University Case Study: Risk Management and the Bhopal Gas Tragedy

This case study examines the Bhopal gas tragedy, a catastrophic industrial disaster. It analyzes the event's causes, focusing on the failure of risk management practices within the Union Carbide India Limited (UCIL) plant. The study delves into the sequence of events leading to the methyl isocyanate (MIC) gas leak, identifying critical failures in safety systems, maintenance, and personnel management. It explores various theories regarding the cause of the disaster, the role of negligence by authorities and the company, and the plant's location in a densely populated area. The paper outlines a risk management plan, discussing the identification, analysis, and response to the risks involved. It proposes strategies such as avoiding, transferring, mitigating, and accepting risks, and suggests tools like a risk register to prevent similar tragedies. The analysis emphasizes the importance of proper maintenance, personnel management, and emergency preparedness, concluding that human negligence was a primary factor in the devastating consequences of the Bhopal gas tragedy.

Running head: RISK MANAGEMENT PLAN
RISK MANAGEMENT PLAN
Name of the Student
Name of the university
Author note

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Abstract
Bhopal gas tragedy happens to be the deadliest industrial mishap in the world’s history. It
brought it with huge destructions and after effect. The various causes that led to the accident
have been a topic of debate. There have been various versions of the causes that led to the
huge destruction. The paper below will be discussing on the risk management ideas related to
Bhopal gas tragedy. The motive of the risk management plan is to define the various risks
associated with the tragedy. The paper concludes by providing certain recommendations on
risk monitoring tool and practices that could have prevented the occurrence of such a huge
disaster.

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Table of Contents
Introduction................................................................................................................................2
Purpose of this Risk Management Plan.................................................................................2
Cause behind the tragedy...........................................................................................................2
Identification of the Risk............................................................................................................3
Risk Analysis.........................................................................................................................4
Risk Response Planning.........................................................................................................5
Risk Monitoring, Controlling, And Reporting.......................................................................6
Tools and Practices....................................................................................................................6
Conclusion..................................................................................................................................6
References..................................................................................................................................8

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Introduction
The disaster that occurred at the Union Carbide India Limited (UCIL) on 2nd and 3rd
December 1984 is known as Bhopal gas tragedy. The pesticide plant is located in the Indian
state of Madhya Pradesh. This incident is tagged under the world’s most pathetic industrial
disaster. Reports suggest that almost 500,000 people were victims of this leakage and were
exposed to the poisonous methyl isocyanate (MIC). Different estimates give different records
on the death toll (Palazzi, Currò & Fabiano, 2015). The reason behind this huge disaster is
always debated upon. According to the Indian government and the local activities the reason
was lack in slack management techniques and improper maintenance. Union Carbide
Corporation argued to this that the incident had taken place due to deliberate attempts of
some people (Mittal, 2016). This paper will be analyzing the incident to find out the most
probable causes and what could have been the proper step to avoid the risk or recover from
the same.
Purpose of this Risk Management Plan
Risk Management refers to the procedure involved in identifying, monitoring, assessing
and reporting the various risks involved in the operations of any organization (Mishra et al.,
2015). The Risk Management Plan will be defining the various risks associated with the
Bhopal Gas Tragedy. It will outline the processes in which the risk management activities
could have been performed to recover from the situation. The cause behind such a big
disaster will be analyzed along with the steps which could have saved the plant form such
disaster.

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Cause behind the tragedy
Description of the events
The facts that led to the huge disaster was the carelessness of the operators and the
authorities at the plant. The refrigeration unit had been decommissioned in the year 1984. The
device that indicates pressure and the level indicating the methyl isocyanate tank were faulty.
The alarm that indicates temperature was not working as well (Goh, Tan & Lai, 2015). The
sequence of events is provided below:
Time of occurrence Events
09.15pm Washing of the relief valve linings prior
isolation.
09.30pm Operator finds out that there is blockage in the
lines.
10.00pm The plant supervisor orders to carry on with the
washing.
10.20pm Pressure measured in the tank number 610 is 2
Psi.
10.45pm Shift changed. Water entry from RVVH to
PVH and the tank.
11.00pm Operator measures pressure in the tank as
10Psi.
11.45pm The plant supervisor notified about the MIC
leakage.
11.50pm MIC operator finds out yellow drip from

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RVVH.
12.00am Supervisor ordered to stop washing.
12.20am Attempt to start vent gas scrubber vent.
12.30am Pressure gauge reading shows high value.
Concrete tanks are very hot.
12.40am MIC operator reports of leakage of MIC
through the vent line.
01.00am Toxic gas alarm alerted but it was switched off.
Patrolling police officials sense of something
wrong inside the plant.
01.15am UCIL staff deny of any such thing.
01.45am Works manager of UCIL informed of the leak.
02.00am-02.30am Safety valve reseated, till then 40-45 tons of
MIC escaped. Public siren alerted.

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Figure 1: MIC storage system
Source: (Okoh & Haugen, 2013).
Identification of the Risk
There exist different theories relating to the water entry into the tanker. The reasons
provided have different versions, some saying that workers the pipes were cleaned by the
workers with water which was when the water entered into the tanks (Yang, Khan &
Amyotte, 2015). According to others, poor maintenance such as leaking valves and usage of
inferior components in machines was the main reason for the tragedy. In the year 1985, as per
the reports of the New York Times, the reason for the disaster was not the entry of water into
the tanks. The plant managers that the huge disaster was result of deliberate attempts of some
disgruntled employee. The investigation could not prove any such thing and thus the debate
continued. Some of the factors that lead to the huge disaster are as follows:

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 Use of Methyl Isocyanate, the hazardous chemical.
 Storage in tanks despite steel drums.
 Corroded pipelines
 Safety systems failure due to lack of proper maintenance
 Safety systems were closed to cut on the costs.
 The plant design was modified to follow the government regulations and associated
economic pressures to bring in reductions of the expenses.
 The plant was based in the region which had the most population.
The various analysis done reveal that Union Carbide Corporation and the Government of
India are the ones responsible for the huge disaster that took place.
Figure 2: Water entry route
Source: (Okoh & Haugen, 2013)

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Risk Analysis
The massive disaster in the plant can be attributed to the poor safety measures and
there were no such security norms in the organizations. The location of plant in densely
populated region as per the outdated theories of industrial location was considered the main
reason for Bhopal gas tragedy. The count of the victims was quite high as it was located in
the region where a lot of people dwelled. Studies suggest that other than the cause of leakage,
the parties to be blamed for this outcome are Union Carbide Corporation and Governments of
India as well as Madhya Pradesh (AlKazimi & Grantham, 2015). The most probable factors
include the outline of the plant and economic pressures. The negligence of the authorities to
maintain the pipelines regularly was another major reason behind the huge disaster. The pipes
were rusted and thus it can be understood that the authorities did not care about the
maintenance of the plant.
The analysis done on the huge disaster provides the following information:
 The main reason for the leakage is still debated on and the water entry theory is
considered the most convincing reasons.
 The immensity of the tragedy dependent on various factors rather than just any one
factor.
 The disaster could have been prevented had the plant authorities taken care of
maintenance.
 Lack in proper Personnel management policy could have helped in resolving the issue
related to disgruntled employees.
 The impact of the disaster could have been lessened if the nearby residents given
proper idea and instructions to deal with such situations.

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 The inadequate medical, economic and social rehabilitation could not mitigate the
health hazards associated with the disaster.
Risk Response Planning
Environmental disasters as the Bhopal gas tragedy are caused due to human activities.
Chemical disasters like this can be prevented if the risks are pre-defined and addressed in
time. The risk response planning needs to be in place to deal with situations like this. The
four risk response strategies could have been made use of in the case of Bhopal gas tragedy.
The four strategies include Avoid, Transfer, Mitigate and Accept (Eckerman & Børsen,
2018). The deaths at the plant were not new as cases of people dying inhaling poisonous
gases were already in news. The disaster could have been avoided if the authorities have
taken these deaths seriously and focused on maintenance of the plant. Heavy industries as
such need to abide by certain industrial rule and regulations to prevent such disasters. The
personnel management policies were not in place to handle the disgruntled employees
(Odysseos, 2015). The responsibility of the disaster was not being taken by the authorities
and the blame game was being played. In that situation it was required that the authorities
come up together to cope up with the situation. The faults should have been found out and the
causes analyzed so that these kinds of situations be avoided in future. Studies suggest that the
plant authorities had already been warned about the potential dangers that the plant posed to
the people of the city, but they did not take any heed to change the existing systems (Tripathi
et al., 2015). This reveals the lack of commitment of the authorities and thus they can be
attributed for the huge disaster. In industries there needs to be safety precautions to handle
situations and the workforce should be given proper training to act wisely in these situations.
Risk Monitoring, Controlling, And Reporting
The industries face many such events which have disastrous impact on their
operations. The best example of such an event is the Bhopal gas tragedy. The negative events

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as such are a hindrance to value creation. Business risk management refers to the risks and
associated opportunities that influence value creation and preservation. These should be
central part of big industries such the Bhopal plant (Mishra, 2015). The main risks that had
been identified in this case was the negligence of the authorities and the lack of proper
maintenance. The plant could have been saved form the disaster if risk management strategies
could have in place and operations monitored well.
Tools and Practices
The plant could have saved itself from the disaster had it maintained a risk register.
The risk register provides the manager and the higher officials with a list of identified risks
that can help in analyzing their parts in the operations of the industries (Fabiano, Seay,
Rehman & Palazzi, 2016). The authorities had been made aware of dangers that the plant
posed to the surroundings but still the management did not take necessary steps to make
improvements in the policies. Risk register would have been effective in helping the
authorities to handle the risks and mitigate the same.
Conclusion
From the above discussion it is evident that the disaster management system was not
in place in the plant and the authorities were negligent about the safety issues. The plant dealt
with poisonous chemicals but had no such provisions for handling serious situations like this.
The employees were not provided appropriate training to handle the machines and neither the
people dwelling nearby given proper instructions to cope up with hazardous conditions as
such. Thus, the negligence of the humans leads to such a huge disaster.

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References
AlKazimi, M. A., & Grantham, K. (2015). Investigating new risk reduction and mitigation in
the oil and gas industry. Journal of Loss Prevention in the Process Industries, 34,
196-208.
Bisht, P. (2018). Social movements and the scaling of memory and justice in
Bhopal. Contemporary South Asia, 26(1), 18-33.
Eckerman, I., & Børsen, T. (2018). Corporate and Governmental Responsibilities for
Preventing Chemical Disasters: Lessons from Bhopal. HYLE: International Journal
for Philosophy of Chemistry, 24.
Fabiano, B., Seay, J., Rehman, A., & Palazzi, E. (2016). A Study on the Determining Role of
Timely Emergency Management Based on Bhopal Accident. Chemical Engineering
Transactions, 53, 277-282.
Goh, Y. M., Tan, S., & Lai, K. C. (2015). Learning from the Bhopal disaster to improve
process safety management in Singapore. Process Safety and Environmental
Protection, 97, 102-108.
Mishra, K. B. (2015). CFD model for large hazardous dense cloud spread predictions, with
particular reference to Bhopal disaster. Atmospheric Environment, 117, 74-91.
Mishra, P. K., Raghuram, G. V., Bunkar, N., Bhargava, A., & Khare, N. K. (2015).
Molecular bio-dosimetry for carcinogenic risk assessment in survivors of Bhopal gas
tragedy. International journal of occupational medicine and environmental
health, 28(6), 921.
Mittal, A. (2016). Retrospection of Bhopal gas tragedy. Toxicological & Environmental
Chemistry, 98(9), 1079-1083.

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Odysseos, L. (2015). The question concerning human rights and human rightlessness:
disposability and struggle in the Bhopal gas disaster. Third World Quarterly, 36(6),
1041-1059.
Okoh, P., & Haugen, S. (2013). Maintenance-related major accidents: classification of causes
and case study. Journal of Loss Prevention in the Process Industries, 26(6), 1060-
1070.
Palazzi, E., Currò, F., & Fabiano, B. (2015). A critical approach to safety equipment and
emergency time evaluation based on actual information from the Bhopal gas
tragedy. Process safety and environmental protection, 97, 37-48.
Tripathi, M. K., Yasir, M., Gurjar, V. S., Bose, P., Dubey, A., & Shrivastava, R. (2015).
Insights from the molecular docking of hydrolytic products of methyl isocyanate
(MIC) to inhibition of human immune proteins. Interdisciplinary Sciences:
Computational Life Sciences, 7(3), 287-294.
Yang, M., Khan, F., & Amyotte, P. (2015). Operational risk assessment: A case of the Bhopal
disaster. Process Safety and Environmental Protection, 97, 70-79.