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LEGACY OF BHOPAL






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MOHAMMAD KAZMI
ELISE MIDDLETON
KARL BYRON SCHNEIDAU





SENG 674
TEXAS A&M UNIVERSITY
APRIL DATE 2014
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EXECUTIVE SUMMARY
MOHAMMAD
Maritime transport is inherently dangerous by nature, and many incidents have resulted in
a significant loss of life, especially since 1890. Investigations into these incidents are conducted
in order to determine what went wrong. The identification of causes, and the development of
ways to prevent recurrence, is important for advances in maritime safety. This term paper
analyzes the affect that technology, human error, and emergency response may have had on six
fatal peacetime maritime accidents that occurred between 1912 and 1994. The incidents analyzed
include the s.s. Mont Blanc, RMS Titanic, RMS Empress of Ireland, ms Estonia and ms Herald
of Free Enterprise.
The root causes and contributing factors of each incident was evaluated in terms of
technology, human error, emergency response, and the regulatory environment in place at the
time of the incident. Root cause failures due to human error and technology were found to have a
greater impact on the incidents analyzed. Whereas failures within emergency response was found
to significantly impact the number of fatalities for each incident.
Considering the analysis of these six incidents, a list of suggested recommendations is
presented that are relevant for improving the safety of maritime operations today.

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Table of Contents
EXECUTIVE SUMMARY ............................................................................................................ 2
Table of Contents..................................................................................................................... 3
I. INTRODUCTION ................................................................................................................... 4
A. BACKGROUND ..................................................................................................................... 4
B. PURPOSE ................................................................................................................................ 4
C. OBJECTIVES .......................................................................................................................... 4
II. THE LEGACY OF BHOPAL ................................................................................................. 6
A. HEALTH ................................................................................................................................. 6
B. ENVIRONMENT .................................................................................................................... 8
1. ENVIRONMENTAL IMPACT (THEN & NOW) ................................................................. 8
2. CURRENT REHABILITATION PLANS .............................................................................. 9
C. CHEMICAL SAFETY REGULATIONS ............................................................................... 9
D. LIABILITY ............................................................................................................................. 9
III. LESSONS LEARNED FROM BHOPAL ............................................................................. 10
A. DISASTERS SIMILAR TO BHOPAL ................................................................................. 10
B. LESSONS LEARNED .......................................................................................................... 11
1. Section 1 ................................................................................................................................ 12
C. EMERGING ISSUES ............................................................................................................ 12
IV. CONCLUSIONS ................................................................................................................... 13
REFERENCES CITED ................................................................................................................. 14


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I. INTRODUCTION
A. BACKGROUND
BYRON
Bhopal disaster statistics: what happened, why it happened, what the outcome was
How the disaster affected Union Carbide
How the disaster affected regulatory requirements in the chemical industry
B. PURPOSE
MOHAMMAD
The purpose of this paper is to understand the impact of the Bhopal incident and to
investigate and explain any ongoing legacy issues.
C. OBJECTIVES
The objective of this term paper is to discuss:
How the Bhopal disaster is believed to be impacting the next generation (e.g. birth
defects) MOHAMMAD
Ongoing environmental impact from the release (soil & groundwater contamination)
MOHAMMAD
Current rehabilitation plans (including the Bhopal Gas Tragedy Relief and
Rehabilitation Ministry) ELISE
Regulatory Implications (US: 1986 EPCRA, establishment of OSHAs PSM
Regulation and EPAs RMP Rule) ELISE
Liability related legacy issues (e.g Union Carbide settlement, litigations, current
ownership) ELISE
Disasters similar to Bhopal after it occurred MOHAMMAD
Lessons learned from the incident including inherently safer design, growth in
process safety management, importance of community engagement and awareness
BYRON
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Emerging Issues related to inherent safety and reactive chemicals BYRON

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II. THE LEGACY OF BHOPAL
Text
A. HEALTH
Text MOHAMMAD
The immediate aftermath of the accident was the resulting death toll controversy. While the
Indian government official put the death toll count as 1,754, this was vehemently denied and
criticized by voluntary organizations on the ground and the NGOs. The Delhi Science
Forum estimated the deaths to be around 5000 whereas the circumstantial evidence of death
such shrouds sold, missing persons estimate put the death toll at about 10,000. (Shrivastava,
64-65). In its report in 2004, Amnesty International estimated that between 7000 and 10 000
people died within 3 days of the disaster, and another 150,000 to 200,000 died from related
caused to the accident from 19852003. These figures are much higher than most official
estimates, and are based on extrapolation of mortality rates. (Sharma)

In the beginning few months of the Bhopal tragedy, it was believed that the aftereffects of
exposure of MIC were temporary and would not cause any long term medical affects
(Boffey). However, due to the overwhelming case of injuries believed to be in the range from
about 200,000 to 300,000, it became abundantly clear that despite MIC being used in the
industrial process for several decades, very little was known about its long-term effects
(Smyth). The most serious and permanent damage which affected the general popular was
related to the respiratory tract. The MIC furthermore also damaged mucus membranes,
perforated tissue, inflamed the lungs and caused secondary lung infections. Many of these
survivors later on went to have asthma, bronchitis, pneumonia, and fibrosis, leave physically
unable to work and earn a living. (Shrivastava, 67-68)

To compound the general populace woes they also had to deal with the effects of other toxic
gases which had leaked from the storage tank. It can be said with certainty that the releasing
gas contained a mixture of MIC with chloroform. (Srivastava, 70). The diverse set of
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symptoms found in the survivors prompted the health organizations to conclude that MIC
alone could not be responsible. The combination of toxic gases inhaled by the victims
possibly contained a mixture of over 20 aqueous and thermal decomposition products, which
included hydrogen cyanide (Sharma). After MIC, the chemical which caused the most havoc
to the residents health was hydrogen cyanide. Even though its a deadly poison, antidotes to
it are known and if Union Carbide had made the local press and hospitals aware of it, rather
than denying its presence, many lives could have been saved (Shrivastava, 71). Thirty five
percent of the patients had contracted gastrointestinal, nervous system and eye damage which
proved that the victims were suffering from cyanide poisoning. (Medico Friends Circle)

Other than fatalities, physical injuries and economic and social disruptions another problem
which enveloped and become epidemic in the survivors were those of psychological
problems. Although fear was the primary psychological symptom of the residents and the
survivors, other symptoms such as sleeplessness, nightmares, anxiety, loss of libido,
projection of guilt and increased family violence were not to be discounted. Mass fear within
the city caused almost 400,000 residents to flee the city and never return. The majority of the
people who suffered such psychological illnesses were women of childbearing age. Such
women also suffered from severe gynecological illnesses, such as shortened periods and
abnormal menstrual cycles (Shrivastava, 73-74). Furthermore about fifty percent of women
reported an inability to breast-feed due to lactation failure (Medico Friends Circle). Out of
2700 pregnancies, 52 ended in stillbirths. Amongst the live births, 132 babies survived only
for a short time and 30 of them were born malformed. (Madhya Pradesh Chronicle)

The challenges related to the accident continue till this day. The medical fraternity did not
believe in chemical asthma, and after a long time have started to believe and realize that
chemicals can cause asthma and treat it (Bisarya and Puri). More than half a million people
were exposed to MIC; around 120 000 of them continue to suffer from chronic respiratory,
ophthalmic, reproductive, endocrine, gastro-intestinal, musculoskeletal, neurological, and
mental disorders (Sharma). Furthermore nowhere else in the world are there more people
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with the diseases called pulmonary fibrosis leading to pulmonary cripples. Treatment for this
disease has been slow and has been marred by the usual litigation and bureaucracy issues.
Reproductive problems still exist with mothers even today giving birth to still born or
deformed fetuses. Lastly cancer cases continue to multiply and mental retardation in the
residents is getting more manifest. (Bisarya and Puri).
B. ENVIRONMENT
Text MOHAMMAD
Even though the damage to plant and animal life was equally devastating, the effects on them
were not studied because all of the available resources were focused on mitigating human losses.
The number of animal deaths, after the initial leak was reported to be about 2000. More than
7000 animals were given therapeutic care and the postmortem done on the animals suggested
cyanide poisoning was involved. The MIC leak destroyed the standing vegetation in the
surrounding areas with the plants suffering from symptoms such as dryness, scorching and
bleaching. A dramatic increase in the free carbon-dioxide and ammonia nitrogen was also
detected in the water after the accident. After the accident up to 22 chemicals were found to be
have dumped by Union Carbide into either air, water or soil. (Shrivastava, 74-75).

1. ENVIRONMENTAL IMPACT (THEN & NOW)
Text MOHAMMAD
A number of investigations done by Indian and international organizations have found that the
subsoil and groundwater are contaminated with heavy metals and persistent organic pollutants
from the abandoned pesticide plant. According to a recent report commissioned by Greenpeace
in 2004, it was found that chemicals such carbon tetrachloride chloroform, trichloroethene,
tetrachloroethene, and dichlorobenzene, were present in concentrations ranging from five to 600
times the safe limits. Keving Brigden of the Greenpeace Science Unit, University of Exeter, UK
said in the report that Persistent organic chemicals stay in the environment for tens of thousands
of years. They have known health effects on the liver and kidney, while some are carcinogenic.
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Based on its findings, Greenpeace gave a list of recommendations for cleaning up the site in
Bhopal. It recommended off-site treatment of the contaminated soil and reuse of the land and has
opposed the idea of converting the site into a landfill, which was proposed by the local state
government. Harald Burmeier of University of Applied Sciences, Gehrden, Germany, explained
that The factory contaminated the environment in three phases: the production phase before the
accident, when there were chemical losses; the accident in which gases leaked and dust
emissions polluted the surrounding areas; and the third phase is the post-accident era when
leftover chemicals soaked into the ground due to rain and other weather conditions. Despite
these recommendations, nothing has been done at the site during the past 20 years. The fence
which was supposed to eclipse the plant has not been completed even till today. As such the
restricted area is open to the public and the children play there, the cattle graze on the local
vegetation and people take away material for building their houses, further endangering their
health. (Sharma)
2. CURRENT REHABILITATION PLANS
Text ELISE
C. CHEMICAL SAFETY REGULATIONS
Text ELISE


D. LIABILITY
Text ELISE


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III. LESSONS LEARNED FROM BHOPAL
TEXT. BYRON
A. DISASTERS SIMILAR TO BHOPAL
TEXT MOHAMMAD
One of the most important lessons learnt from Bhopal was the need to study both the short-term
and long term effects of chemicals used in the industry. Unfortunately this important lesson has
still not been applied in practice, where to this day the effects of most industrial chemicals
remain poorly understood. If an accident such as Bhopal were to happen again, doctors are still
likely to be faced with treating a mysterious poison as they were in Bhopal (Mukerjee).

The Organization for Economic Cooperation and Development recorded 74 major
accidents in the eight years preceding to Bhopal. Even after Bhopal, the next eight years the
number of major gas releases reached 106. In the USA alone between 1980 and 1990, the
number of gas releases that exceeded Bhopal in quantity and toxicity totaled 15. According to
Donald J. Lisk of Cornell University, the reason behind not studying the damage industrial
chemicals cause, is that unlike pesticides and drugs, the industrial chemicals were not intended to
be ingested. Hence, studying them is not a priority. In present day, adequate toxicology exists
for only 2 to 3 percent of the more than 70,000 substances used to create about five million
products, observes Joseph LaDou of the University of California at San Francisco. He further
says that for 75 percent, there is no toxicology at all. This cavalier attitude goes on to show that
in the event of a leak or a release, it will be the workers and general populace who will be treated
as guinea pigs as was in the case of understanding the health effects of MIC. (Mukerjee)

One of the main reasons for the Bhopal accident to occur was corporate oversight and greed.
The incident of Bhopal raises important questions about the accountability of corporations and
the availability of legal redress for the most vulnerable members of the society such as the poor,
the uneducated, the disenfranchised, the unrepresented, and the marginalized-who have been
directly affected by harmful corporate actions (Dussias). The story of Bhopal in corporate
actions repeats itself in many cases, and one of these examples relates to the environmental
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destruction of Corrientes River Basin of the northeastern Peruvian Amazon caused by the actions
of Occidental Petroleum Corporation. Just like Bhopal, the local residents continue to suffer
from the lingering effects of the environmental degradation caused and have been doing so for
the last 30 years. According the lawsuit filed in the State of California in May, 2007, the
plaintiffs claim that that Occidental "knowingly engaged in destructive practices which severely
contaminated unique and sensitive ecosystems and caused profound impacts upon the rights and
health of the communities living there." More specific claims included in the complaint were
claims for wrongful death, negligence, battery, trespass, fraud, and public and private nuisance.
(Dussias)

The question remains to be asked is why would the governments of India and Peru be willing to
subject poor, vulnerable citizens of their own countries to the risky, environmentally destructive
practices of multinational corporations? Why would they not regulate such industries and have
effective measures to counter any unsafe practices. The root cause of the problem is that in both
the Achuar and Bhopal scenarios, the superior political and economic power of multinational
corporations was welcomed by the governments in question. The governments did not ask or
require the consent of the people whose lands, lives, and livelihoods were threatened by such
operations. To summarize when government goals came in conflict with the human, property,
and other rights of vulnerable, effectively disenfranchised segments of the population, the
government gave top priority to accomplishment of its own goals, which were more likely to
bring benefits to other segments of the population. The lesson learnt in such a scenario is that
even democratically elected governments may place what they see as important development
goals and projects above the health and safety of segments of their population that are not in a
position to effectively protest (Dussias). To avoid incidents like this to be repeated it is vital to
have a truly representative democracy. The people who will be exposed to the risk that these
plants must have a say in the opening and workings of these plants. (Dussias)

B. LESSONS LEARNED
BYRON
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1. Section 1
Text
C. EMERGING ISSUES
BYRON


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IV. CONCLUSIONS
Text ELISE
The precursors that lead to the incident and the direct impact on Union Carbide
How the incident impacted regulations and industry focus; and
The future of the ongoing legacy issues

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REFERENCES CITED
Armstrong, John Griffith. The Halifax Explosion and the Royal Canadian Navy. Vancouver:
UBC Press, 2002. Print.
Baker, Howard. When Hell came to Halifax. History Today Dec. 2002: 42-43. Print.
Bird, Michael J. The Town That Died. Toronto: McGraw-Hill Ryerson, 1962. Print.
Butler, Daniel Allen. Unsinkable: The Full Story of RMS Titanic. New York: Stackpole Books,
1998. Print.
Caltex Philippines v. Sulpicio Lines. No. 131166. Supreme Court of the Philippines. 30 Sep.
1999. Print.
Croall, James. Fourteen Minutes: The Last Voyage of the Empress of Ireland. New York: Stein
and Day, 1979. Print.
Fowler, Dave. "Building the Titanic." Titanicfacts.net. Titanic Facts, 2011. Web. 20 Nov. 2013
Historic inflation calculator: how the value of money has changed over the years. Mail Online.
Office For National Statistics, 2011. Web. 20 Nov 2013.
Hooper McCarty, Jennifer and Tim Foecke. What Really Sank the Titanic: New Forensic
Discoveries. New York: Citadel, 2008. Print.
Hutchings, David F. and Richard de Kerbrech. RMS Titanic Manual. Somerset: Haynes
Publishing Group, 2011. Print.
Karppinen, Tuomo and Klaus Rakha. "Investigation and Causes of the Sinking of MV
Estonia." Technology, Law and Insurance. N.D. 1998: 149-162. Print.
Kletz, Trevor. What Went Wrong? 5
th
ed. Burlington: Gulf Professional Publishing, 2009. Print.
Lancaster, J. F., Engineering Catastrophes: Causes and Effects of Major Accidents. Boca Raton,
FL: CRC, 2000. Print.
Lane, Allison. "Impact of Titanic Upon International Maritime Law." Titanic Research.
Encyclopedia Titanica, 31 Aug. 2004. Web. 10 Nov. 2013.
Laur, Uno, Kari Lehtola and Ann-Louise Eksborg. Estonia, Finland and Sweden. Joint Accident
Investigation Commission. Final Report MV Estonia. 1997. Print.
Mannan, Sam. Lees Loss Prevention in the Process Industries. Waltham: Elsevier, 2012. Print.
Mentzer, Ray. Industrial Safety Engineering SENG 321/670. Jack E. Brown Engineering
Building, College Station. 15 Oct. 2013. Lecture.
Minichiello, Ray. Titanic Tragedy Spawns Wireless Advancements. The Radio Club of
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America, Inc. Fall. 1997: 5-11. Print.
Morrison, Ted. "This Day in History - RMS Empress of Ireland." Helping Baby Boomers
Overcome Challenges, Part 3 of 3. SafetyXChange, 29 May 2009. Web. 19 Nov. 2013.
Passenger Ship Safety. International Maritime Organization. International Maritime
Organization, 2013. Web. 17 Nov. 2013.
Perez, Anthony R. et al. The Sinking of the MV Doa Paz A Critique on Maritime Disaster
Preparedness in the Philippines: An analysis of the event. Acta Medica Philippina
March. 2011: 1-5. Print.
Philippines Inflation Rate. Trading Economics. National Statistics Office, 5 Nov. 2013. Web.
17 Nov. 2013.
Smith, Tracy, Michael H. Standart, and Erik D. Wood. "The Californian Incident, A Reality
Check." Encyclopedia Titanica. Titanic Research, 8 Nov. 2001. Web. 20 Nov. 2013.
Spouge, J. R. Passenger Ferry Safety in the Philippines. Naval Architect May. 1991:179-198.
Print.
United Kingdom Department of Transport. mv HERALD OF FREE ENTERPRISE, Report of
Court No. 8074. Formal Investigation. London: Her Majestys Stationery Office, 1987.
Print.
Vector Shipping Corp. v. Macasa. No. 160219. Supreme Court of the Philippines. 21 Jul. 2008.
Print.
Whittingham, R. B. The blame machine: why human error causes accidents. Elsevier
Butterworth-Heinemann, 2004. Print.
Winkelstein, Warren Jr. The Halifax Explosion. Epidemiology May. 2007: 409. Print.
Zeni, David. Forgotten Empress: The Empress of Ireland Story. Fredericton, N.B.: Goose Lane,
1998. Print.
Zimmermann, David. Review of The Halifax Explosion and the Royal Canadian Navy.
International Journal Summer. 2005: 866-868. Print.