A confidential Indian government report concludes that Union Carbide Corporation and its Indian subsidiary bear direct responsibility for a disastrous gas leak at the company's plant in Bhopal last December. The as-yet-unreleased report, which resulted from seven weeks of work by a team of Indian government officials, places responsibility for the leak on a combination of design flaws, operating errors, defective systems, and managerial mistakes. The leak was the worst industrial accident in history, killing more than 2,000 people.
Although completed before Union Carbide released the findings of its own investigation last Wednesday, the document is a clear reply to the charges of the parent firm in Danbury, Conn. Union Carbide said the leak was caused by ``gross violations of established safety procedures'' at the Bhopal plant by its Indian workers and Union Carbide's Indian affiliate.
``There just were no safety procedures adequate to deal with the disaster,'' an Indian investigator says. ``And we have plenty of documentation to substantiate that Danbury, Conn., knew exactly what was happening at the Bhopal plant.''
Added India's minister of state for law and justice, H.R. Bharadwaj, ``How can Union Carbide disown its own subsidiary?'' (The American company owns 50.9 percent of Union Carbide India Ltd.)
Indian investigators were also incredulous, and clearly annoyed, at Union Carbide's suggestion that sabotage may have been involved when a water pipe was connected ``inadvertently or deliberately'' to an underground storage tank containing 43.6 metric tons of methyl isocyanate gas. It was the entrance of water into storage tank 610 that provoked a chemical reaction and an extraordinary buildup of heat, which caused the gas to be forced out of its stainless-steel container and a relief valve to burst. This scenario is one of the few points on which the Indian and American investigators tend to agree.
How the water entered the storage tank -- one of three at the Bhopal plant -- is still under investigation, authorities here say. One theory contained in the Indian report is that the Indian affiliate could have contributed to water seeping into the tank by changing a crucial piping system from the one originally installed -- which was based on US specifications.
In what is believed to have been a cost-cutting measure, engineers connected two previously independent sets of pipes leading to a scrubber meant to neutralize leaking gas. Was this a safe measure? Knowledgeable sources have expressed doubts, and do not discard the possibility that the new piping system could have been faulty and improperly sealed.
The dispute between New Delhi and Danbury is bound to grow even more heated in the weeks ahead, as both sides put the finishing touches on strategies for lawsuits totaling more than $250 billion. The suits could begin next month if highly sensitive negotiations now under way fail to produce an out-of-court settlement.
[India's minister for chemicals and fertilizer, Veerendra Patil, said Monday he expects Union Carbide to offer the Indian government an out-of-court settlement, Reuters reports].
An Indian judicial inquiry is scheduled to begin next week, at which time the results of India's investigation will be publicized. However, sources close to the investigation have disclosed some of the reports main conclusions:
1. Plant safety procedures were inadequate to deal with such a large-scale leak, even though plant officials knew the potential dangers of such a leak.
All three systems designed to prevent or neutralize gas leaks failed when the gas began to escape Dec. 3. The safety systems were either not in operation or were simply inadequate.
A vent gas scrubber, meant to neutralize escaping gas by passing it through a caustic soda solution, had been closed for maintenance on Oct. 22. Even had it been working, it would have been able to handle only one-quarter of the 43.6 metric tons of gas that leaked.
A flare tower, meant to burn off escaping gas, was switched off for maintenance Nov. 29 because a number of its lead pipes had corroded and choked. On the night of the leak, a piece of pipe was missing from the tower, ``about to be replaced.''
A third safety system, a water spray designed to contain a chemical leak, was found ``inadequate'' in an American inspection of the plant in May 1982. Union Carbide headquarters ``strongly recommended'' that a larger system be installed, but the change was never made. Water pressure available at the time of the leakage was adequate for only two houses in the 80-acre compound.
2. For at least three days before the gas leak, plant technicians knew that something was very wrong with Tank 610, but nothing was done to try to discover what the technical problems were.
On Nov. 30, workers discovered it was impossible to get the methyl isocyanate (MIC) out of the tank. Each time they tried to push it out and into the plant producing the pesticide Sevin by pumping in nitrogen, the nitrogen leaked out. None of the workers appeared to know where.
3. Of the three interconnected MIC storage tanks, one was to remain empty at all times to take in any escaping gas, according to the company's safety manual. The ``overflow'' tank, however, No. 619, contained more than one ton of MIC, cutting off yet another escape route through which the gas could pass.
4. Gauges and instruments on the tanks were so unreliable, and the level of technical training so low, that it took plant officials nearly a week to establish how much gas had actually been in the three potentially lethal tanks.
5. A crucial refrigeration unit, designed to keep the MIC cool and inhibit chemical reactions, had been shut down by the plant officials several months before the leak, despite the presence of large quantities of MIC in all three storage tanks.
6. Emergency procedures were inadequate, and the initial response to the disaster was slow.
No foolproof or early-warning system appears to have ever been installed. And, in the event of a leak, nothing was contemplated beyond sounding an alarm and informing the district authorities. There was no adequate alarm system for the public, and no precautions had been taken to protect or evacuate people living near the plant.
A two-tiered alarm system in the plant's central control room was meant to alert employees inside the plant. On the fateful evening, it failed to function until nearly an hour after the leak began, when a pathetic ``beep'' sputtered from one of the systems. By then, most of the plant's employees had panicked and fled.
``Except for the use of human noses to detect odd smells, and human guinea pigs who could report gas leakage, after suffering breathing discomfort and irritation of eyes, there seems to have been no warning system,'' an investigator says.
7. Leaky valves were a constant problem at the pesticide plant, and had been responsible for at least six serious accidents, acknowledged by management, between 1978 and 1982. But according to information provided by the plant's employee insurance plan, 14 additional toxic gas leaks had occurred in the same period. Three of the leaks involved MIC.
8. Union Carbide never fully advised either the Indian government or the district administration of the dangers involved in producing and storing MIC. Though the plant began operating in February 1980, it had never tested MIC to determine its basic characteristics, its potential neutralization, or its antidote.