TED Case Studies

Bhopal Disaster




          CASE NUMBER:         233 
          CASE MNEMONIC:      BHOPAL
          CASE NAME:          Bhopal Disaster

A.   IDENTIFICATION

1.   THE ISSUE

Developing countries are particularly vulnerable to industrial
crises.  However, industrial accidents such as Bhopal are not
just an Indian or even a Third World problem but are industrial
disasters waiting to happen , whether they are in the form of
"mini-Bhopals", smaller industrial accidents that occur with
disturbing frequency in chemical plants in both developed and
developing countries, and "slow-motion Bhopals", unseen chronic
poisoning from industrial pollution that causes irreversible
pain, suffering, and death (Weir, pp. xi-xii).  These are the key
issues we face in a world where toxins are used and developed
without fully knowing the harm that can come from their use or
abuse.

2.   DESCRIPTION

Developing countries, such as India, are particularly vulnerable
as they lack the infrastructure (e.g. communication, training,
education etc.) required to maintain technology but are
nevertheless, eager to set up and maintain industrial plants.  As
a result, they compete globally to attract multinational
companies for their investment and capital, and in this process,
often tend to ignore the safety and health violations that many
MNC's engage in.  "Developing countries confer upon MNC's a
competitive advantage because they offer low-cost labor, access
to markets, and lower operating costs.  Once there, companies
have little incentive to minimize environmental and human risks. 
Lax environmental and safety regulation, inadequate capital
investment in safety equipment, and poor communications between
companies and governments compound the problem" (Cassels, p.279).

The Bhopal facility was part of India's Green Revolution aimed to
increase the productivity of crops.  Considered an essential
factor in the effort to achieve self-sufficiency in agricultural
production, pesticide production use increased dramatically
during the late 1960's and early 1970's.  The decision to
manufacture the pesticides in India, as opposed to relying on
imports was based on India's goal of preserving foreign exchange
and its policy of industrialization (Cassels, p.39).  In 1969,
Union Carbide (UCC-the parent company) set up a small plant
(Union Carbide India Ltd.- UCIL) in Bhopal, the capital city of
Madhya Pradesh, to formulate pesticides.

Bhopal was chosen as the site for the Carbide plant because of
it's central location in India, a railway system that spanned the
country, a large lake which provided a reliable source of water,
and sufficient electricity and labor to sustain a large scale
industrial plant.  The MIC facility was located in the existing
Carbide plant to the north of the city, adjacent to an existing
residential neighborhood and barely two kilometers from the
railway station.  Union Carbide claims that the "squatter
settlements" around the plant arrived only after it did. 
However, "all three of the worst-affected communities in the
disaster apparently existed before the Union Carbide plant
opened" (Weir, p.36).

Until 1979, the Indian subsidiary of Carbide used to import MIC
or methyl isocyanate from the parent company.  After 1979, it
started to manufacture its own MIC.  MIC is one of many
"intermediates" used in pesticide production and is a dangerous
chemical.  It is a little lighter than water but twice as heavy
as air, meaning that when it escapes into the atmosphere it
remains close to the ground.  It has the ability to react with
many substances:  water acids, metals, and the small deposits of
corrosive materials that accumulate in pipes, tanks, and valves. 
The MIC in Bhopal was used for the production of various
pesticides, mainly Sevin brand carbaryl insecticide and Temik
brand aldicarb pesticide.  All the pesticides produced at UCIL
were sold in the Indian market.

According to many, Bhopal is the site of the greatest industrial
disaster in history.  On the night of December 23, 1984, a
dangerous chemical reaction  occurred in the Union Carbide
factory when a large amount of water got into the MIC storage
tank # 610.  The leak was first detected by workers about 11:30
p.m. when their eyes began to tear and burn.  They informed their
supervisor who failed to take action until it was too late.  In
that time, a large amount, about 40 tons of Methyl Isocyanate
(MIC), poured out of the tank for nearly two hours and escaped
into the air, spreading within eight kilometers downwind, over
the city of nearly 900,000.  Thousands of people were killed
(estimates ranging as high as 4,000) in their sleep or as they
fled in terror, and hundreds of thousands remain injured or
affected (estimates range as high as 400,000) to this day.  The
most seriously affected areas were the densely populated shanty
towns immediately surrounding the plant -- Jayaprakash Nagar,
Kazi Camp, Chola Kenchi, and the Railway Colony.  The victims
were almost entirely the poorest members of the population.

This poisonous gas, caused death and left the survivors with
lingering disability and diseases.  Not much is known about the
future medical damage of MIC, but according to an international
medical commission, the victims suffer from serious health
problems that are being misdiagnosed or ignored by local doctors
(Lancet, "Round...").

Exposure to MIC has resulted in damage to the eyes and lungs and
has caused respiratory ailments such as chronic bronchitis and
emphysema, gastrointestinal problems like hyperacidity and
chronic gastritis, ophthalmic problems like chronic
conjunctivitis and early cataracts, vision problems, neurological
disorders such as memory and motor skills, psychiatric problems
of various types including varying grades of anxiety and
depression, musculoskeletal problems and gynecological problems
among the victims.  It is estimated that children born in Bhopal
after the disaster face twice the risk of dying as do children
elsewhere, partly because parents cannot care for them
adequately.  Surprisingly enough, despite the serious health
problems and the deaths that have occurred, Union Carbide claims
that the MIC is merely a "mild throat and ear irritant" (Lancet,
"Round..." p.952).

The Bhopal disaster was the result of a combination of legal,
technological, organizational, and human errors.  The immediate
cause of the chemical reaction was the seepage of water (500
liters)into the MIC storage tank.  The results of this reaction
were exacerbated by the failure of containment and safety
measures and by a complete absence of community information and
emergency procedures.  The long term effects were made worse by
the absence of systems to care for and compensate the victims.  

Furthermore, safety standards and maintenance procedures at the
plant had been deteriorating and ignored for months.  A listing
of the defects of the MIC unit runs as follows:

     -Gauges measuring temperature and pressure in the various
     parts of the unit, including the crucial MIC storage tanks,
     were so notoriously unreliable that workers ignored early
     signs of trouble (Weir, pp.41-42).

     -The refrigeration unit for keeping MIC at low temperatures
     (and therefore less likely to undergo overheating and
     expansion should a contaminant enter the tank) had been shut
     off for some time (Weir, pp.41-42).

     -The gas scrubber, designed to neutralize any escaping MIC,
     had been shut off for maintenance.  Even had it been
     operative, post-disaster inquiries revealed, the maximum
     pressure it could handle was only one-quarter that which was
     actually reached in the accident (Weir, pp.41-42).

     -The flare tower, designed to burn off MIC escaping from the
     scrubber, was also turned off, waiting for replacement of a
     corroded piece of pipe.  The tower, however, was
     inadequately designed for its task, as it was capable of
     handling only a quarter of the volume of gas released (Weir,
     pp.41-42).

     -The water curtain, designed to neutralize any remaining
     gas, was too short to reach the top of the flare tower, from
     where the MIC was billowing (Weir, pp.41-42).   

     -The lack of effective warning systems; the alarm on the
     storage tank failed to signal the increase in temperature on
     the night of the disaster (Cassels, p.19).

     -MIC storage tank number 610 was filled beyond recommended
     capacity; and

     -a storage tank which was supposed to be held in reserve for
     excess MIC already contained the MIC (Cassels, p.19).

Ironically, in Bhopal, the people living around the Union Carbide
plant were warned of potential hazards in a series of local
newspaper articles, but residents ignored these warnings because
they did not know how to react to them, while local officials
dismissed them as sensationalist reporting (Technology Review,
p.73).

Interestingly enough, Carbide tried to hide its poor safety and
maintenance record along with the other faults already mentioned,
by claiming publicly that the company was the victim of sabotage
by a 'disgruntled employee'.  Yet, Carbide didn't release the
name of this employee or bring charges against him/her.  However,
there is evidence to the contrary which supports the view that
Carbide (both the parent company and its Indian subsidiary) was
a negligent company that failed to improve its deteriorating
plant.  Incidentally, in a report (May 1982) of the Indian
subsidiary conducted by a three-member safety team from the Union
Carbide headquarters in the U.S., indicated that "a serious
potential for sizeable releases of toxic materials in the MIC
unit either due to equipment failure, operating problems, or
maintenance problems thus requiring various changes to reduce the
danger of the plant; there is no evidence the recommendations
were ever implemented" (Weir, pp.40-41).

Furthermore, "Carbide persistently shows 'wanton and wilful
disregard for the health and safety of its workers and the
communities in which it operates'"(New Statesman and Society,
"Surviving..." p.5).  Additionally, a scientific report published
by two U.S. organizations, the National Toxic Campaign and the
international  Council on Public Affairs, Union Carbide continues
to be " 'a major discharger of toxic substances into the
environment, and a major generator of hazardous waste'.  In 1988,
the company generated more than 300 million pounds of hazardous
waste - an increase of 70 million compared with 1987" (New
Statesman and Society, "Surviving..." p.5).  

Carbide had dropped the safety standards at the Bhopal plant well
below those it maintained at a nearly identical facility in West
Virginia.  It is also important to note here that Carbide was
able to operate its deteriorating plant  because industrial
safety and environmental laws and regulations were lacking or
were not strictly enforced by the state of Madhya Pradesh or the
Indian government making them indirectly responsible for the
tragedy at Bhopal.

3.   RELATED CASES

     VEAL case
     EUMEAT case
     ECFURBAN case
     BASEL case
     CHERNOB case
     BASMEX case

     Keyword Clusters         

     (1): Impact                   = INDIA
     (2): Bio-geography            = TROPical
     (3): Environmental Problem    = HEALTH

4.   DRAFT AUTHOR:  Trupti Patel

B.   LEGAL CLUSTER

5.   DISCOURSE AND STATUS: DISagreement and COMPlete

This disaster gave rise to the world's largest lawsuit, one that
spanned half-way around the world and dragged on for more than
seven years.  Although the final settlement ($470 million)
satisfied the imperatives of the company and the Government of
India, it was condemned by the victims (Cassels, preface). 

For years after the tragedy, the delay in delivering final
compensation to the victims has further propagated the suffering
to the victims.  Furthermore, other elements of relief ordered by
the Indian Supreme Court haven't been implemented.  These are the
medical surveillance program, the contingency insurance and the
new hospital.  There has been much dissent and several 
organizations have voiced that the settlement  with Union
Carbide, made on behalf of the victims by the Indian government,
should be voided.  These petitioners argue that the Indian court
had no authority to dismiss criminal charges or grant immunity
against future charges, to Union Carbide since pleas bargaining
is not permitted under Indian law.

The petitioners also argued that while the settlement amount was
based on an estimated 40,000 severely injured victims, medical
studies suggest the number may be closer to 400,000 (Forbes, "The
ghost..." p.108).  Also, many medical experts believe that
liability to provide adequate compensation and facilities for the
handicapped victims requiring long-term follow up and treatment
should rest with Union Carbide Corporation and not with the
Indian Government (Lancet, "Round..." p.952).  Moreover, more
than 250,000 claims were never documented or classified, making
it hard for these victims to obtain compensation.  Much to the
anger and outrage of these groups and victims and the relief of
Union Carbide, on October 1991, the Indian Supreme Court upheld
the Bhopal settlement of $470 million dollars.  Many feel that
this is a clear signal from the Indian government that MNC's
investing in the country will receive only a "slap on the wrist"
in the event that something like this happens again.

6.   FORUM AND SCOPE:  INDIA and BILATeral

Issues of jurisdiction were central to the legal battle that
followed the tragedy.  These centered around the relationship of
the parent Union Carbide Corporation to its Indian subsidiary and
the appropriateness of the place where litigation is being
conducted.  Union Carbide Corporation maintains that it's
subsidiary is separate from the parent company and so it only
should be liable instead of the whole corporation.  The Indian
government's petition argues that insofar as Union Carbide
designed, constructed, owned, and operated the plant from which
the chemical escaped, the company should be held absolutely
liable for all the resulting damage.  Second, the company, in
undertaking an activity that it knew was ultra-hazardous to the
public at large, is strictly liable for the harm that was the
material consequence of such activity, regardless of whether the
harm that resulted was through fault of another or its own
negligence.  Third, the company was negligent in designing,
constructing, operating and maintaining its plant and thus,
failed to exercise its duty of care to protect the public from
the dangers inherent in its plant and processes (Morehouse and
Subramaniam, pp. 81-82).

Lawsuits were filed in both U.S. and Indian courts but
ultimately, it was decided that the case should be tried in an
Indian court.  Lawsuits filed in U.S. courts related to the
Bhopal case were refused on the grounds that the immediate
location of  the accident was in India, the victims were Indian,
and he U.S. connection with its Indian affiliate did not appear
to give it an unusual degree of control.

7.   DECISION BREADTH: 2

8.   LEGAL STANDING:  LAW

Following the disaster, the Government of India passed the Bhopal
Gas Leak Disaster (Processing of Claims) Act, 1985.  The Act gave
power to the Central Government to represent all claimants in
appropriate forums, appoint a Welfare Commissioner and other
staff and to discharge duties connected with hearing of the
claims and distribution of compensation.  Under this Act, in
1985, the Government formulated a scheme known as the Bhopal Gas
Leak Disaster Scheme, for the registration, processing, and
determination of compensation to each claim and appeals arising
from thereon.

Since the tragedy, the victims have waged an "unrequited struggle
for justice, but they have been ill-served by the Indian
government, which failed to pursue the victims' case aggressively
in the Indian courts, opting instead to go easy on Union Carbide
and maintain a favorable investment climate" (New Statesman and
Society, "Toxin..." p.18). Union Carbide settled out of court for
$470 million, thus avoiding any damaging legal precedent or
liability. In return, India's Supreme Court ordered the dismissal
of all civil and criminal charges against Carbide and its
officers, and gave them immunity from future prosecution.  The
Supreme Court felt that in this case, the victims needed
immediate relief, not further legal delay.

International Law at present plays almost no role in a Bhopal
scenario.  Substantive international law remains weak in the area
of pollution, industrial hazards, and multinational business
regulation (Weir, p.46).  An international treaty is needed under
which it would be agreed that, if courts in a signatory country
award compensation after due process of law, then the award would
automatically be enforced by courts in other signatory countries
(Economist, p.70).

C.   GEOGRAPHIC CLUSTER

9.   GEOGRAPHIC LOCATIONS

     a.   DOMAIN:  ASIA
     b.   SITE:  South Asia [SASIA]  
     c.   IMPACT:  INDIA       

10.  SUB-NATIONAL FACTORS:  NO

11.  TYPE OF HABITAT: TROPical

D.   TRADE CLUSTER

12.  TYPE OF MEASURE: Regulatory Standard [REGSTD]

With regard to process standards, it is apparent that Union
Carbide had double standards when operating its plant in India
and in West Virginia.  An investigation of both the UCIL plant
and its counterpart in Institute, West Virginia revealed  that
"while the latter plant had computerized warning and monitoring
system, the former relied on manual gauges and the human senses
to detect gas leaks.  The capacity of the storage tanks, gas
scrubbers, and flare tower was greater at the Institute plant. 
Finally, emergency evacuation plans were in place in Institute,
but nonexistent in Bhopal" (Cassel, p.19).  Also, the manner in
which Carbide decided to manufacture MIC was questioned at the
design stage when a controversy arose regarding the question of
whether substantial storage capacity or nominal storage of MIC
would be required.  UCC, which provided the basic design of the
plant, supervised its engineering, and defined operating
procedures to run it, insisted on the former [despite the fact
that] UCIL felt that the latter was...inherently safer (Morehouse
and Subramaniam, p.3).

13.  DIRECT OR INDIRECT:  DIRECT

14.  RELATION OF MEASURE TO IMPACT

     a.  DIRECTLY RELATED:    Yes  CHEMical
     b.  INDIRECTLY RELATED:  No
     c.  NOT RELATED:         No
     d.  PROCESS RELATED:     Yes Health

15.  TRADE PRODUCTION IDENTIFICATION: CHEMical

16.  ECONOMIC DATA

Estimates of the number dead and injured vary widely.  Poor
documentation, mass burials and cremations, and conflicting
medical opinions ensure that the precise number will never be
known.  In addition, death records may not include homeless and
transient individuals who perished.  The original count of the
dead was more than 2,000.  By 1987, the official death toll stood
at about 3,500 and by 1992, it was over 4,000.  Victims'
organizations placed the figure many thousands higher.  In
addition, 30,000 to 40,000 people were maimed and seriously
injured, and 200,000 were otherwise affected through minor
injury, death of a family member, and economic and social
dislocation (Cassels, p.5).

17.  IMPACT OF TRADE RESTRICTION: LOW

18.  INDUSTRY SECTOR: CHEMical

19.  EXPORTER AND IMPORTER: USA and INDIA

D.   ENVIRONMENT CLUSTERS

20.  ENVIRONMENTAL PROBLEM TYPE: Pollution Air [POLA]

Not very much is known about the environmental impacts of the gas
leak from the Bhopal plant.  The Indian Council of Agricultural
Research has issued a preliminary report on damage to crops,
vegetables, animals, and fish from the accidents, but these offer
few conclusive findings since they were reported in the early
stages after the disaster. This report however, did indicate that
the impact of whatever toxic substances emerged from the Carbide
plant were highly lethal on exposed animals.  Large number of
cattle (estimates range as high as 4,000), as well as dogs, cats,
and birds were killed.  Plant life was also severely damaged by
exposure to the gas.  There was also widespread defoliation of
trees, especially in low lying areas (Morehouse and Subramaniam,
pp.36-38).

21.  SPECIES INFORMATION

     SPECIES:       Homosapiens
     GENERA:        NA
     DIVERSITY:     NA

22.  IMPACT AND EFFECT:  HIGH and PRODuct

23.  URGENCY AND LIFETIME: LOW and 70 years

24.  SUBSTITUTES:: Biodegradable products [BIODG]

E.   OTHER FACTORS

25.  CULTURE:  NO

There appear to be have been serious communication problems and
management gaps between Union Carbide and its Indian operation. 
This failure to communicate hazards was the result of the parent'
companies hands-off approach to its overseas operation, and can
be traced to cross-cultural barriers.  These can possibly be 
related to "disruptions and flaws which appear in multinational
operations because of "the absence of common values, norms, and
expectations among managers in different nations, from tendencies
towards ethnocentric attitudes, from psychological impediments to
cross-cultural understanding, and from obstructions and
deficiencies in the flow of information within the transnational
system attributable to distance and shared ownership.  The fact
that the operating manuals at Bhopal were printed only in English
is an emblematic example of these problems (Cassels, p.21). 

26.  TRANS-BOUNDARY ISSUES:: NO

27.  HUMAN RIGHTS:  YES

In mid-July 1985, the government of India Health Minister stated
that 36 pregnant women had spontaneously aborted, 21 babies were
born with deformities, and there were 27 stillbirths, all
suspected to have been caused by the poison gas leak in Bhopal.
An examination of 114 women in the field clinics in two of the
gas affected slums in Bhopal three months after the disaster
revealed that an extremely high proportion of these women had
developed gynecological diseases such as leucorrhoea (90%),
pelvic inflammatory disease (79%), cervical erosion and/or
endocervicitis (75%), excessive menstrual bleeding since exposure
to the gas (31%), and suppression of lactation (59%).  Also,
there were several thousand pregnant women in the communities
that were among the worst affected by the gas.  Respiratory
complication and the resulting hypozyia were bound to affect the
fetuses as much as it did the mothers (Morehouse and Subramaniam,
pp. 33-4).

28.  RELEVANT LITERATURE:

"After Bhopal".  Lancet, Issue 603.  July 16, 988.

"Bhopal:  Absolutely Liable".  Economist, Volume 308, Issue 560. 
July 23, 1988.

"Coping With Disaster".  Technology Review, Volume 91, Issue 6. 
August 1988.

Cassels, Jamie.  The Uncertain Promise Of Law:  Lessons From 
Bhopal.  University Of Toronto Press Incorporated.  1993.

Chakravarty, Subrata N.  "The Ghost Returns".  Forbes, Volume
146, Issue 13.  December 10, 1990.

"Editorial:  Toxic Futures".  New Statesman And Society.  Volume
3, Issue 85.  January 26, 1990.

"Freaks of Nature:  Errors of Man".  World Health.  January 1991.

"Fresh Disaster At Bhopal Indian Politics Threaten To Compou". 
Barron's, Volume 68, Issue 5.  February 1, 1988.

Hearing Before the Subcommittee in Asian and Pacific Affairs of
the Committee on Foreign Affairs House of Representatives. 
Ninety-Eight Congress, Second Session.  December 12, 1984.

Jasanoff, Sheila.  Learning From Disaster:  Risk Management After
Bhopal.  University of Pennsylvania Press, Philadelphia.  1994.

Khera, S.S.  The Establishment Of The Heavy Electrical Plant At
Bhopal.  Committee of Case Studies.  The Indian Institute of
Public Administration, New Delhi.  1963.

Kurzman, Dan.  A Killing Wind:  Inside Union Carbide and The
Bhopal Catastrophe.  McGraw Hill Book Company.  1987.

"Land That Time Forgot".  Barron's.  January 22, 1990.

Lappen, Alyssa A.  "Breaking Up Is Hard To Do".  Forbes, Volume
146, Issue 13.  December 10, 1990.

Morehouse, Ward and Subramaniam M. Arun.  The Bhopal Tragedy: 
What Really Happened And What It Means For American Workers And
Communities At Risk.  Council on International and Public
Affairs.  1986.

"Poison Gas, Up Two Bucks".  Nation, Volume 248, Issue 9.  March
6, 1989.

"Round The World:  India--Long Term Effects of MIC".  Lancet,
Issue 644.  April 29, 1989.

"Second Thoughts On Bhopal".  Barron's, Volume 69, Issue 8. 
February 20, 1989.

"Spectrum:  Update--Reforestation, Chernobyl, Bhopal". 
Environment, Volume 30, Issue 5.  June 1988.   

"Surviving Bhopal".  New Statesman And Society, Volume 3, Issue
127.  November 16, 1990.

"The Ghosts of Bhopal".  Economist, Volume 310, Issue 590. 
February 18, 1989.

"Toxin Town", New Statesman And Society, Volume 7, Issue 331. 
December 2, 1994.

Weir, David.  The Bhopal Syndrome:  Pesticides, Environment, And
Health.  Sierra Club Books, San Francisco.  1987. 

Kumar, Sanjay "India:  The Second Bhopal Tragedy".  Lancet,
Volume 341, Issue 854, May 8,1993.


                          References





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