A complete case study on Bhopal gas leak incident Visit my youtube channel to view video presentations : https://www.youtube.com/channel/UCtgw7WI5PPHISERF33ZrpSw

1. BHOPAL GAS TRAGEDY
A Case Study
Presented by :
KhushbooVerma

2. CONTENTS
 Introduction
 Union Carbide
 Summary
 Immediate Aftermath
 PEST Analysis
 Possible reasons
 Major Problem of the Case
 Suggested Strategies
 Conclusion

3. INTRODUCTION
 Occurrence: 3rd December 1984
 Place of occurrence: Bhopal, Madhya Pradesh, India
 Company: Union Carbide India Ltd.(UCIL)
 Chemical: Methyl Isocyanate(MIC)
 Cause: Gas leak from storage tank
 Deaths: At least 3,787; over 16,000 claimed
 Injuries: At least 558,125
 Counted among the “World’sWorst Industrial Disaster”

4. UNION CARBIDE
 The Union Carbide Corporation(UCC)
was established in 1969 in Bhopal
 UCIL was the Indian subsidiary of
UCC
 WarrenAnderson was the UCC CEO
at the time of the disaster
 Phosgene, Monomethlyamine,
Methyl Isocyanate (MIC) and the
pesticide Carbaryl, also known as
Sevin.
 Taken over by DOW Chemicals in
2001

5. SUMMARY
 During night of 2-3 Dec 1984, tank E610 containing MIC
leaked
 MIC is an extremely reactive chemical and is used in
production of the insecticide carbaryl
 The scientific reason for the accident was that water
entered the tank where about 40 cubic meters of MIC
was stored
 When water and MIC mixed, an exothermic chemical
reaction started, producing a lot of heat
 As a result, the safety valve of the tank burst because of
the increase in pressure
 It is presumed that between 20 and 30 tonnes of MIC
were released into the atmosphere during the hour that
the leak took place

7. IMMEDIATE AFTERMATH
 Poisonous MIC cloud resulted in respiratory disorders,
cancer and reproductive hazards among those who came
in contact
 Trees in the vicinity became barren
 The water, air and food become polluted in that area.
 Over 5 lakhs people were exposed to MIC gas and other
chemicals
 Massive cremations & burials of humans and animals
took place

9. PEST ANALYSIS

10. POLITICAL FACTORS
 In an attempt to achieve industrial self-sufficiency, India
invited and allowed Union Carbide to set up a plant near
residential area in the city of Bhopal to produce MIC
 The Madhya Pradesh State government had not
mandated any safety standards.
 The government neglected the occurrence of six
accidents between 1981 and 1984 in UCIL plant, at least
three of which involved MIC or phosgene.
 This coupled with political power and scientific expertise
worked together to changed the people’s perception of
what was dangerous and more importantly what was
safe.

11. ECONOMICAL FACTORS
 70% of the plants employee was fined before the disaster
for refusing to deviate from their proper safety
regulations under pressure from the management
 UCIL followed cost-cutting strategy. By 1983 two third of
skilled engineer working from the beginning had already
left the company

12. SOCIAL FACTORS
 Plant location closed to densely populated area
 Lack of experienced operator
 Communication problem(worker were forced to use
English manual even though only a few had a grasp of
the language)

13. TECHNOLOGICAL FACTORS
 Poor maintenance and inadequate emergency
 Use of more dangerous pesticides manufacturing
methods
 The MIC tank alarm had not been working for 4 yrs and
their was only 1 manual backup
 The reduced energy cost the refrigeration system was
idle, the MIC was kept at 20 degree Celsius not the 4.5
degree advised by the manual.

14. POSSIBLE REASONS
Corporate
Negligence
Worker
sabotage

15. POSSIBLE REASONS
 Corporate Negligence : “A potent combination of under-
maintained and decaying facilities, a weak attitude
towards safety, and an undertrained workforce,
culminating in worker actions that inadvertently enabled
water to penetrate the MIC tanks in the absence of
properly working safeguards”
 Worker Sabotage : “ A disgruntled plant employee,
apparently bent on spoiling a batch of methyl
isocyanate, added water to a storage tank”

16. MAJOR PROBLEM OF THE CASE
Who is responsible?
GOI
UCC
UCIL

17. GOVERNMENT OF INDIA
 Granted a license to setup manufacturing and storing
unit of deadly poisonous chemical in residential area
Bhopal where nearly 120,000 people resided
 In December 1982, Govt. said, “There is no danger to
Bhopal, nor will there ever be”, even though UCC officials
warned about the upcoming disaster after a field
investigation
 Protected the company neglecting all the complaints and
warnings saying a sum of Rs. 250 million had been
invested in that unit, which being a large one can’t be
shifted elsewhere

18. UNION CARBIDE CORPORATION
 UCIL was UCC’s subsidiary company but it pulled out its
interest after a huge loss
 It didn’t strongly enforce the rules and policies so that
UCIL management team showed poor management and
regulation of the company
 Although standards were set for security and
maintenance, it didn’t impose on UCIL
 It did not have any kind of emergency plans in place for
unseen disaster at UCIL contrary to what was said in
UCC’s document so the hospital staff had no idea of what
had happened or what to do with MIC related disorders

19. UNION CARBIDE INDIA LTD.
 MD of the company only focused on cost cutting, cutting
off the jobs of more than 200 skilled and experienced
workers.
 Shut down of principal safety systems shows the
unethical and irresponsible behavior of MD
 MIC in the tank was filled to 87% of its capacity while
maximum permissible limit was 50%
 Factory officials reveal about the disaster only after an
hour of the leakage although they knew it one hour
before

20. SUGGESTED STRATEGIES
 GOI should not have permitted to build company at
Bhopal. Instead they should have suggested any other
non-residential area
 GOI should have enforced strong policies regarding
company operations and its security system
 GOI should have used the power to shut down the
company after security issues were raised because safety
of its people comes first
 UCC should have regulated UCIL’s operation even cost
cutting strategy was encouraged.
 UCIL should have enforced proper management to
maintain standard of securities.

21. CONCLUSION
 The Bhopal gas tragedy could have been averted
 There were lapses on part of the government and UCC
 The actual reason for the tragedy is contrary to popular
belief
 An alternate way to produce carbaryl was suggested
 Design of Inherently safer process was required