Issues Related to Safety Management

(i) Plant design - There was a major error in the plant design. There was no need of storing such a hazardous substance in such huge amounts - this has been felt by the experts evaluating the causes of this accident. It was also felt that the safety devices along with such high storage amounts of hazardous material were highly inadequate. A refrigeration unit that could b be put off or go out of order. a scrubber that could not perform its task, a non-functional flare, and non-usable u7ater spray were highly inadequate by any standards. Another failure of the designers was, that they could not, visualise the probable emergency scenario - and there was only one gate for exit, and walls were high with barbed wire top. Once the gate was affected by gas how could the victims escape, and how could help reach them - all these aspects were not even thought of.

 (ii) Standards of Maintenance - The standards of maintenance in the plant were poor -this can be firmly stated on the basis of findings of several inspection teams. Putting the pieces of information together it is also apparent that maintenance was the item of least priority for its management, as none of the safety devices was functional. The lesson that could be learnt from this case is that the maintenance programme should have recognized the major hazard potential and all maintenance jobs should have been carried out in a planned, regular and phased manner.

(iii) System and Procedures of work - It is essential to prepare and follow a well-thought out procedure of operations. A set procedure makes concerned people responsible for their actions. If this was so in the Union Carbide factory the responsibility for the unusual moves like switching off the refrigeration, and non-functioning flare could have been fixed.

(iv) Emergency preparedness - It is abundantly clear that there was no preparedness of any kind on the part of the organization to meet out such an eventuality. The company was being governed by a management located several continents away, unaware of the ground realities of this place. As a result the potential of disaster was either unknown or under evaluated by them. It would have been logical for the management to make a real assessment and to draw an emergency plan to help minimise any loss and mitigate the suffering in case of emergency of this magnitude.

The arrangements for obtaining emergency help from agencies like fire brigades, medical aid, rescue and relief arrangements should have been some of the minimum precautions taken.

(v) A community unprepared - The affected community comprised people living in near by villages, which had no idea, whatsoever as to how to deal, with such a emergency. The unsuspecting people were sleeping when the disaster occurred that lead to panic, helplessness and gross suffering.

Likewise local authorities, were caught unawares. Had the police and administrators been aware of the ways of handling, they could have guidedpeople to cover their faces with wet towels and run in the right direction.

Similarly the hospitals and medical profession also did not know what was happening, and how to cope up with the unending stream of victims.

(vi) Training of Employees - This accident also brought to light the poor picture of the training of employees. A unit with a major hazard potential should train all their employees right from managers, to the last grade worker, about all the safety aspects on a regular basis. Each one should have been fully aware of the hazards and know what to do in an emergency. Operating manuals, instruction manuals and safety instructions should have been made available to them.

(vii)Legal controls - The legislation covering 'safety at work in factories' is the Factories, Act 1948. This act was amended in 1976, but did not have adequate provisions to effectively check potential dangers like bulk storage of dangerous material and lack of emergency preparedness. In 1987, the Factories Act was amended again and this amendment had added the required provisions. After this accident, the government also

took a series of steps, that included a nation-wide exercise to identify all the installations that could be hazardous. Absence of adequate legal controls is one of the main reasons which made possible the existence of installations like this with major hazard potential without required safety arrangements. When it comes to the safety of the community then the enforcement machinery comes into focus to ensure that legal controls are operating. Thus all development work planned needs to be scrutinised from the point of safety and health of the people.