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Guest perspective on Bhopal – Ronald J. Willey
Journal of Loss Prevention in the Process Industries 35 (2015) 247e248
Contents lists available at ScienceDirect
Journal of Loss Prevention in the Process Industries journal homepage: www.elsevier.com/locate/jlp
Editorial
Guest perspective on Bhopal e Ronald J. Willey
Editorial note: Here is the fourth entry in a series of guest perspectives on the Bhopal disaster that will appear in the journal throughout 2015. (See the editor's perspective in volume 32.) Ronald J. Willey is a Professor of Chemical Engineering at Northeastern University in Boston, MA and the Editor of Process Safety Progress. First, let me thank the Editor, Paul Amyotte for an invitation to provide my perspective on the accident in Bhopal on December 2, 1984. A little background about myself. I began my industrial career in the paper industry at International Paper at a paper mill located in Corinth, New York in June 1974. I had just graduated summa cum laude from the University of New Hampshire with a BS in Chemical Engineering. My first day began in the personnel office. I was surprised when the personnel director told me that I had to wear steel-toed shoes. That personal safety and safe operation was the first expectation within the mill. This was 180 from my expectation. I thought that I'd be called upon to solve difficult differential equations, or complete a material balance, or use my knowledge of Laplace transforms. Instead, my initial training through each of the mill departments always began with an emphasis on personal safety. I learned about the response required in a confined space accident. Do not go in; seek help immediately. I give credit to the management of International Paper as safety was truly first at that paper mill. Later on, a career choice occurred in the form of a layoff. I reflected and decided to teach chemical engineering students and returned to graduate school. Although my professors were outstanding, none of them focused on the idea of integrating process safety within their curriculum. When it was my turn in the classroom in September 1983, I began to use my industrial experience in the classroom. However, I did not focus on process safety. It took the incident at Bhopal, and the encouragement of Ralph Buonopane, Chair of Chemical Engineering at Northeastern, who said to me “Ron, I have something that you're going to like.” He paid for the travel to a three-week workshop on process safety offered by Dan Crowl and Joe Louvar at BASF in Wyandotte, Michigan around 1988. My eyes were opened. I saw that process safety could be integrated into a chemical engineering curriculum. Further, I could create an awareness with students before they entered into their careers. Through the next 25 years, I have met many outstanding engineers and individuals involved in process safety. I joined a committee called Safety and Chemical Engineering Education (SACHE) where I found opportunities to write process safety case histories. Since the occurrence of Bhopal, I have had a curiosity to know
http://dx.doi.org/10.1016/j.jlp.2015.05.015 0950-4230/© 2015 Published by Elsevier Ltd.
what happened. I had received many second-hand impressions such as that from a classmate employed by Union Carbide who quit after the accident. Another impression I recall was sitting in a Boston section AIChE meeting. There, someone from Arthur D. Little Corporation told us at the dinner table that the whole story of the incident at Bhopal would be forthcoming from their investigation commissioned by Union Carbide. In 1988, AD Little employee Ashok S. Kalelkar presented the findings e “a deliberate act” e at a process safety meeting in London (Kalelkar, 1988). What followed was an outburst from the experts. For example, at a SACHE meeting following the presentation, Walt Howard, a giant in the field of process safety, said to me that the London presentation was disgraceful e even damaging to the respected AD Little Corporation. This puzzled me more. Why? I decided to try to write a case history on Bhopal based on the facts of the case, which could be used in the classroom for teaching purposes. I also decided to coordinate this case history with Union Carbide's review. The “direct” cause versus the root cause (discussed below) was a series of runaway exothermic reactions. The molecule methyl isocyanate (MIC) reacts with water exothermically. As the temperature rises, other exothermic reactions begin. Approximately 500 kg of water entered a storage tank holding 41 tonne of MIC. How did the water enter the tank? As Dennis Hendershot once said to me, “it doesn't matter.” Let me explain more below. Unfortunately, the root cause of the incident at Bhopal had warning signs at the plant's inception. The market for pesticide produced at the Bhopal plant was underestimated. Cultural environments surrounding the Bhopal plant, the Indian State of Madhya Pradesh, and the Government of India significantly influenced the decisions made on behalf of the plant (D'Silva, 2006). These were not based on good engineering practice. For example, part of the agreement with Union Carbide India Limited and the Indian government was that the plant be turned over to full operation by “Indian Hands”. Normally, one would like to think that this is not a problem. Unfortunately, many jobs were passed on to those who had connections or relatives; not so much to the people who were qualified. The plant was initially built in a more rural section on the outskirts of Bhopal. Zoning existed. However, local politicians ignored the zoning regulations in place of votes, and several shanty towns with populations on the order of 30,000 built up around the plant. Finally, with only one-third of the designed capacity able to be sold, the plant management was under significant pressure to keep cost under control. Further, rumors circulated that the plant was going to be shut down and moved elsewhere. Plant management ignored their safety systems in the name of cost
248
Editorial / Journal of Loss Prevention in the Process Industries 35 (2015) 247e248
savings. This included not replacing a corroded pipe on the flare system in a timely manner. It included discontinuing a refrigeration system attached to the storage tank for the purposes of removing excess heat of reaction via contamination or self-reaction. It included the layoff of qualified personnel and replacing them with workers who received less than one day of training when they moved over to the MIC plant. Finally, a sodium hydroxide scrubber system was placed on standby. In summary, we as engineers need to consider more than the impact of our engineering. We need to understand the cultural aspects that surround our industrial site. When external reports appear about our plant site that are critical, we must lend some credence to them, and consider if there are facts behind these reports. It is a complicated world. Our engineering training at the undergraduate level must include process safety as well as an introduction to cultural differences that we will encounter as we
begin practice as engineers. The senior management, who these days may be trained with an MBA, must understand the “risk” involved when safety systems and training are compromised. This message must be relayed from the operators and workers right on up to the CEO. Understanding morale within a plant is nearly as important as having a functioning relief system. Remember e a portion of Bhopal's relief system worked; the tanks did not explode.
References D'Silva, T., 2006. The Black Box of Bhopal: a Closer Look at the World's Deadliest Industrial Disaster. Trafford Publishing, Victoria, Canada. Kalelkar, A.S., 1988. Investigation of Large-magnitude Incidents: Bhopal as a Case Study, IChemE Symposium Series No. 110. Institution of Chemical Engineers, UK, pp. 553e575.
Contents lists available at ScienceDirect
Journal of Loss Prevention in the Process Industries journal homepage: www.elsevier.com/locate/jlp
Editorial
Guest perspective on Bhopal e Ronald J. Willey
Editorial note: Here is the fourth entry in a series of guest perspectives on the Bhopal disaster that will appear in the journal throughout 2015. (See the editor's perspective in volume 32.) Ronald J. Willey is a Professor of Chemical Engineering at Northeastern University in Boston, MA and the Editor of Process Safety Progress. First, let me thank the Editor, Paul Amyotte for an invitation to provide my perspective on the accident in Bhopal on December 2, 1984. A little background about myself. I began my industrial career in the paper industry at International Paper at a paper mill located in Corinth, New York in June 1974. I had just graduated summa cum laude from the University of New Hampshire with a BS in Chemical Engineering. My first day began in the personnel office. I was surprised when the personnel director told me that I had to wear steel-toed shoes. That personal safety and safe operation was the first expectation within the mill. This was 180 from my expectation. I thought that I'd be called upon to solve difficult differential equations, or complete a material balance, or use my knowledge of Laplace transforms. Instead, my initial training through each of the mill departments always began with an emphasis on personal safety. I learned about the response required in a confined space accident. Do not go in; seek help immediately. I give credit to the management of International Paper as safety was truly first at that paper mill. Later on, a career choice occurred in the form of a layoff. I reflected and decided to teach chemical engineering students and returned to graduate school. Although my professors were outstanding, none of them focused on the idea of integrating process safety within their curriculum. When it was my turn in the classroom in September 1983, I began to use my industrial experience in the classroom. However, I did not focus on process safety. It took the incident at Bhopal, and the encouragement of Ralph Buonopane, Chair of Chemical Engineering at Northeastern, who said to me “Ron, I have something that you're going to like.” He paid for the travel to a three-week workshop on process safety offered by Dan Crowl and Joe Louvar at BASF in Wyandotte, Michigan around 1988. My eyes were opened. I saw that process safety could be integrated into a chemical engineering curriculum. Further, I could create an awareness with students before they entered into their careers. Through the next 25 years, I have met many outstanding engineers and individuals involved in process safety. I joined a committee called Safety and Chemical Engineering Education (SACHE) where I found opportunities to write process safety case histories. Since the occurrence of Bhopal, I have had a curiosity to know
http://dx.doi.org/10.1016/j.jlp.2015.05.015 0950-4230/© 2015 Published by Elsevier Ltd.
what happened. I had received many second-hand impressions such as that from a classmate employed by Union Carbide who quit after the accident. Another impression I recall was sitting in a Boston section AIChE meeting. There, someone from Arthur D. Little Corporation told us at the dinner table that the whole story of the incident at Bhopal would be forthcoming from their investigation commissioned by Union Carbide. In 1988, AD Little employee Ashok S. Kalelkar presented the findings e “a deliberate act” e at a process safety meeting in London (Kalelkar, 1988). What followed was an outburst from the experts. For example, at a SACHE meeting following the presentation, Walt Howard, a giant in the field of process safety, said to me that the London presentation was disgraceful e even damaging to the respected AD Little Corporation. This puzzled me more. Why? I decided to try to write a case history on Bhopal based on the facts of the case, which could be used in the classroom for teaching purposes. I also decided to coordinate this case history with Union Carbide's review. The “direct” cause versus the root cause (discussed below) was a series of runaway exothermic reactions. The molecule methyl isocyanate (MIC) reacts with water exothermically. As the temperature rises, other exothermic reactions begin. Approximately 500 kg of water entered a storage tank holding 41 tonne of MIC. How did the water enter the tank? As Dennis Hendershot once said to me, “it doesn't matter.” Let me explain more below. Unfortunately, the root cause of the incident at Bhopal had warning signs at the plant's inception. The market for pesticide produced at the Bhopal plant was underestimated. Cultural environments surrounding the Bhopal plant, the Indian State of Madhya Pradesh, and the Government of India significantly influenced the decisions made on behalf of the plant (D'Silva, 2006). These were not based on good engineering practice. For example, part of the agreement with Union Carbide India Limited and the Indian government was that the plant be turned over to full operation by “Indian Hands”. Normally, one would like to think that this is not a problem. Unfortunately, many jobs were passed on to those who had connections or relatives; not so much to the people who were qualified. The plant was initially built in a more rural section on the outskirts of Bhopal. Zoning existed. However, local politicians ignored the zoning regulations in place of votes, and several shanty towns with populations on the order of 30,000 built up around the plant. Finally, with only one-third of the designed capacity able to be sold, the plant management was under significant pressure to keep cost under control. Further, rumors circulated that the plant was going to be shut down and moved elsewhere. Plant management ignored their safety systems in the name of cost
248
Editorial / Journal of Loss Prevention in the Process Industries 35 (2015) 247e248
savings. This included not replacing a corroded pipe on the flare system in a timely manner. It included discontinuing a refrigeration system attached to the storage tank for the purposes of removing excess heat of reaction via contamination or self-reaction. It included the layoff of qualified personnel and replacing them with workers who received less than one day of training when they moved over to the MIC plant. Finally, a sodium hydroxide scrubber system was placed on standby. In summary, we as engineers need to consider more than the impact of our engineering. We need to understand the cultural aspects that surround our industrial site. When external reports appear about our plant site that are critical, we must lend some credence to them, and consider if there are facts behind these reports. It is a complicated world. Our engineering training at the undergraduate level must include process safety as well as an introduction to cultural differences that we will encounter as we
begin practice as engineers. The senior management, who these days may be trained with an MBA, must understand the “risk” involved when safety systems and training are compromised. This message must be relayed from the operators and workers right on up to the CEO. Understanding morale within a plant is nearly as important as having a functioning relief system. Remember e a portion of Bhopal's relief system worked; the tanks did not explode.
References D'Silva, T., 2006. The Black Box of Bhopal: a Closer Look at the World's Deadliest Industrial Disaster. Trafford Publishing, Victoria, Canada. Kalelkar, A.S., 1988. Investigation of Large-magnitude Incidents: Bhopal as a Case Study, IChemE Symposium Series No. 110. Institution of Chemical Engineers, UK, pp. 553e575.