The Hindu : Opinion / Leader Page Articles : Bhopal and beyond

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Wednesday, Dec 15, 2004

Opinion

Opinion - Leader Page Articles

Bhopal and beyond

By Venkat Venkatasubramanian

Major disasters rarely occur due to a single failure. Most accidents share certain common patterns of failures, which point to the lessons to be learnt by the corporations, governments and communities.

TWENTY YEARS ago the people of India, and indeed the world, woke up to the horror of the worst ever industrial disaster, the Bhopal gas tragedy. Thousands were killed and hundreds of thousands were seriously affected by the methyl isocynate gas that was released in the disaster at the Union Carbide plant. It is important for a society to learn the right lessons after such monstrous events so that such disasters may be avoided in the future. In this article, we examine the Bhopal tragedy in the broader context of major industrial accidents and discuss some general lessons to be learnt.

In the history of chemical plant disasters, three others besides Bhopal served as wakeup calls. The first was the Flixborough accident in June 1974 in the United Kingdom when certain modifications in the plant led to the leakage and explosion of cyclohexane, which killed 28 people and destroyed the plant. Another was the July 1988 accident known as the Piper Alpha Disaster. The Piper Alpha was an offshore oil platform in the North Sea, about 200 miles from Aberdeen, Scotland, operated by the United States-based Occidental Petroleum Company. Piper Alpha accident killed 167 people and resulted in $2 billion losses. The third was the more recent plant explosion that rocked the southern French city of Toulouse in September 2001, killed 29 people and caused thousands of injuries. The accident destroyed the Azote de France (AZF) fertilizer plant and damaged about 10,000 buildings including several dozen schools, a university and a hospital. The explosion happened at a warehouse that held about 300 tonnes of ammonium nitrate fertilizer.

Bhopal, of course, dwarfs all these in the staggering magnitude of the lives lost. There have been other large chemical plant accidents over the years but these are the ones with a great loss of lives.

While these are different accidents that happened in different plants, triggered by different chemicals and events, there are, however, certain common underlying patterns behind such systemic failures. To understand these patterns and learn from them we need to analyse these accidents in the broader perspective of complex engineered systems.

Modern technological advances have resulted in a myriad of complex systems, processes and products. These increasingly complicated processes, systems and products pose considerable challenges in their design, analysis, control, and management for successful operation over their life cycles. In the process industries, for example, the maintenance and management of complex process equipment and processes, and their integrated operation with the assistance of well trained personnel, play a crucial role in ensuring the safety of plant personnel and the environment as well as the timely delivery of quality products.

However, this is not a problem limited only to the chemical industries. In the discrete parts industries, such as the auto industry, many product malfunctions are due to unanticipated dynamic interactions, due to repeated use or misuse of components, which result in accidents such as the Ford Explorer ATX tyre tread failure that killed dozens of people on U.S. highways. In the pharmaceuticals industry in the U.S., product recalls have gone up over the recent years due to such challenges.

These dynamic interactions thrive in complex systems when the combined effects of complexity, uncertainty and operational adversity are not properly addressed either in design or in operation. Complex systems are challenging because they are highly interconnected among subsystems and components. It is their interconnectedness that can make them fragile when the cumulative effects of multiple abnormalities can cause systemic failures.

Given the size, scope, and complexity of the systems and interactions it is becoming increasingly difficult for plant personnel to anticipate, diagnose and control serious abnormal events in a timely manner. In a large process plant, there may be as many as 1500 process variables observed every few seconds leading to information overload. Furthermore, the measurements may be insufficient, incomplete and/or unreliable due to a variety of reasons. In addition, the need for quick diagnosis aggravates the situation by causing considerable psychological stress on plant personnel. Hence, it should come as no surprise that human operators can and do make erroneous decisions that result in accidents.

All the chemical plant disasters mentioned above have certain common patterns of failures. Major disasters rarely occur due to a single failure of an equipment or personnel. Even though company management typically tries to spin the cause of an accident as some unanticipated equipment failure or operator error, that is rarely the case in reality. Again and again, accident investigations have shown that there are several layers of failures of equipment, processes and people that have caused major accidents. Such studies show that the safety procedures had been deteriorating at these sites for weeks, if not for months, prior to the accident. Thus, it becomes a question of not if an accident would occur but when. And often, the responsibility for the accident goes all the way to the top levels of company management.

Another common pattern is that people had not anticipated all the serious potential hazards. They had often failed to conduct a thorough process hazards analysis that would have exposed the serious hazards that resulted in the disasters later. Inadequate training of the plant personnel to handle emergencies is also a common characteristic. Another common element is the poor design that allowed the storage of large quantities of hazardous materials when perhaps an alternative inherently safer design could have avoided this danger.

Another common people failure is the lack of management systems and procedures to ensure safety. The top levels of management must communicate clearly with the rest of the corporation about the importance of safety and that the management is committed to it seriously. Accident post-mortems have revealed that the company management often had only paid a lip service to safety.

Addressing all these concerns, of course, costs money and cuts into the bottom line. Since investment in safety systems pays off more in the long run, and is seen as an expensive line item in the short run, a company's management may hesitate to commit to such an investment. However, as these and other accidents have shown, if one compromises on safety too much it can destroy the company as well as the people and environment around it. It is important to strike a proper balance here and err on the side of safety.

Have we learnt our lessons from these accidents? Globally, we have learnt some but there is still considerable room for improvement. More specifically, did we learn all we should have from Bhopal? Did we do the right things in the aftermath? As it was discussed in the excellent op-ed piece by Kalpana Sharma in this page recently, we have quite some way to go in learning the lessons or seeing justice served for the Bhopal victims.

Ironically, as pointed out by Ms. Sharma, it was the U.S. that learned some important lessons and passed several new regulations. For instance, the Process Safety Management standard Title 29 CFR 1910.119 by the Occupational Safety and Health Administration (OSHA) requires a thorough hazards analysis of all the major chemical plant facilities in the U.S. However, it is the developing countries that really need to pay more attention, pass such regulations and enforce them.

Safety is not the responsibility of just the environment, health and safety (EHS) department. It is everyone's responsibility in the plant. It is also the responsibility of the community surrounding such industrial plants, as well as the society at large, which should demand proper disclosure of potential hazards, information about systems and procedures to avoid or mitigate such hazards, emergency plans, and finally demand accountability should things go wrong.

In the long run, considerable technological help would come from progress in the emerging discipline of complex systems science and engineering, which would result in more effective prognostic and diagnostic systems for monitoring, analysing, interpreting, advising and controlling such abnormal events. However, communities should always continue to be vigilant and demand safer designs and practices from industries through appropriate rules and regulations to ensure overall safety.

(Prof. Venkat Venkatasubramanian is University Faculty Scholar and Professor of Chemical Engineering at Purdue University, U.S. He is internationally recognised for his research contributions in process safety, computer-aided materials design, pharmaceutical manufacturing, artificial intelligence and complex systems.)

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