This tragic historically important case study discusses about bhopal tragedy lucidly and clearly giving it a proper perspective

1. The DeathSmog Night
An introspection of Bhopal
Tragedy

2. The DeathSmog Night
• December 3, 1984. Union Carbide Plant. Night Shift
• Methyl Isocyanides Gauge Showed High Value
– Methyl Isocyanides is 500 times more poisonous than cyanide
– Does explosive reaction with many things including water.
– Operator thought “They got Corroded”…….
• 11:30 PM: Workers felt eyes burning….
– Many minor leakages case it sometimes….So they remained indifferent
– Many illiterate workers were unaware of the poison….
• 12:40 AM: Workers were chocking with fumes
• 12:45 AM: Emergency Valve of storage tank exploded
– White toxic gas began shooting from a pipe stack towards the downwind town…

3. The Immediate Attempt to Mitigate
• The cooling unit should have switched on automatically…
– It was disabled for at least a year!
• Manager ordered fire-trucks to spray water on stack to neutralize…
– The water pressure was not high enough to reach 12’ stack…
• The operator rushed to put on the vent scrubber
– It was in shutdown since 15 days
• The workers rushed to open the flare tower
– The pipes were corroded….It was under repair..
• Un-Tamed death rushed to the town…..

4. What followed that night
• Panicked workers rushed out of plant
• The deadly fume flowed silently to slums, temples, shops
• Hundreds choked helplessly in their sleep in violent spasms as their
burning lungs filed with fluid.
• Thousands lost vision, had burns in nasal and bronchial passages.
• By morning when it was over….
– Dead 2,000
– Injured 200,000
• Majority of death were in illegally build slums around the plant

5. The Flashback…
• Union Carbide (US) built this plant in 1969 with blessing of GOI
• There were many advantages …
– Pesticides from this plant helped cut annual grain loss from 25 to 15%
– 15 Million tons grain could be saved, can feed 70 Million for a year
– It also provided much needed jobs in the company..
• GOI provided cheap-labor, low taxes, some legal support
– In turn they installed all equipments GOI asked for.
– GOI standards were much below what they maintain in US!
• Union Carbide Plant was considered a law-abiding citizen as
compared to other plants in India!

6. Last few years of the DeathSmog Night…
• American Managers controlled budgets, made technical and other
policies.
• Indian managers took steps since running $4 Million in Loss..
– Operator /Shift reduced from 12 to 5
– Morale Dropped – many skilled operators left the company
– These posts were filled by illiterate, unskilled workers, violating
requirements of company manuals!
• American managers also justified these cost cuts!
• Two years ago some expert engineers from US suggested some
safety systems were down, Indian managers reported that were
done…Actually…
• American Managers suggested to stop the plant but Indian state and
city officials requested to run the plant for sometime to save jobs.

7. Dilemmas…Cross Roads (Which way to go)
• To run the plant (Satisfy Society) or to close (Satisfy Stock Holders)
– Save Jobs, Or Stop Losses
• To make plant operation “human” or exploit people
– 5 instead of 12 operators per shift
• To save cost or follow guideline
– Skilled technicians or illiterate workers
• To do own duty or run the plant
– Overlooking high value in gauge
• To make process safe or just run somehow
– Bypassing the Auto-Spray provision

8. Reversible? Universalizable?
• Would US managers allow such standards of safety at their country?
– Indian norms were fulfilled but they did not suggest its inadequate
• Would Indian managers allow their children to live near such a toxic
plant or allow to work in such environments?
– Slums were built – but no one educated the risk.
– Workers not educated about the cyanide they inhale everyday…
– Are they human leak detectors?
• Would Indian managers expect false report from the doctor about
the health of their child?
– They reported that the suggested safety problems were fixed.

9. Law (enough?) or Morality
• Indian laws were fulfilled as per safety norms and equipments
– Every one knew its less than original safety maintained at US
• Would Indian managers allow their children to live near such a toxic
plant or allow to work in such environments?
– Slums were built – but no one educated the risk.
– Workers not educated about the cyanide they inhale everyday…
• Would Indian managers expect false report from the doctor about
the health of their child?
– They reported that the suggested safety problems were fixed.
• Would illegally built slums be allowed near toxic plants?
– Was not it a responsibility of management to sensitize the issue?

10. Some more Decisions in Dilemma (Business or Society)
• Why such a plant was made in densely populated area?
• A pesticide without MIC was costly to produce so the company had
chosen to produce a cheap pesticide with MIC.
• Workers forced to follow English manuals (They recruited such
people who by no means would know English)
• To reduce energy costs, the refrigeration system, designed to inhibit
the volatilization of MIC, had been left idle – the MIC was kept at 20
degrees Celsius, not the 4.5 degrees advised by the manual, and
some of the coolant was being

11. Aftermath….Moral Corporate ?
• The company denied any responsibility, They claimed it’s a
sabotage by an employee (unnamed)
• Donated about $17M for relief, Sold its stake in India to Eveready
and with the money collected – about $100M building a hospital to
serve the people who still have lungs, eye and heart problems.
• Ongoing contamination, the clean-up operation undertaken by Union
Carbide is a concern..
The company paid… It was sold..
Underwent lawsuits at both US and India and paid the
cost of doing Business while depriving Society

12. The DeathSmog Night – Still alive in their nightmares
Lets take a vow to do a business with morality….
Society (stake holders) should get back its fare share in lieu of what it
gives to a business….
Ethics is not just being success full in stopping un-ethical things…
To start with an honest attempt even though we fail will be OK….