Safety Codes

You seem to be condemning a very large group of talent with your baseless indictment of "Engineers". Like engineers were the only ones trying to squeeze every penny of profit out of the operation that they could???? Really, lets place the blame where it belongs!

And the answer is "scrubber".

What was the question again?

How do u explain the Bhopal tragedy?

In the absence of decent forensic analysis, we don't try to explain it. Hurling around undefined acronyms and loose accusations do not help.

As Tornado stated, we as engineers do not assume or surmise and are reliant on objective evidence. That being said - there are two main view points related to the 'potential' cause of the accident:

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Causes of the disaster: overview

There are two main lines of argument involving the disaster. The "Corporate Negligence" point of view argues that the disaster was caused by 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.^[5][22]

The "Worker Sabotage" point of view argues that it was not physically possible for the water to enter the tank without concerted human effort, and that extensive testimony and engineering analysis leads to a conclusion that water entered the tank when a rogue individual employee hooked a water hose directly to an empty valve on the side of the tank. This point of view further argues that the Indian government took extensive actions to hide this possibility in order to attach blame to UCC.^[41]

Theories differ as to how the water entered the tank. At the time, workers were cleaning out a clogged pipe with water about 400 feet from the tank. They claimed that they were not told to isolate the tank with a pipe slip-blind plate. The operators assumed that owing to bad maintenance and leaking valves, it was possible for the water to leak into the tank.^[5][42]

However, this water entry route could not be reproduced despite strenuous efforts by motivated parties.^[43] UCC claims that a "disgruntled worker" deliberately connecting a hose to a pressure gauge connection was the real cause.^[5][41]

Early the next morning, a UCIL manager asked the instrument engineer to replace the gauge. UCIL's investigation team found no evidence of the necessary connection; however, the investigation was totally controlled by the government, denying UCC investigators access to the tank or interviews with the operators.^[41][44]

Causes of the disaster: The "corporate negligence" argument

This point of view argues that management (and to some extent, local government) did not uphold spending on safety and allowed for a dangerous working environment to develop and continuously worsen. Factors cited include the filling of the MIC tanks beyond recommended levels, poor maintenance after the plant ceased MIC production at the end of 1984, allowing several safety systems to be inoperable due to poor maintenance, and switching off safety systems to save money- including the MIC tank refrigeration system which could have mitigated the disaster severity, and non-existent catastrophe management plans.^[5][22] Other factors identified by government inquiries included undersized safety devices and the dependence on manual operations.^[5] Specific plant management deficiencies that were identified include the lack of skilled operators, reduction of safety management, insufficient maintenance, and inadequate emergency action plans.^[5][13]

Underinvestment

Underinvestment is cited as contributing to an environment. Attempts to reduce expenses affected the factory's employees and their conditions. Kurzman argues that "cuts ... meant less stringent quality control and thus looser safety rules. A pipe leaked? Don't replace it, employees said they were told ... MIC workers needed more training? They could do with less. Promotions were halted, seriously affecting employee morale and driving some of the most skilled ... elsewhere".^[45] Workers were forced to use English manuals, even though only a few had a grasp of the language.^[42][46]

Subsequent research highlights a gradual deterioration of safety practices in regard to the MIC, which had become less relevant to plant operations. By 1984, only six of the original twelve operators were still working with MIC and the number of supervisory personnel had also been halved. No maintenance supervisor was placed on the night shift and instrument readings were taken every two hours, rather than the previous and required one-hour readings.^[42][45] Workers made complaints about the cuts through their union but were ignored. One employee was fired after going on a 15-day hunger strike. 70% of the plant's employees were fined before the disaster for refusing to deviate from the proper safety regulations under pressure from the management.^[42][45]

In addition, some observers, such as those writing in the Trade Environmental Database (TED) Case Studies as part of the Mandala Project from American University, have pointed to "serious communication problems and management gaps between Union Carbide and its Indian operation", characterised by "the parent companies [sic] hands-off approach to its overseas operation" and "cross-cultural barriers".^[47]

Adequacy of equipment and safety regulations

The factory was not well equipped to handle the gas created by the sudden addition of water to the MIC tank. The MIC tank alarms had not been working for four years and there was only one manual back-up system, compared to a four-stage system used in the United States.^{[5][22][42][48]} The flare tower and several vent gas scrubbers had been out of service for five months before the disaster. Only one gas scrubber was operating: it could not treat such a large amount of MIC with sodium hydroxide (caustic soda), which would have brought the concentration down to a safe level.^[48] The flare tower could only handle a quarter of the gas that leaked in 1984, and moreover it was out of order at the time of the incident.^{[5][22][42][49]} To reduce energy costs, the refrigeration system was idle. The MIC was kept at 20 degrees Celsius, not the 4.5 degrees advised by the manual.^{[5][22][42][48]} Even the steam boiler, intended to clean the pipes, was non-operational for unknown reasons.^{[5][22][42][48]} Slip-blind plates that would have prevented water from pipes being cleaned from leaking into the MIC tanks, had the valves been faulty, were not installed and their installation had been omitted from the cleaning checklist.^[5][22][42] As MIC is water-soluble, deluge guns were in place to contain escaping gases from the stack. However, the water pressure was too weak for the guns to spray high enough to reach the gas which would have reduced the concentration of escaping gas significantly.^{[5][22][42][48]} In addition to it, carbon steel valves were used at the factory, even though they were known to corrode when exposed to acid.^[11]

According to the operators, the MIC tank pressure gauge had been malfunctioning for roughly a week. Other tanks were used, rather than repairing the gauge. The build-up in temperature and pressure is believed to have affected the magnitude of the gas release.^{[5][22][42][48]} UCC admitted in their own investigation report that most of the safety systems were not functioning on the night of 3 December 1984.^[50] The design of the MIC plant, following government guidelines, was "Indianized" by UCIL engineers to maximise the use of indigenous materials and products. Mumbai-based Humphreys and Glasgow Consultants Pvt. Ltd., were the main consultants, Larsen & Toubro fabricated the MIC storage tanks, and Taylor of India Ltd. provided the instrumentation.^[16] In 1998, during civil action suits in India, it emerged that the plant was not prepared for problems. No action plans had been established to cope with incidents of this magnitude. This included not informing local authorities of the quantities or dangers of chemicals used and manufactured at Bhopal.^{[5][11][22][42]}

Safety audits

Safety audits were done every year in the US and European UCC plants, but only every two years in other parts of the world.^[5][51] Before a "Business Confidential" safety audit by UCC in May 1982, the senior officials of the corporation were well aware of "a total of 61 hazards, 30 of them major and 11 minor in the dangerous phosgene/methyl isocyanate units" in Bhopal.^[5][52] In the audit 1982, it was indicated that worker performance was below standards.^[5][44] Ten major concerns were listed.^[5] UCIL prepared an action plan, but UCC never sent a follow-up team to Bhopal. Many of the items in the 1982 report were temporarily fixed, but by 1984, conditions had again deteriorated.^[44] In September 1984, an internal UCC report on the Virginia plant in the USA revealed a number of defects and malfunctions. It warned that "a runaway reaction could occur in the MIC unit storage tanks, and that the planned response would not be timely or effective enough to prevent catastrophic failure of the tanks". This report was never forwarded to the Bhopal plant, although the main design was the same.^[53]

Causes of the disaster: the "disgruntled employee sabotage" case

Now owned by Dow Chemical Company, Union Carbide maintains a website dedicated to the tragedy and claims that the incident was the result of sabotage, stating that sufficient safety systems were in place and operative to prevent the intrusion of water.^[54]

The impossibility of the "negligence" argument

According to the "Corporate Negligence" argument, workers had been cleaning out pipes with water nearby. This water was diverted due to a combination of improper maintenance, leaking and clogging, and eventually ended up in the MIC storage tank. Indian scientists also suggested that additional water might have been introduced as a "back-flow" from a defectively designed vent-gas scrubber. However, none of these theoretical routes of entry were ever successfully demonstrated during tests by the Central Bureau of Investigators (CBI) and UCIL engineers.^{[42][44][51][55]}

An analysis by Arthur D. Little argues that the Negligence argument was impossible for several tangible reasons:^[41]

1. The pipes being used by the nearby workers were only 1/2 inch in diameter and were physically incapable of producing enough hydraulic pressure to raise water the more than 10 feet that would have been necessary to enable the water to "backflow" into the MIC tank.
2. A key intermediate valve would have had to be open for the Negligence argument to apply. However, this valve was "tagged" closed, meaning that it had been inspected and found to be closed. While it is possible for open valves to clog over time, the only way a closed valve allows penetration is if there is leakage, and 1985 tests carried out by the government of India found this valve to be non-leaking.
3. In order for water to have reached the MIC tank from the pipe-cleaning area, it would have had to flow through a significant network of pipes ranging from 6 to 8 inches in diameter, before rising ten feet and flowing into the MIC tank. Had this occurred, most of the water that was in those pipes at the time the tank had its critical reaction would have remained in those pipes, as there was no drain for them. However, investigation by the Indian government in 1985 revealed that the pipes were bone dry.

The argument for sabotage

The Arthur D. Little report concludes that it is likely that a single employee secretly and deliberately introduced a large amount of water into the MIC tank by removing a meter and connecting a water hose directly to the tank through the metering port.^[41]

UCC claims the plant staff falsified numerous records to distance themselves from the incident and absolve themselves of blame, and that the Indian Government impeded its investigation and declined to prosecute the employee responsible, presumably because that would weaken its allegations of negligence by Union Carbide.^[56]

The evidence in favor of this point of view includes:

1. A key witness (the "tea boy") testified that when he entered the control room at 12:15am, prior to the disaster, the "atmosphere was tense and quiet".
2. Another key witness (the "instrument supervisor") testified that when he arrived at the scene immediately following the incident, he noticed that the local pressure indicator on the critical Tank 610 was missing, and that he had found a hose lying next to the empty manhead created by the missing pressure indicator, and that the hose had had water running out of it.
3. This testimony was corroborated by other witnesses.
4. Graphological analysis revealed major attempts to alter logfiles and destroy log evidence.
5. Other logfiles show that the control team had attempted to purge 1 ton of material out of Tank 610 immediately prior to the disaster. An attempt was then made to cover up this transfer via log alteration. Water is heavier than MIC, and the transfer line is attached to the bottom of the tank. The Arthur D. Little report concludes from this that the transfer was an effort to transfer water out of Tank 610 that had been discovered there.
6. A third key witness (the "off-duty employee of another unit") stated that "he had been told by a close friend of one of the MIC operators that water had entered through a tube that had been connected to the tank." This had been discovered by the other MIC operators (so the story was recounted) who then tried to open and close valves to prevent the release.
7. A fourth key witness (the "operator from a different unit") stated that after the release, two MIC operators had told him that water had entered the tank through a pressure gauge.

The Little report argues that this evidence demonstrates that the following chronology actually took place:

• At 10:20pm, the tank was at normal pressure, indicating the absence of water.
• At 10:45pm, a shift change took change, during which time the MIC storage area "would be completely deserted".
• During this period, a "disgruntled operator entered the storage area and hooked up one of the readily available rubber water hoses to Tank 610, with the intention of contaminating and spoiling the tank's contents."
• Water began to flow, beginning the chemical reaction that caused the disaster.
• After midnight, control room operators saw the pressure rising and realized there was a problem with Tank 610. They discovered the water connection, and decided to transfer one ton of the contents out to try and remove the water.
• The disaster then occurred, a major release of poisonous gas.
• The cover-up activities discovered during the investigation then took place.

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Above taken from:

https://en.wikipedia.org/wiki/Bhopal_disaster

Yes, a good place to start is to actually read the history and findings in the official reports of this very famous disaster rather than jumping to conclusions.

How does one "peculate" to a "fact"? What do you fancy you are talking about?

It also reported (not speculated) that, "

1. In order for water to have reached the MIC tank from the pipe-cleaning area, it would have had to flow through a significant network of pipes ranging from 6 to 8 inches in diameter, before rising ten feet and flowing into the MIC tank. Had this occurred, most of the water that was in those pipes at the time the tank had its critical reaction would have remained in those pipes, as there was no drain for them. However, investigation by the Indian government in 1985 revealed that the pipes were bone dry.

perculated

PERCULATED Definition, Anagrams, and related Scrabble ...

I haven't been able to find any such word. "Peculate" = "embezzle", but that doesn't fit the context of anything here.

What we have here, is failure to communicate.

Percolated? Speculated?

The Oxford English Dictionary is available widely from booksellers both real and virtual. These postings suggest a copy would be a good investment.

Well, certainly not by blaming, "the Engineers manning the core industries".

I'd explain it as the complete lack of local, regional and national regulatory oversight that would have mandated the maintenance steps that would have increased the safety at the plant to an acceptable level.

Blame can also be placed on management, (The Indian government owned 49% and Union Carbide 51%) again not engineers, who put profit over personal safety, because it was in India and they could "get away with it".

I can't find any breakdown on engineers vs other disciplines or Indian employees vs foreign employees but to blame engineers for this disaster is irresponsible, wrong and reckless!

One buys a copy of the investigative report. Try the Institution of Chemical Engineers, in Rugby, UK, whose phone number is on their webpage (usual disclaimer). All one needs to obtain a copy is a telephone and a credit card; it is posted worldwide.

I am very sure you are way off base on this statement.

Operations and management dictate to maintenance and all other departments of any company/organization what will be executed, when it will be executed, and how it will be executed as well as dictating all budgetary constraints.

Engineering does not control nor dictate maintenance and/or operations policies nor budgetary decisions.

Once an error or catastrophic event takes place then after-the-fact the engineering group is expected to perform a "root-cause" investigation to identify the real cause/causes and generate their report to/for management and any/all investigative authorities.

This is a classic case of what results from operating equipment outside of safety design constraints and without proper preventative maintenance under the mistaken assumption it will increase profit margin(s).

1. All the Engineers I have ever known always take it for granted that something WILL go wrong, and do their best to put controls in place to eliminate or mitigate that risk.

2. I have NEVER seen a single Engineer compromise safety codes. Not saying it can't/hasn't happened, but not that I have ever seen.

3. I don't know what kind of ID10T Engineers you work around in your country, but I take offense at your slanderous statements.

You might want to rethink (3). If you yourself posit ID10T Engineers, than the OP is not slanderous.

Don't fool yourself. I have seen plenty of "dumb" things done by Engineers over the last 40 years. But when the OP writes "compromise the safety codes", he/she is talking about something done intentionally. Big difference.

Admittedly, if that person is surrounded by Engineers of that caliber, it might seem to them that what are actually mistakes are intentional.

I'm with Lyn here... it is generally the engineering community at-large that drives the creation and development of these safety codes you so superficially reference.

I think you need to dig deeper and paint with a smaller brush when trying to illustrate blame.

Your thinking of incompetent middle management and accounts attempting to squeeze every penny at the expense of maintenance and safety margins.

Here's a question - Who's fault is it when something goes wrong, the under trained, under qualified maintenance staff with a dangerously limited maintenance budget or those that put them in that position just to save money and maximise profit.

What brought this on all of a sudden?

Reported as demeaning and offensive!

Engineers don't normally control the budget.

If you want to identify the issue with the tragedy at Bhopal, you might want to look at those who do.

Your post is offensive. Engineers are some of the most safety concious people on the planet, and are responsible for your (taken for granted) safety in everyday life.

I for one am directly involved in life safety and property protection and am deeply offended by your post.

You say something offensive and inflammatory then disappear.

Quite the cowardly twit you are.

Disappearance is a good thing, then. One suspects the original poster has disappeared so as to write a safety code; one couldn't blame anyone for doing that - leadership by example is a good thing.