Case 3-9
Bhopal, India: A Tragedy of Massive Proportions
We are citizens of the world. The tragedy of our times is that we do not know this.
Woodrow T. Wilson (1856–1924), 28th president of the United States
At five past midnight on December 3, 1984, 40 tons of the chemical methyl isocynate (MIC), a toxic gas, started to
leak out of a pesticide tank at the Union Carbide plant in Bhopal, India. The leak was first detected by workers about
11:30 p.m. on December 2, 1984, when their eyes began to tear and burn. According to AcuSafe, 1 “in 1991 the
official Indian government panel charged with tabulating deaths and injuries counted more than 3,800 dead and
approximately 11,000 with disabilities.” However, estimates now range as high as 8,000 killed in the first three days
and over 120,000 injured.2 There were 4,000 deaths officially recorded by the government, although 13,000 death
claims were filed with the government, according to a United Nations report, and hundreds of thousands more claim
injury as a result of the disaster.3 On June 7, 2010, an Indian court convicted eight former senior employees of Union
Carbide’s Indian subsidiary to two years in jail each for causing “death by negligence” over their part in the Bhopal
gas tragedy in which an estimated 15,000 people died more than 25 years ago. While the actual numbers may be
debatable, there can be no doubt that the Bhopal incident raises a variety of interesting ethical questions including:
• Did the company knowingly sacrifice safety at the Bhopal plant?
• Did the Indian government properly oversee the functioning of the plant consistent with its regulatory
authority?
• Did the company react quickly enough to avoid sustained health problems to those injured by the leak of
toxic fumes?
1AcuSafe is an Internet resource for safety and risk management information that is a publication of AcuTech, a
global leader in process safety and security risk management located in Houston, Texas,
www.acusafe.com/Incidents/Bhopal1984/incidentbhopal1984.htm.
2According to CorpWatch, www.corpwatch.org/
3United Nations, United Nations University Report (UNU Report) on Toxic Gas Leak,
www.unu.edu/unupress/unupbooks/uu21le/ uu211eOc.htm.
• In the aftermath of the disaster, were the disclosures made by Union Carbide sufficiently transparent to
enable a concerned public to understand the causes of the leak and the steps the company was taking to address all
of the issues?
• Did the company and the Indian government reach a fair resolution of the thousands of claims filed by
Indian citizens?
• Is “business risk” a valid basis on which to make business decisions?
You make up your own mind as you read about the tragedy that is Bhopal.
In the Beginning
On May 4, 1980, the first factory exported from the West to make pesticides using methyl isocyanate (MIC) began
production in Bhopal, India. The company planned to export the chemicals from the United States to make the
pesticide, Sevin. The new CEO of Union Carbide had come over from the United States especially for the occasion.4
As you might expect, the company seemed very concerned about safety issues. “Carbide’s manifesto set down
certain truths, the first being that ‘all accidents are avoidable provided the measures necessary to avoid them are
defined and implemented.’ ” The company’s slogan was: “Good safety and good accident prevention practices are
good business.”
Safety Measures
The Union Carbide plant in Bhopal was equipped with an alarm system with a siren that was supposed to be set off
whenever the “duty supervisor in the control room” sensed even the slightest indication that a possible fire might be
developing “or the smallest emission of toxic gas.” The “alarm system was intended to warn the crews working on
the factory site.” Even though thousands of people lived in the nearby bustees (shantytowns), “none of the
loudspeakers pointed outward” in their direction. Still, they could hear the sirens coming from the plant. The siren
went off so frequently that it seemed as though the population became used to it and weren’t completely aware that
one death and several accidental poisonings had occurred before the night of December 2, and there was a
“mysterious fire in the alpha-naphtol unit.”
In May 1982, three engineers from Union Carbide came to Bhopal to evaluate the plant and confirm that everything
was operating according to company standards. The investigators identified more than 60 violations of operational
4Dominique LaPierre and Javier Moro, Five Past Midnight in Bhopal (New York: Warner Books, 2002).
and safety regulations. An Indian reporter managed to obtain a copy of the report that noted “shoddy workmanship,”
warped equipment, corroded circuitry, “the absence of automatic sprinklers in the MIC and phosgene production
zones,” a lack of pressure gauges, and numerous other violations. The severest criticism was in the area of
personnel. There was “an alarming turnover of inadequately trained staff, unsatisfactory instruction methods and a
lack of rigor in maintenance reports.”
The reporter wrote three articles proclaiming the unsafe plant. The third article was titled “If You Refuse to
Understand, You Will Be Reduced to Dust.” Nothing seemed to matter in the end because the population was
assured by Union Carbide and government representatives that no one need be concerned because the phosgene
produced at the plant was not a toxic gas.
The Accident
The accident occurred when a large volume of water entered the MIC storage tanks and triggered a violent chain
reaction. Normally, water and MIC were separated but on the night of December 2, “metal barriers known as slip
blinds were not inserted and the cleaning water passed directly into the MIC tanks.” It is possible that additional
water entered the tanks later on in trying to control the reaction. Shortly after the introduction of water,
“temperatures and pressures in the tanks increased to the point of explosion.”
The report of consultants that reviewed the facts surrounding the accident indicates that workers made a variety of
attempts to save the plant including: 5
• They tried to turn on the plant refrigeration system to cool down the environment and slow the reaction but
the system had been drained of coolant weeks before and never refilled as a cost savings measure.
• They tried to route expanding gases to a neighboring tank but the tank’s pressure gauge was broken and
indicated the tank was full when it was really empty.
• They tried other measures that didn’t work due to inadequate or broken equipment.
• They tried to spray water on the gasses and have them settle to the ground but it was too late as the
chemical reaction was nearly completed.
The Workers and Their Reaction
5Ron Graham, “FAQ on Failures: Union Carbide Bhopal,” Barrett Engineering Consulting,
www.tcnj.edu/rgraham/failures/UCBhopal.html.
It was reported that the maintenance workers did not flush out the pipes after the factory’s production of MIC
stopped on December 2. This was important because the pipes carried the liquid MIC produced by the plant’s
reactors to the tanks. The highly corrosive MIC leaves chemical deposits on the lining of the tanks that can
eventually get into the storage tanks and contaminate the MIC. Was it laziness, as suggested by one worker?
Another worker pointed out that the production supervisor of the plant left strict instructions to flush the pipes but it
was late at night and neither worker really wanted to do it. Still, they followed the instructions for the washing
operation but the supervisor had omitted the crucial step to place solid metal discs at the end of each pipe to ensure
hermetically sealed tanks.
The cleansing operation began when one worker connected a hosepipe to a drain cock on the pipe work and turned
on the tap. After a short time it was clear to the worker that the injected water was not coming out of two of four
drain cocks. The worker called the supervisor who walked over to the plant and instructed the worker to clean the
filters in the two clogged drain cocks and turn the water back on. They did that but the water did not flow out of one
drain. After informing the supervisor who said to just keep the water flowing, the worker left for the night. It would
now be up to the night shift to turn off the tap.
The attitude of the workers as they started the night shift was not good as Union Carbide had started to cut back on
production and lay off workers. They wondered if they might be next. The culture of safety that Union Carbide tried
to build up was largely gone as the workers typically handled toxic substances without protective gear. The
temperature readings in the tanks were made less frequently and it was rare when anyone checked the welding on
the pipe work in the middle of the night.
Even though the pressure gauge on one of the tanks increased beyond the “permitted maximum working pressure,”
the supervisor ignored warnings coming from the control room because he was under the impression that Union
Carbide had built the tanks with special steel and walls thick enough to resist even greater pressures. Still, the duty
head of the control room and another worker went to look directly at the pressure gauge attached to the three tanks.
They confirmed the excessive pressure in one tank.
The duty head climbed to the top of that tank, examined the metal casing carefully, and sensed the stirring action.
The pressure inside was increasing quickly leading to a popping sound “like champaign corks.” Some of the gas
then escaped and a brownish cloud appeared. The workers returned to where the pipes had been cleaned and turned
off the water tap. They smelled the powerful gas emissions. They heard the fizzing sound as if someone was blowing
into an empty bottle. One worker had a cool enough head to sound the general alarm, but it was too late for most of
the workers and many of those living in the shantytowns below the plant.
The Political Response
Union Carbide sent a team to investigate the catastrophe but the Indian government had seized records and denied
the investigators access to the plant and the eyewitnesses. The Madhya Pradesh state government tried to place the
blame squarely on the shoulders of Union Carbide. It sued the company for damages on behalf of the victims. The
ruling Congress Party was facing national parliamentary elections three weeks after the accident and it “stood to lose
heavily if its partners in the state government were seen to be implicated, or did not deal firmly with Union
Carbide.”6
The government thwarted early efforts by Union Carbide to provide relief to the victims to block its attempt to gain
the goodwill of the public. The strategy worked as the Congress Party won both the state legislative assembly and
the national parliament seats from Madhya Pradesh by large margins.
Economic Effects
The economic impact of a disaster like the one that happened in Bhopal is staggering. The $25 million Union
Carbide plant in Bhopal was shut down immediately after the accident, and 650 permanent jobs were lost. The loss
of human life means a loss of future earning power and a loss of economic production. The thousands of accident
victims had to be treated and in many cases rehabilitated. The closure of the plant had peripheral effects on local
businesses and the population of Bhopal. It is estimated that “two mass evacuations disrupted commercial activities
for several weeks, with resulting business losses of $8 to $65 million.”
In the year after the accident, the government paid compensation of about $800 per fatality to relatives of dead
persons. About $100 was awarded to 20,000 victims. Beginning in March 1991, new relief payments were made to
all victims who lived in affected areas and a total of $260 million was disbursed. Overall, Union Carbide agreed to
pay $470 million to the residents of Bhopal. By the end of October 2003, according to the Bhopal Gas Tragedy
Relief and Rehabilitation Department, compensation had been awarded to 554,895 people for injuries received and
15,310 survivors of those killed. The average amount to families of the dead was $2,200.
Union Carbide’s Response
6United Nations, United Nations University Report (UNU Report) on Toxic Gas Leak.
Shortly after the gas release, Union Carbide launched what it called “an aggressive effort to identify the cause.”
According to the company, the results of an independent investigation conducted by the engineering consulting firm
Arthur D. Little were that “the gas leak could only have been caused by deliberate sabotage. Someone purposely put
water in the gas storage tank, causing a massive chemical reaction. Process safety systems had been put in place that
would have kept the water from entering the tank by accident.”7
In a 1993 report prepared by Jackson B. Browning, the retired vice president of Health, Safety, and Environmental
Programs at Union Carbide Corporation, Browning stated that he didn’t find out about the accident until 2:30 a.m.
on December 3. He claims to have been told that “no plant employees had been injured, but there were fatalities—-
possibly eight or twelve—in the nearby community.”
A meeting was called at the company’s headquarters in Danbury, Connecticut, for 6 a.m. The chair of the board of
directors of Union Carbide, Warren M. Anderson, had received the news while returning from a business trip to
Washington, DC. He had a “bad cold and a fever” so Anderson stayed at home and designated Browning as his
“media stand-in” until Anderson could return to the office.8
At the first press conference called for 1:00 p.m. on December 3, the company acknowledged that the disaster had
occurred at its plant in Bhopal. The company reported that it was sending “medical and technical experts to aid the
people of Bhopal, to help dispose of the remaining [MIC] at the plant and to investigate the cause of the tragedy.”
Notably, Union Carbide halted production at its only other MIC plant in West Virginia and it stated its intention “to
convert existing supplies into less volatile compounds.”
Warren Anderson traveled to India and offered aid of $1 million and the Indian subsidiary of Union Carbide pledged
the Indian equivalent of $840,000. Within a few months the company offered an additional $5 million in aid that was
rejected by the Indian government. The money was then turned over to the Indian Red Cross and used for
relief efforts.
The company continued to offer relief aid with “no strings attached.” However, the Indian government rejected the
overtures and it didn’t help the company to go through third parties. Union Carbide believed that the volatile
7Union Carbide started a Web site, www.bhopal.com, after the leak to provide its side of the story and details about
the tragedy. In 1998 the Indian state government of Madhya Pradesh took full responsibility for the site.
8Jackson B. Browning, The Browning Report, Union Carbide Corporation, 1993,
www.bhopal.com/pdfs/browning.pdf.
political situation in India—Prime Minister Indira Gandhi had been assassinated—hindered its relief efforts,
especially after the election of Rajiv Gandhi on a government reform platform. It appeared to the company that
Union Carbide was to be made an example of as an exploiter of Indian natural resources and the government may
have wanted to “gain access to Union Carbide’s financial resources.”
Union Carbide had a contingency plan for emergencies but it didn’t cover the “unthinkable.” The company felt
compelled to show its “commitment to employee and community safety and specifically, to reaffirm the safety
measures in place at their operation.” Anderson went to West Virginia to meet with the employees in early February
1985. At that meeting, as “a measure of the personal concern and compassion of Union Carbide employees,” the
workers established a “Carbide Employees Bhopal Relief Fund and collected more than $100,000 to aid the
tragedy’s victims.” 9
Analysis of Union Carbide’s Bhopal Problems
Documents uncovered in litigation10 and obtained by the Environmental Working Group of the Chemical Industry
Archives, an organization that investigates chemical company claims of product safety, indicate that Union Carbide
“cut corners and employed untested technologies when building the Bhopal Plant.” The company went ahead with
the unproven design even though it posed a “danger of polluting subsurface water supplies in the Bhopal area.” The
following is an excerpt from a document numbered UCC 04206 and included in the Environmental Working Group
Report on Bhopal India.11 It also reveals the indifferent attitude of the Indian government toward environmental
safety.
The systems described have received provisional endorsement by the Public Health Engineering Office of the State
of Madhya Pradesh in Bhopal. At present there are no State or Central Government laws and/or regulations for
environmental protection, though enactment is expected in the near future. It is not expected that this will require
any design modifications.
The comparative risk of poor performance and of consequent need for further investment to correct it is considerably
higher in the [Union Carbide-India] operation than it would be had proven technology been followed throughout . . .
9The Browning Report, p. 8.
10Bano et al. v. Union Carbide Corp & Warren Anderson, 99cv11329 SDNY, filed on 11/15/99.
11Environmental Working Group, Chemical Industry Archives,
www.chemicalindustryarchives.org/dirtysecrets/bhopal/index .asp.
the MIC-to-Sevin process, as developed by Union Carbide, has had only a limited trial run. Furthermore, while
similar waste streams have been handled elsewhere, this particular combination of materials to be disposed of is new
and, accordingly, affords further chance for difficulty. In short, it can be expected that there will be interruptions in
operations and delays in reaching capacity or product quality that might have been avoided by adoption of proven
technology.
[Union Carbide-India] finds the business risk in the proposed mode of operation acceptable, however, in view of the
desired long term objectives of minimum capital and foreign exchange expenditures. As long as [Union Carbide-
India] is diligent in pursuing solutions, it is their feeling any shortfalls can be mitigated by imports. Union Carbide
concurs.
As previously mentioned there was one death and several accidental poisonings at the Bhopal plant before
December 3, 1984. The International Environmental Law Research Center prepared a Bhopal Date Line that showed
the death occurred on December 25, 1981, when a worker was exposed to phosgene gas. On January 9, 1982, 25
workers were hospitalized as a result of another leak. On October 5, 1982, another leak from the plant led to the
hospitalization of hundreds of residents.12
It is worth noting that the workers had protested unsafe conditions after the January 9, 1982, leak but their warning
went unheeded. In March 1982 a leak from one of the solar evaporation ponds took place and the Indian plant
expressed its concern to Union Carbide headquarters. In May 1982 the company sent its U.S. experts to the Bhopal
plant to conduct the audit previously mentioned.
Union Carbide’s reaction to newspaper allegations that Union Carbide-India was running an unsafe operation was
for the plants’ works manager to write a denial of the charges as baseless. The company’s next step was, to say the
least, bewildering. It rewrote the safety manuals to permit switching off of the refrigeration unit and a shutdown of
the vent gas scrubber when the plant was not in operation. The staffing at the MIC unit was reduced from 12
workers to 6. On November 29, 1984, three days before the disaster, Union Carbide had completed a feasibility
report and the company had decided to dismantle the plant and ship it to Indonesia or Brazil.
12S. Muralidhar, “The Bhopal Date Line,” International Environmental Law Research Centre,
www.ielrc.org/content/n0409.htm.