was needed for remaining
On December 5, UCC-USA advised from West Virginia on treatment for the
victims. They advised the use of, among others, amyl nitrite for cyanide
poisoning and, if this did not work, to combine it with injections of
sodium thiosulphate. Later, UCC retracted this advice, stating that a
misunderstanding had occured, and recommended that such injections should
On December 8 a Munich doctor showed that blood samples of dead victims
contained 2 ppm cyanide. Further autopsies confirmed this. He and another
doctor then proceeded to give 50 thiosulphate injections. Both thought
that those receiving this treatment showed an amelioration of symptoms
but this effort was terminated after a dispute with the local health authorities.
The question arises here as to where the cyanide in the blood came from
- did the cyanide come from MIC or was cyanide also released in the leak?
Such an amount of cyanide ions in the blood have to come from outside
- there is no possibility that they are a biochemical product. On the
other hand, UCC, Bayer AG (a West German chemical company which also produces
MIC) and Dr. Jaeger of the WHO all state that the cyanide did not come
from the MIC. If this is true, then there is the possibility that other
gases leaked together with MIC.
Wherever the cyanide came from, the controversy continued until the Indian
Council for Medical Research stated that thiosulphate treatment could
be given provided haemoglobin and urinalysis tests were also carried out.
These conditions were satisfied in various hospital departments and so
this treatment was continued on an essentially experimental basis.
A door-to-door survey on the after-effects of the accident, carried out
by a community action group Zahreli Gas Kand Sangharsh Morcha in the last
week of December 1984 in one very affected colony and one less affected
colony, found that 75% of the workforce was incapable of work, insofar
as their capacity to carry loads was reduced by one-third.
among the poor manual laborers means that heavy physical work is now impossible
or difficult so that their earning ability is reduced a situation that
affects thousands. It seems that this chronic lung disease will become
a permanent handicap. In fact, some patients subjected to sensitive lung
function tests show definite signs of fibrosis, emphysema and bronchitis.
In addition, the respiratory tract may become hypersensitive to a variety
of irritants. Such sensitized people develop acute allergic reactions
to a secondary exposure, and this, even if mild, could prove fatal. Exposure
to other irritants can also result in an acute reaction, as already witnessed
by affected women working in a cigarette-rolling factory. These have been
affected by small amounts of chemicals emanating from tobacco, which resulted
in respiratory distress and asthma. Textile dust has also been reported
affecting the lungs of victims.
A large number of pregnant women were exposed to the MIC and resultant
hypoxia, infection, stress and drugs, each of which can cause damage to
the fetus and result in miscarriage, stillbirth or birth defects.
A study to assess the health problems of women due to exposure to MIC
was carried out by Dr. Rani Bang and Dr. Mira Sadgopal in Feburary 1985.
This showed that 3 months after the disaster an extremely high proportion
of women in two of the gas-affected slums has developed gynecological
diseases such as leucorrhoea (94%), pelvic inflammatory disease (79%)
and excessive menstrual bleeding (46%). Suppression of lactation, impotence
in husbands, still-births and spontaneous abortions were other such effects.
The patterns of disease are so striking and so obviously clearly associated
with exposure to MIC that it can be safely inferred that there are definite
gynecological ill-effects from the disaster.
Some of these problems are especially important because of their sequellae.
Women with pelvic imflammatory disease generally have a 10-fold increased
risk of ectopic pregnancy as well as anything up to a 60% chance of infertility.
Ectopic pregnancy is always an emergency, even in the best of conditions
in hospital surroundings. This then is a problem which should be closely
Excessive menstrual bleeding can result in severe anaemia in already malnourished
slum women, reducing their working capacity. These women clearly need
added rations or at least iron and vitamin supplements. Like-wise extra
rations are needed for those babies or mothers who found that their milk
supply was suppressed. Suppression of lactation in 57%of those studied
is alarmingly high; exposure to gas, stress or drugs could have been the
cause of this, and often leads to malnutrition in the infants of poor
All these medium-and long-term effects imply that there may be delayed
outbreaks of secondary diseases or effects-bronchial diseases, infections,
pneumonia, tuberculosis and allergic conditions. The fact that MIC reacts
with other organic molecules in the body to produce a large number of
sometimes toxic products would tend to confirm such fears. The WHO and
the Indian government have a heavy responsibility in monitoring developments.
MIC also gives this same reaction with water and various organic materials
in plants. MIC reacts with water to form methyl amine which again reacts
with MIC to form dimethyl urea. Methylamine is also known to react with
nitrates or nitrites, normally present in lake waters, to form nitrosamines,
which are known cancer-causing agents.
Similar concerns regard the effect of the gas on vegetation, and more
specifically, vegetables and fruit for consumption. The gas immediately
affected trees surrounding the factory, causing visible damage in changing
their colour and blackening leaves. Leafy vegetables such as cabbages
showed white spots on their green leaves. In short, vegetable crops all
showed signs of being badly affected. These short-and long-terms effects
of the MIC pollution on crops and in water deserve to be intensively studied.
This section on the health effects of the MIC gas leak has purposely been
kept brief, mainly because detailed accounts have already appeared in
the press. Even this brief account, however, shows the strong need for
more stringent regulations forcing companies to give exact information
on the health hazards of the chemicals they use.
Was the Bhopal
disaster unique, or could it happen again? Are the factors that
led to the accident confined to Union Carbide, pesticide plants, India,
or developing countries, or are they common?
Union Carbide Corporation (UCC) has had a checkered safety record.
The company was involved in the worst single industrial health tragedy
in American history. In 1930 and 1931, a Union Carbide subsidiary , The
New Kanawah power company, drove a hydro-electric tunnel near the town
of Gauley Bridge, West Virginia. The rock was almost pure silica, a fact
well known to Union Carbide, since the company used the excavated rock
in a nearby steel plant. The hazards of silica were well known in 1930,
but the company took no precautions. A total of 476 workers died from
silicosis (a dust disease of the lungs), some after only a few months'
work. Many were buried in unmarked graves, with no autopsies or death
certificates. Senator Rush Drew Holt of West Virginia later called the
tragedy "the most barbaric example of industrial construction
that ever happened in this world . That company knew well what it was
going to do it these men. The company openly said that if they killed
off those men there were plenty of other men to be had."
In 1978, a Union Carbide product, NIAX catalyst ESN, used in the production
of polyurethane foam, caused severe bladder paralysis among workers handling
it. Union Carbide pulled the material off the market. It was later determined
that. While Union Carbide had tested the acute toxicity of the main ingredient
in rats, they had never bothered to autopsy the animals, and had
thereby missed finding the bladder problems.
In 1970, a survey by the Oil. Chemical and Atomic workers Union (OCAW,
affiliated to ICEF) in a Union Carbide Lindane Division plant in
Tonawanda, New York, uncovered seven causes of emphysema in an 18 worker
department making molecular sieves. Union Carbide workers in other plants
have been the victims of liver cancer from vinyl chloride, skin cancer
from coal-tar products and higher than average rates of leukemia and brain
tumors from as yet unknown causes. Union Carbide's international
record is less well documented , but a Union Carbide battery plant in
Indonesia has been charged with responsibility for severe cadmium poisoning
of the surrounding community.
Fundamentally, however, Union Carbide is no different from other global
chemical companies. All have experienced safety and health problems. In
fact, a 1981 survey of the eight largest chemical companies in the U.S.
ranked Union Carbide first in overall safety and health, based on goverment
inspection statistics . Members of the mission familiar with union
Carbide plants in other countries report them to be generally about as
safe as any other chemical plants. Union carbide Corporation and its Indian
subsidiary were certainly responsible for the Bhopal tragedy, but the
fault does not lie in any unique characteristic of the company.
In the weeks following the Bhopal disaster, governments around the world
quickly initiated inspections of plants making and using MIC. Union Carbide
upgraded its safety systems in Iinstitute and other MIC facilities. One
of UCC'S major American customers announced that it would build a new
derivatives unit in Texas. MIC is not a widely used chemical and the response
to the Bhopal accident makes it unlikely that another large accident
makes will happen in the limited number of plants using it.
However, MIC is only one of thousands of highly dangerous chemicals in
use in industry. Some chemicals, such as phosgene, chlorine, ammonia,
cyanide, hydrogen sulfide and many pesticides can causes sudden death.
Others, such as benzene, vinyl chloride, and acrylonitrile can causes
chronic disease, including cancer. Other chemicals are highly explosive;
liquified natural gas killed 452 people in Mexico City on November 19,
1984, less than two weeks before Bhopal. The Flixborough accident was
caused by dioxin, a substance usually present in the process in only trace
amounts, but which escaped when the reaction went out of control. Clearly,
many different chemicals can cause major accidents.
Similarly, such accidents can happen in any part of the world. The disasters
listed above happened in chemical accidents killing at least 200 people
each have been documented in Brazil, Spain, Federal Republic of Germany,
Mexico, the United States, and now, India.
The Bhopal disaster was caused by a combination of factors, including
the long term storage of MIC in the plant, the potentially undersized
vent gas scrubber, the shutdown of the MIC refrigeration units, the use
of the backup tank to store contaminated MIC, the company's failure to
repair the flare tower, leaking valves, broken gauges, and cuts in manning
levels, crew sizes, workers training, and skilled supervision. The accident
might have been prevented if UCC had done more to follow up its 1982 safety
inspection, or of UCIL or the government had heeded the complaints
of unions representing Bhopal workers. The effects of the accident
were exacerbated by the company's failure to provide adequate information
to its subsidiary, authorities and community residents, the siting of
the plant close to residential areas, and UCIL'S lack of disaster
The specific items which caused the tragedy and the specific
way they came together on the night of December 2, 1984, were unique.
But the underlying causes are not unique:
- Insufficient attentions to safety in the process design,
- Dangerous and irresponsible operating procedures,
- Inadequate maintenance,
- Faulty equipment,
- Cutbacks in manning,
- Inadequate training,
- Management and government unresponsivess to safety complaints,
- The Siting of potentially dangerous plants in heavily populated areas,
- Lack of Information,
- Lack of disaster planning.
Members of the mission represent chemical unions and have visited chemical
plants around the world, In our experience the factors that led to the
Bhopal disaster are common.
Most government set standards for routine , day to day exposure to chemicals.
Some government have extensive environmental regulations.
designed to limit normal emissions of air- and water-pollutants.
However , those regulations are not designed to prevent catastrophic accident
like Bhopal or Seveso or Flixborough. The conditions that led to the MIC
release in Bhopal, had they occurred in the United states or in any of
several other developed countries, would not have violated
any specific workplace or environmental standard. Unless
better national and international regulations are written and strictly
monitored by management and trade unions as well as by local. regional,
national and international authorities, the next chemical disaster is
only a matter of time.
like Bhopal are to prevented in the future, steps must be taken to
address the problems that are posted by the production and use of hazardous
chemicals and processes. These problems are not limited by national
boundaries and will require attention and action by government, industry,
international organizations and trade union movement throughout the world.
Our recommendations for such action are follow are as follows:
Government Organization( i,e, ILO, WHO, OECD) must:
- a) Established
strict health and safety standards to govern hazardous substances and
technologies giving special consideration to major accident hazards.
Standards must include requirements for the proper siting and design
of new production processes and equipment : institution of all necessary
controls to prevent releases and accidents; monitoring and alarm systems;
emergency plans for the worksite and community; training of workers
and supervisors; and appropriate transport and disposal of hazardous
- b) Adopt
legislation and rules requiring complete information on the identity,
hazards and control of hazardous chemical and process to be provided
to workers, the general public and local medical authorities.
an adequate system of inspection of hazardous processes conducted
by trained personnel with the necessary equipment and resources to
do the job.
Chemical manufacturers, importers and users of hazardous chemicals
and processes must:
- a) Institute
the safest possible operating procedures for hazardous chemicals or
processes; proper design and control measures; maintenance of
equipment and controls; adequate manning for safe operation; training
of workers; limited storage of hazardous substances; and establishment
of emergency plans for the worksite and community.
- b) Provide
all necessary training to workers, supervisors and managers who are
responsible for the use or production of hazardous chemicals- in a language
understood by them- about the hazards, proper operating procedures,
control measures, and plans for emergency response.
full information on hazardous chemicals and processes to workers-
in a language understood by them - the public and purchasers of the
substance and processes in all countries.
- d) Provide
the same highest degree of safety in all plants, in all countries in
which they operate.
- a) Develop
comprehensive guideline for the use of hazardous chemicals and processes,
giving special emphasis to measures to control major accident hazards.
- b) Develop
and distributes hazard and control information on chemical substances
and processes for use by governments, employees trade union organization
and workers, particularly in developing countries.
- a) Seek
national laws and international instruments which guarantee workers
and their representatives complete information on the identity, hazards
and control of chemical substances and processes.
- b) Establish
a unified trade union program for the control of major accident hazards;
and seek the adoption of such a control program in all countries through
national laws and international instruments.
their national centers and international trade secretariats, establish
the chemical hazards to union members in all countries.
- d) Promote
the establishment of local safety and health committees and health and
safety representatives to monitor the workplace, and institute training
programs for these union representatives.
on accident like Bhopal and Mexico City, ICFTU affiliates presented a resolution
to the ILO'S annual Labor Conference in June, 1985. The resolution was adopted
by the conference. As it represents to a great extent the will of governments,
employers and workers, we include the text in full. It is our intention
to push for the development of more effective national and international
measures to improve safety in dealing with hazardous substances.
Resolution concerning the promotion of Measures against Risks and Accidents
Arising out of the Use of Dangerous Substances and Processes in Industry.
conference of the International Labor Organization.
Expressing deep concern at the growing risks and the increasing number of
serious accidents related to the use of hazardous substance and chemical
Regretting that such accidents have in the recent past caused considerable
damage and have led to the death of several thousands of persons both insides
and outside undertaking or serious injury to their health,
that such tragedies demonstrate
- (a) the
inadequacy of safety and supervisory measures and the lack of workers'
information and training concerning the hazards linked to certain
dangerous substances and the technical processes that are in use;
correlation between workers' safety and that of the public and the
Emphasizing that in the design and implementation of their industrial
development policies, competent public authorities and industry should
take fully into account the possible safety and heath effects of hazardous
substances and processes on workers and the general public,
Noting with serious concern that in some countries and in particular
the developing countries, substances continue to be used and produced,
and processes introduced, which present risks and which have been
prohibited or subjected to restrictions in other countries,
Emphasizing the basic responsibility of multinational companies' central
managements over the organisation and control of the management of
all their subsidiary units,
Considering that special activities must be undertaken in order to
improve the control of major hazards and safety measures, having regard
to the permanent dangers arising from the widespread use of
chemical and other dangerous substances throughout the world,
Recalling the guide-lines regarding the protection of safety and health
contained in the International Labour Organisation's Tripartite Declaration
of Principles concerning Multinational Enterprises and Social Policy,
as well as the provisions contained in the relevant international
labour Conventions and Recommendations and codes of practice concerning
occupational safety and health and the working environment,
Stressing that international labour standards on safety and health
should be universally applied and strengthened, and stressing in particular
that this resolution applies to the activities of all enterprises,
multinational or otherwise;
- 1. Calls
upon the governments of all States Members of the International Labour
Organisations to adopt, in full consultation with workers' and employers'
organisations, integrated and comprehensive policies for hazard
prevention in connection with the use of dangerous processes as well
as the production, transport, storage, handling and disposal of hazardous
- a) Safeguards
to ensure that the introduction of new hazardous substances and processes
are effectively monitored and covered by adequate health and safety
- b) the
establishment of strict and adequate safety and health standards to
govern, inter alia, the choice of substances and technologies to be
used in industry; the location and design of new production processes
and equipments; the setting up of safe hazard control and alarm systems
in all chemical plants and facilities; detailed emergency plans for
factory areas and surrounding communities; maximum permissible exposure
levels for workers and local populations; the provision of adequate
protective clothing and equipment at the workplace; the safe transport
by air, sea and road as well as the safe storage of toxic chemicals
establishment of a centralised and independent national authority
responsible for submitting recommendations concerning the granting
of licences for industrial operations involving hazardous occupations
and substances as well as for the import and introduction of new and
potentially hazardous technologies and substances in industry;
- d) the
pursuit of international agreements on the export of hazardous substances
and technologies, including provisions to stop importation of substances
banned in other countries.
2. Further calls upon the government of States Members
of the International Labour Organisation
- a. to
re-examine the possibilities for a wider and more effective application
of the provisions contained in the ILO Tripartite Declaration of Principles
concerning Multinational Enterprises and Social Policy, as well as in
other international instruments dealing with the economics and social
responsibilities of multinational enterprises;
upon workers' organisations
- b. to
encourage and stimulate effective tripartite cooperation in all bodies
dealing with safety and health of workers involved in the production,
transport, storage, handling and disposal of hazardous products and
issue adequate legislation and rules for full and clear information
concerning the potential dangers of products and technologies to be
provided prior to their marketing or export by producing companies.
upon employers and company managements in chemical and other hazardous
- a) to
provide for the safest possible operating and control systems in their
enterprises and where transportation is involved, for the safest possible
mode of transport;
- b) to
replace, whenever possible, dangerous substances and processes by safer
- c) to
avoid or minimise the stockpiling of toxic and hazardous substances;
- d) to
ensure the exchange and dissemination of research information concerning
safety and health particulars of hazardous processes and substances
and their alternatives;
- e) to
ensure, as a matter of priority, that all workers, technicians and managers
who play any role in the safety control system of the enterprise be
given adequate specialised training for this purpose;
- f) to
provide to all workers in the enterprise, and in a language they can
understand, the necessary training, information and instructions as
well as equipment required for the protection of their individual and
collective safety and health at the workplace.
identify and asses risks arising out of dangerous industries;
- a) to
contribute towards the improvement of safety conditions in industry
by setting up health and safety departments and locating scientific,
medical and legal experts for advice on matters of safety and health;
- b) to
elect safety and health representatives to monitor the workplace;
- c) to
initiate training courses for such representatives;
- d) to
establish more contacts between workers' organisations in the same national
or multinational enterprises in order to acquire a better understanding
of matters concerned with safety and health.
5. Invites the Governing Body of the International
Labour Office to instruct the Director General
- a) to
make arrangements for ad hoc expert meeting
advise the Office on
general safety measures specific to highly hazardous industries;
measures required to improve safety and health in the production,
storage and transportation of dangerous substances;
the appropriate transportation standards and a code of practice;
- b) to
make every effort, through the International Labour Office's activities
in the fields of technical co-operation, promotion of standards, research
and information, to provide maximum assistance to member States for
the establishment and strengthening of national infrastructures and
institutions conducive to ensuring high levels of safety and health
standards in the production, transport, storage, and handling of hazardous
substances and to strengthen the International Labour Office's ongoing
programmes in the field of training in occupational safety and health;
- c) to
continue to put emphasis, in the context of Industrial Committtee meetings,
on safety and health aspects of the introduction of potentially hazardous
substances and technologies in the relevant industrial sectors;
- d) to
devote adequate attention and resoureces to the International Labour
Office's participation in the International Programme on Chemical Safety
carried out jointly with the World Health Organisation and the United
Nations Environment Programme, and to pursue maximum strengthening of
cooperation with other relevant United Nations agencies for the improvement
and effective application of international standards in the field of
hazard control and accident prevention as well as the protection of
the safety and health of workers employed in chemical and other potentially
- e) to
continue to submit proposals to the Governing Body for the inclusion
in the agenda of future sessions of the International Labour Conference
of technical items dealing with acute safety and health problems in
chemical and other hazardous industries with a view to the strengthening
of international labour standard in this field and in particular to
examine the possibility, as a matter of priority, of including the subject
of hazard control and accident prevention related to the use of hazardous
substances and processes in industry in the agenda of an early session
of the International Labour Conference.