Bhopal Leaves a Lasting Legacy

The disaster taught some hard lessons that the chemical industry still sometimes forgets.

By Trevor A. Kletz, Loughborough University

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If just one person at Buncefield had known about just one incident, had realized that a similar event could happen there, and had alerted colleagues, the explosion might not have occurred.

If the designers or operators had carried out a search for incidents at similar installations, the explosion probably wouldn’t have occurred. Failing to carry out such a search, and then estimating probability of an explosion and extent of damage, was a dereliction of duty by all organizations involved; they, not just the firm that failed to maintain the high-level trips on the tank, should share cost of the damage.

Many companies now have learned the lessons of Flixborough, Bhopal and Buncefield and have reduced amounts of hazardous materials in process or storage — however, many others still have to learn them. We’re now less likely to build plants near or in urban or built-up areas or allow development close to existing plants, but many current sites are “grandfathered.”

Almost every company has applied the “Don’t Have” principle to employees and has reduced their numbers, often successfully. In many cases, though, what firms have called “empowerment” of remaining employees has been a euphemism for loss of support. The classic example was a 1998 explosion at an Esso gas plant in Longford, Australia, that left the whole state of Victoria without natural gas for two weeks. In this case, the company decided to relocate all professional engineers from the plant to headquarters 200 miles away. The official report on the explosion [6] said moving the engineers “appears to have had a lasting impact on operational practices at the Longford plant. The physical isolation of engineers from the plant deprived operations personnel of engineering expertise and knowledge, which previously they gained through interaction and involvement with engineers on site. Moreover, the engineers themselves no longer gained an intimate knowledge of plant activities. The ability to telephone engineers if necessary, or to speak with them during site visits, did not provide the same opportunities for informal exchanges between the two groups, which are often the means of transfer of vital information.”

Another misuse of the “Don’t Have“ principle concerns knowledge of past accidents at a company or elsewhere. Chemical makers investigate and report on accidents and make changes — but then file away and soon forget the reports. Moreover, they don’t always share them with other firms.

This is a widespread lapse: “It is a truism in business and industry that things go wrong when the last man who remembers the previous disaster retires,” commented Roger Ford in Modern Railways (p. 18, Aug. 2009).

Necessary Steps
Engineers are good at solving problems but not as good at recognizing ones that should be solved. The major safety problem companies should address is maintaining awareness of incidents. Chemical makers should set up systematic procedures — rather than rely on memory — to recall lessons of the past, lessons for which we have paid a high price in deaths and injuries as well as money.

Following are a few of the actions that can prevent the same accidents from recurring so often:
1. Include in every instruction and code a note on the reasons for it and accounts of accidents that wouldn’t have occurred if the instruction or code had existed at the time and been followed.
2. Never remove equipment or ignore instructions before you know why they were adopted.
3. Describe old accidents as well as recent ones in safety bulletins and discuss them at safety meetings.
4. Check at regular intervals to see that recommendations made after accidents are being followed — in design as well as operations.
5. Remember the first step down the road to an accident occurs when someone turns a blind eye to a missing blind.

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