1. CGS Safety Presentation (25 August 2015) 1 "Try not to become a man of SUCCESS, but rather try to become a man of VALUE" BHOPAL TRAGEDY The World Worst Industrial Disasters of it is time By: Miduk Aritonang BHOPAL TRAGEDY The World Worst Industrial Disasters of it is time By: Miduk Aritonang

2. CGS Safety Presentation (25 August 2015) 2 "Try not to become a man of SUCCESS, but rather try to become a man of VALUE" PREVIEW OF OCCURENCE Time of occurrence: 3 rd December 1984 Place of occurrence: Bhopal, Madhya Pradesh, India Company: UCIL - UCC Cause: Methyl Iso-Cyanate (MIC) gas leak  ± 40 ton Time of occurrence: 3 rd December 1984 Place of occurrence: Bhopal, Madhya Pradesh, India Company: UCIL - UCC Cause: Methyl Iso-Cyanate (MIC) gas leak  ± 40 ton

3. CGS Safety Presentation (25 August 2015) 3 "Try not to become a man of SUCCESS, but rather try to become a man of VALUE" ABOUT BHOPAL PLANT  Owned and operated by UCIL (Union Carbide India Limited) - UCC (Union Carbide Corporation)  Pesticide plant which is started in 1969  As chemical complex with containing miles of complicated pipings, hundreds of specialized reactors, pressure vessels, HE, etc  Formulation plant for phosgene, mono-methyl-amine, methyl ico- cyanate (MIC), chemical carbaryl, then formulated it into insecticide brand products such as SEVIN and TEMIK.  At the beginning, UCC provide the design, engineering and construction, but UCC’s process design were changed and developed by UCIL it self. Finally, plant cannot be constructed from process design packages to minimize cost.  Owned and operated by UCIL (Union Carbide India Limited) - UCC (Union Carbide Corporation)  Pesticide plant which is started in 1969  As chemical complex with containing miles of complicated pipings, hundreds of specialized reactors, pressure vessels, HE, etc  Formulation plant for phosgene, mono-methyl-amine, methyl ico- cyanate (MIC), chemical carbaryl, then formulated it into insecticide brand products such as SEVIN and TEMIK.  At the beginning, UCC provide the design, engineering and construction, but UCC’s process design were changed and developed by UCIL it self. Finally, plant cannot be constructed from process design packages to minimize cost.

4. CGS Safety Presentation (25 August 2015) 4 "Try not to become a man of SUCCESS, but rather try to become a man of VALUE" Pict 01: Bhopal Chemical Complex Plant

5. CGS Safety Presentation (25 August 2015) 5 "Try not to become a man of SUCCESS, but rather try to become a man of VALUE" CAUSE OF THE TRAGEDY  A large volume of water was introduced into the methyl iso- cyanate (MIC) storage tank (E-610) and triggered a exothermal reaction that resulted in the toxic gas release  From MIC storage tank (E-610), MIC gas was flowing through the scrubber at more than 200 times its design capacity without gas neutralization. (Whereas, MIC in the storage tank was filled to 87% of its capacity while the maximum permissible was 50%  A large volume of water was introduced into the methyl iso- cyanate (MIC) storage tank (E-610) and triggered a exothermal reaction that resulted in the toxic gas release  From MIC storage tank (E-610), MIC gas was flowing through the scrubber at more than 200 times its design capacity without gas neutralization. (Whereas, MIC in the storage tank was filled to 87% of its capacity while the maximum permissible was 50%

6. CGS Safety Presentation (25 August 2015) 6 "Try not to become a man of SUCCESS, but rather try to become a man of VALUE" MSDS OF MIC  Methyl Iso-Cyanate (C2H3NO)  Liquid form  Volatile  Colourless  Reactive, strong, sharp odour  Flash Point: -7 ºC  Molecular weight: 57.05  Boiling point (760 mm Hg): 102ºF (39.1ºC)  Freezing point: -49ºF  Vapor pressure: 348 mm Hg at 68ºF (20 ºC)  Vapor density: 1.42 (air = 1.00)  Water solubility: Reactive 6.7% at 68ºF (20 ºC)  Flammability: Highly flammable  Flammable Range: 5.3% to 26% (concentration in air)  Permitted exposure limit: < 0.02 ppm  Methyl Iso-Cyanate (C2H3NO)  Liquid form  Volatile  Colourless  Reactive, strong, sharp odour  Flash Point: -7 ºC  Molecular weight: 57.05  Boiling point (760 mm Hg): 102ºF (39.1ºC)  Freezing point: -49ºF  Vapor pressure: 348 mm Hg at 68ºF (20 ºC)  Vapor density: 1.42 (air = 1.00)  Water solubility: Reactive 6.7% at 68ºF (20 ºC)  Flammability: Highly flammable  Flammable Range: 5.3% to 26% (concentration in air)  Permitted exposure limit: < 0.02 ppm

7. CGS Safety Presentation (25 August 2015) 7 "Try not to become a man of SUCCESS, but rather try to become a man of VALUE" SAFETY FEATURES AT TIME OF TRAGEDY Pict 02: Safety features condition at Bhopal plant at time of disaster

8. CGS Safety Presentation (25 August 2015) 8 "Try not to become a man of SUCCESS, but rather try to become a man of VALUE" Pict 03: Safety features at Bhopal plant at time of disaster (by Bhopal Medical Appeal, 2002)

9. CGS Safety Presentation (25 August 2015) 9 "Try not to become a man of SUCCESS, but rather try to become a man of VALUE" 6 SAFETY FEATURES FAILED  Gas scrubber (33 m height) failed to neutralize MIC gas by spray of caustic soda due to shut down for maintenance.  Water curtain failed to neutralize MIC gas exposure, whereas its designed to reach a height at 12-15 m, but MIC gas exposure was gushing out at 33 m.  Flare stack could not be used because a length of piping was corroded, and being repaired by maintenance team.  Refrigeration system to cool MIC liquid was shut down from June 1984 for saving money.  No body opened interconnection block valves between tanks (E- 610 with E-619 was empty) to release pressure from tank E- 610.  No block valves to prevent water entering the MIC storage tanks  Gas scrubber (33 m height) failed to neutralize MIC gas by spray of caustic soda due to shut down for maintenance.  Water curtain failed to neutralize MIC gas exposure, whereas its designed to reach a height at 12-15 m, but MIC gas exposure was gushing out at 33 m.  Flare stack could not be used because a length of piping was corroded, and being repaired by maintenance team.  Refrigeration system to cool MIC liquid was shut down from June 1984 for saving money.  No body opened interconnection block valves between tanks (E- 610 with E-619 was empty) to release pressure from tank E- 610.  No block valves to prevent water entering the MIC storage tanks

10. CGS Safety Presentation (25 August 2015) 10 "Try not to become a man of SUCCESS, but rather try to become a man of VALUE" VICTIMS  Killed at least 4.000 local residents instantly  Already killed around 20,000 caused health problems until today  Almost 100,000 – 500,000 peoples still suffer from chronic disease consequential to gas exposure until today  Killed about 1,000 animals  7,000 animals were injured “By research in 2004, this pollution by MIC gas leak still causes peoples to fall ill”  Killed at least 4.000 local residents instantly  Already killed around 20,000 caused health problems until today  Almost 100,000 – 500,000 peoples still suffer from chronic disease consequential to gas exposure until today  Killed about 1,000 animals  7,000 animals were injured “By research in 2004, this pollution by MIC gas leak still causes peoples to fall ill”

11. CGS Safety Presentation (25 August 2015) 11 "Try not to become a man of SUCCESS, but rather try to become a man of VALUE" Pict 04: Gas leak killed local resident instantly

12. CGS Safety Presentation (25 August 2015) 12 "Try not to become a man of SUCCESS, but rather try to become a man of VALUE" Pict 05: Disability caused by MIC gas leak

13. CGS Safety Presentation (25 August 2015) 13 "Try not to become a man of SUCCESS, but rather try to become a man of VALUE" Pict 06: Gas leak killed animals at that time

14. CGS Safety Presentation (25 August 2015) 14 "Try not to become a man of SUCCESS, but rather try to become a man of VALUE" REMEDIATION  In 1994, UCIL was permitted to undertake clean-up work prior to the sale and spent some USD 2 million on that effort, which included beginning construction of a secure landfill to hold the wastes on the site. All activities at the site was closely monitored and controlled by CBI (Central Bureau of Investigation)  In 1998, the Madhya Pradesh State Government (MPSG) took over the facility including the completion of any additional remediation.  In 2001, Dow Chemical Company took control of UCIL, and continue to clean up this potential minefield of toxic chemicals  In 1994, UCIL was permitted to undertake clean-up work prior to the sale and spent some USD 2 million on that effort, which included beginning construction of a secure landfill to hold the wastes on the site. All activities at the site was closely monitored and controlled by CBI (Central Bureau of Investigation)  In 1998, the Madhya Pradesh State Government (MPSG) took over the facility including the completion of any additional remediation.  In 2001, Dow Chemical Company took control of UCIL, and continue to clean up this potential minefield of toxic chemicals

15. CGS Safety Presentation (25 August 2015) 15 "Try not to become a man of SUCCESS, but rather try to become a man of VALUE" SETTLEMENT AND COMPENSATION  In 1989, UCC and UCIL accepted the India government’s claim against all Bhopal tragedy litigation in the amount of USD 470 million. UCC paid USD 425 million and UCIL paid USD 45 million to the GOI.  In 1989, UCC and UCIL accepted the India government’s claim against all Bhopal tragedy litigation in the amount of USD 470 million. UCC paid USD 425 million and UCIL paid USD 45 million to the GOI. Pict 07: The Bhopal victim’s family complaints against UCC

16. CGS Safety Presentation (25 August 2015) 16 "Try not to become a man of SUCCESS, but rather try to become a man of VALUE" LESSON LEARNED  Process safety procedure were neglected because of budget cuts Ex: no block valves to prevent water entering the MIC storage tanks, no automatic sprinklers in the MIC and phosgene production zone, the cooling installation was shut down due to saving money  The maintenance crews was cut in half, including eliminating maintenance supervisor position due to saving money, so minimize maintenance supervision at plant  Safety training for workers was decreased due to saving money  Poor housekeeping Ex: strewn with oily old drums, strewn with unused piping, pools of used oil and chemical waste likely to cause fire, etc  Sloppy maintenance reports and also safety reports  When the gas leak occurred, there were no information to medivac team, this caused the correct treatment and emergency measures to be held off.  Process safety procedure were neglected because of budget cuts Ex: no block valves to prevent water entering the MIC storage tanks, no automatic sprinklers in the MIC and phosgene production zone, the cooling installation was shut down due to saving money  The maintenance crews was cut in half, including eliminating maintenance supervisor position due to saving money, so minimize maintenance supervision at plant  Safety training for workers was decreased due to saving money  Poor housekeeping Ex: strewn with oily old drums, strewn with unused piping, pools of used oil and chemical waste likely to cause fire, etc  Sloppy maintenance reports and also safety reports  When the gas leak occurred, there were no information to medivac team, this caused the correct treatment and emergency measures to be held off.

17. CGS Safety Presentation (25 August 2015) 17 "Try not to become a man of SUCCESS, but rather try to become a man of VALUE" POOR HOUSEKEEPING Pict 08: Haphazard dumping of hazardous materials

18. CGS Safety Presentation (25 August 2015) 18 "Try not to become a man of SUCCESS, but rather try to become a man of VALUE" REFERENCES  www.bhopal.com  “The Bhopal Gas Tragedy”, by Sanjib Dutta, ICFAI Center for Management Research (ICMR)  “Bhopal Gas Tragedy”, www.worldofteaching.com  “Anthropogenic environmental disasters”, http://www.lenntech.com/environmental-disasters.htm#ixzz25Za1qfke  www.bhopal.com  “The Bhopal Gas Tragedy”, by Sanjib Dutta, ICFAI Center for Management Research (ICMR)  “Bhopal Gas Tragedy”, www.worldofteaching.com  “Anthropogenic environmental disasters”, http://www.lenntech.com/environmental-disasters.htm#ixzz25Za1qfke

19. CGS Safety Presentation (25 August 2015) 19 "Try not to become a man of SUCCESS, but rather try to become a man of VALUE" THE END Pict 09: Me at Hyderabad, Andhra Pradesh, India (660 km from Bhopal, Madhya Pradesh)