CHERNOBYL AND BHOPAL TEN YEARS ON

Comparisons and Contrasts

Malcolm C. Grimston, MA (Cantab.), BA (Open)

Senior Research Fellow

Centre for Environmental Technology
Imperial College of Science Technology and Medicine
London SW7 2PE

SUMMARY

Within eighteen months in mid-1980s, two of the most serious industrial accidents in
history occurred. At Bhopal, capital of Madhya Pradesh in central India, in the early
hours of December 3, 1984, an explosion occurred at Union Carbide of India Ltd
(UCIL)’s methyl isocyanate (MIC) plant. Some 40 tonnes of a complex chemical
mixture were released, causing several thousand deaths and hundreds of thousands of
injuries.

At Chernobyl in the north of Ukraine, then part of the USSR, in the early hours of
April 26, 1986, an explosion at a state-owned nuclear power plant caused the release
of some 6 tonnes (possibly more) of radioactive materials. The ‘immediate’ death toll
was much lower than at Bhopal. The usually-quoted figure of 30, all of whom were
on site in the immediate aftermath of the explosion, includes two who died on site
from burns and falling masonry and 28 who died within the following few weeks
from Acute Radiation Syndrome. (Another person on site died of a heart attack,
which it is difficult to associate directly with the accident.) However, the effects of
the accident were widespread, especially in Belarus, Ukraine and Russia, and
theoretical calculations suggest that further illness and premature deaths are to be
expected for several years to come.

This paper compares and contrasts these two accidents. There are striking
similarities.
Both accidents involved highly technical industrial processes and plant which were
set in relatively backward regions. Madhya Pradesh is one of the least industrialised
states in India, manufacturing accounting for only 11% of the State Domestic Product
in 1978/79, while Ukraine is a largely agrarian economy, with the exception of its five
nuclear power stations.

Both accidents occurred in the early morning, were blamed on ‘operator error’ and led
to prosecutions of individuals. However, HOT (Human, Organisational,
Technological) analysis reveals that deeper institutional and managerial weaknesses
contributed significantly to both accidents. For example, in the case of Chernobyl,
experiments similar to those which led to the accident had been carried out on
previous occasions, while at Bhopal several of the technical factors which were
causes of the accident had previously been identified but not rectified. Indeed, if the
term ‘operator error’ is used to mean actions by operators which were simple mistakes
(inadvertent deviations from operating codes) then it is not clear that the phrase can be
used in either case, with the exceptions of only one or two actions in each case. It
seems that the operators in question generally knew precisely what they were doing
(or at least they carried out their actions quite deliberately). They broke safety ‘rules’
because of other institutional pressures, such as the unexpected need to generate
electricity on the afternoon of April 25 1986 in Chernobyl, and general commercial
pressures in a loss-making plant at Bhopal.

In both cases technological factors were also implicated. Both plants had
fundamental design flaws, such as the storage of MIC in large tanks and the back-
fitted ‘jumper line’ in the pipework at Bhopal, and the positive void coefficient at
Chernobyl which led to a positive power coefficient at low power outputs. Both
plants also allowed operators to disable key safety equipment, contributing to the
accidents. However, while there was considerable component failure at Bhopal (e.g.
the failure of the pressure valve of tank E610), there was no apparent component
failure at all at Chernobyl.

Both accidents were exacerbated by a lack of information and immediate action on

the part of the local authorities, which both reduced the effectiveness of measures
which could have been taken earlier, and led to a loss of confidence in those
authorities among the affected people. As a result, the detrimental effects of both
accidents were wider than the somatic health problems caused by the toxic releases
themselves, and included considerable problems related to stress.

In both cases, different interested groups made widely different interpretations of the
accidents and their effects. The States and operating organisations involved tended to
concentrate on technical, quantifiable factors, while affected individuals and
international activists tended to concentrate on the effects on humans and to rely on
hearsay and anecdote as the source of information. The failure of these two
approaches to address the concerns and interests of the others undoubtedly
contributed further both to anxiety among those affected and to frustration on the part
of the operators and regulators.

Both accidents, to a greater or lesser extent, became ‘defining events’ for political
activism against the chemical and nuclear industries respectively.
Nonetheless, there are striking differences between the two accidents.

At Bhopal, the morale of operators and supervisors was very low. The plant was
losing money in a division which was regarded as a career ‘dead-end’ within Union
Carbide. Highly skilled staff generally moved on rapidly. This was compounded by
poor instrumentation (e.g. pressure gauges which could not be seen from the control
desk, and in different and incompatible units; instructions in English which many
operators did not speak) and poor maintenance. Chernobyl, by contrast, was the
flagship plant of one of the Soviet system’s flagship technologies, and operators, who
were well trained and well paid by Soviet standards and with high social status,
appeared to believe it impossible for any major accident to occur, and therefore felt
confident in ignoring operating instructions. The overall effect in both cases was
remarkably alike; the human contributions to both accidents following similar
courses. It would appear that there is a necessary ‘morale envelope’ to operating high
technologies; operators must become neither too complacent nor too depressed.

The demonstrable health effects of the material releases at Bhopal (3 800 deaths and
203 000 injuries by official 1990 estimates) considerably outweigh those of the
material releases from Chernobyl (33 deaths - the original 30 plus three deaths from
thyroid cancer, with perhaps one other among those who suffered from Acute
Radiation Syndrome - and more than 600 cases of thyroid cancer, by late 1995).

The real financial cost of responding to the Chernobyl accident worldwide has been
considerably higher than that for Bhopal. Radioactivity can be detected at much
lower levels than chemicals such as methyl isocyanate, and is much more persistent in
the environment. As a result evidence of the Chernobyl accident could be detected far
afield (e.g. caesium contamination in fields in Cumbria and North Wales), while no
such evidence was found for migration of the plume from the Bhopal accident. Hence
countermeasures could be (and still are being) taken against the Chernobyl releases,
even where it was felt that these were extremely unlikely to cause significant health
problems, while similar countermeasures could not be taken against a potential health
problem which could not be detected.

Probably for the same reason, there has been far more research into the long-term
effects of the Chernobyl accident than of Bhopal. As a result comparisons of the
long-term health implications of the two accidents are difficult to make with any
confidence, though it would seem that the overall health effects of Bhopal
considerably outweigh those of Chernobyl.

The place of the two accidents in public perceptions is rather different. Bhopal is
largely forgotten by the general public and the media; there was for example,
relatively little interest in the tenth anniversary of the accident, in 1994. Chernobyl,
by contrast, still attracts considerable attention, the fifth anniversary being marked by
three television documentaries in the UK, for example, and the incident continuing to
attract constant, if low-level, media interest.

The reasons for this would appear to be a mixture of factors contingent on the
accidents themselves (especially the fact that Chernobyl happened on the edge of
Europe while Bhopal occurred in the Third World), and differences in the perception
of risks from radiation and from chemicals. Of particular relevance is the fact that
fallout from Chernobyl can be detected at very low levels and so is perceived as a
potential risk to everyone and to future generations, while it is assumed that the MIC
released at Bhopal was hydrolysed relatively rapidly in the environment and hence
does not represent a continuing and widespread threat.

Accidents involving large numbers of acute deaths are far more frequent in
developing countries and the former Soviet Union than in the developed world.
Comparison of Bhopal and Chernobyl with incidents like the leak of aldicarb oxime
in 1985 from the UCC plant at Institute, West Virginia, and with Three Mile Island,
Pennsylvania (1979), cannot yield firm conclusions over why this should be the case,
but certain themes do emerge, albeit tentatively.

The level of human and organisational failings in the American accidents seem to be
very similar to those at Bhopal and Chernobyl. For example, a very similar incident
to that which led to the Three Mile Island accident had occurred at another Babcock
and Wilcox nuclear plant two years previously, while an internal UCC report just
three months before the Bhopal accident raised the possibility of a runaway reaction
involving water at Bhopal. In neither case was the information passed on to the
relevant plant management or operators.

This would seem to point to superior technology in the developed world. For
example, the emergency safety equipment at Institute stopped the leak of aldicarb
oxime within 15 minutes. However, the severity of the Bhopal accident was clearly a
function of the very high population density near the plant, compared e.g. to Institute.
The month before Bhopal, for example, there was a release of an MIC/chloroform
mixture from Institute which amounted to about one sixth of the release from Bhopal.
Presumably had that occurred in an area as densely populated as Bhopal the death toll
would have been about 500. Three Mile Island, by contrast, released about one
millionth as much radioactive material as did Chernobyl, and remains the most
serious incident in a Western nuclear power station. It may also be the case, then, that
it is possible to design ‘failsafe’ nuclear stations while it is not possible to do the same
with chemical installations (though there may well be other approaches to inherent
safety in the chemical industry, e.g. reducing or eliminating storage of hazardous
intermediates on the process site). However, more research would be necessary
before any great confidence could be put in such conclusions.

A BRIEF OUTLINE OF THE ACCIDENTS AT BHOPAL AND CHERNOBYL

Bhopal

Background

Bhopal is the capital of the central Indian State of Madhya Pradesh. This is one of the
least industrialised States in India, manufacturing accounting for just over 11% of the
State Domestic Product in 1978/9 (Minocha, 1981) but the city was undergoing rapid
expansion (from 102 000 in 1961 to 670 000 in 1981).

In 1984 the Union Carbide Corporation (UCC) was America’s seventh largest
chemical company, with both assets and sales of about $10 billion worldwide. It
owned or operated companies in some 40 countries, producing a wide range of
chemical products such as petrochemicals, industrial gases, pesticides, metals, carbon
products, consumer products and technology services. However, there were questions
over Union Carbide’s profitability, which was considerably lower than its major
competitors such as Dow Chemical, Du Pont and Monsanto (Hiltzik, 1985).

As a result, the late 1970s saw the company concentrate its investment in its most
profitable lines such as industrial gases, consumer products, technology services and
speciality products (UCC, 1984). Other, less profitable businesses were divested
(Business Week, 1979). At the same time, economies associated with forward and
backward integration of processes (e.g. reductions in transportation costs, economies
of sales) were explored. One example was a move towards manufacturing component
chemicals for various UCC products.

Union Carbide’s Indian subsidiary had been formed in 1934 as the Ever Ready
Company (India) Ltd, manufacturing batteries in Calcutta and Madras.
Diversification in the mid-1950s led the company to change its name to Union
Carbide (India) Ltd, UCIL, in 1959. By 1984 UCIL was India’s 21st largest company,
with annual sales of around $170 million. 51% of UCIL’s shares were owned by
UCC, 23% by the Indian Government, the rest by private investors and other
institutions.

Diversification into chemicals and plastics continued through the 1960s, and in 1969 a
plant to formulate pesticides and to act as headquarters for the Agricultural Products
Division was established in the north of Bhopal, close to the railway and bus stations
(Figure 1).

One of the operations in which the plant was engaged was the manufacture of
pesticides. There was some concern that the potentially hazardous chemicals
involved should be processed within a very densely populated part of the city, but as
the plant was at first used for ‘formulation’ (the mixing of stable substances to make
pesticides) it was accepted that it did not represent a major risk to local people.

In 1974 UCIL was granted a license to manufacture pesticides, which involved

reacting chemicals together to produce desired substances. By 1977 UCIL was
producing more hazardous pesticides such as carbaryl, which was marketed under the
name Sevin.

Carbaryl is made from phosgene, naphthol and methylamine (aminomethane). There

are two broad ways of carrying out the manufacturing process. Phosgene and
naphthol can be reacted together, and the resulting compound reacted with
methylamine. This route does not involve any highly dangerous intermediates
(though of course phosgene itself is poisonous), and has been used e.g. by Bayer in
Germany. Alternatively, phosgene and methylamine can be reacted together to form
methyl isocyanate, MIC, CH3 NCO, which is then reacted with napthol. This route
involves the production and storage of MIC, which was known to be hazardous
although relatively little work had been done on its long-term effects on human
health, but is also generally regarded as being more economic, especially if there is an
external market for MIC. It was the latter method that was chosen for Bhopal.
At this stage the component chemicals for carbaryl, one of which is methyl
isocyanate, were imported in small quantities to Bhopal from what was then UCC’s
only MIC manufacturing plant, at Institute, West Virginia.

The policy of (backward) integration of processes led UCIL to decide, in 1979, to

manufacture five component chemicals for the pesticides, including MIC, at Bhopal.
The technology to be used was basically similar to that at Institute, though pressure
from the local government to maximise employment led to the use of manual rather
than computerised control systems.

Surprisingly little was known of MIC’s possible consequences on human health - or at

least surprisingly little was in the public domain. (There were suggestions both that
UCC had carried out research which had not been made public, and that work done by
various national Governments had been kept secret owing to the potential use of MIC
in chemical weapons (Delhi Science Forum, 1985).) Though it is not a member of the
cyanide family, it could be associated with a range of serious medical conditions,
especially affecting the eyes, skin, respiratory tract and immune system (e.g. Smyth,
1980).

The chemical is unstable, and has to be stored at low temperatures. Municipal

authorities objected to the manufacture and use of dangerous chemicals in a very
highly populated area, contrary to the plant’s original license for commercial and light
industrial use (Bhopal Town and Country Planning Department, 1975). UCIL was a
very powerful company in India and in Madhya Pradesh, however, and the state and
central Governments overruled the city authorities and gave permission for the
manufacture of MIC. There seemed to be a widespread belief among local managers
and workers alike that MIC was ‘no worse than tear gas’, and that its effects could not
be fatal. There was no known antidote to the gas.

The early 1980s was a time of considerable overcapacity in the pesticides industry,
coupled with reductions in demand. As a result, UCIL decided in July 1984 that the
Bhopal plant, with the exception of the MIC plant, should be sold (US District Court,
1985).

Before the Accident

MIC for use in manufacture of carbaryl (or, if contaminated, for reprocessing) was
stored at Bhopal in three large underground tanks, designated E610, E611 and E619.
This system was generally regarded as being potentially more dangerous than the
alternatives, viz. small-drum storage, or use of a manufacturing method which does
not necessitate the production of MIC such as that used by Bayer. ‘UCC insisted on a
process design requiring large MIC storage tanks over the objections of UCIL
engineers’ (ICFTU, 1985). ‘The UCIL position was that only token storage of MIC
was necessary’, but UCC ‘imposed the view and ultimately made to be built large
bulk storage tanks patterned on the similar UCC facilities at Institute, West Virginia’
(Wall Street Journal Europe, 4.2.85).

MIC was manufactured in batches in a refining still, and carried along a stainless steel
pipe which branched off into the three tanks. When the MIC was required it was
transferred out of the tanks under (very pure) nitrogen pressure. It then passed
through a safety valve to another stainless steel pipe, the ‘relief-valve header’, which
led to the production reactor. This pipeline was about 7 metres above ground level.
Another common pipe took rejected MIC back to the tanks for reprocessing, while
contaminated MIC was taken to a vent-gas scrubber for neutralisation with caustic
soda. Excess nitrogen could be released from the tanks through a ‘process pipe’ fitted
with a blow-down valve. The relief-valve pipe and the process pipe, despite their
very different functions, were connected by another pipe, the ‘jumper system’, fitted a
year before the accident to simplify maintenance (Figure 2).

The normal storage pressure in the tanks was 1 x 10 5 Nm-2, or about 1 atmosphere (15
psi). Each storage tank had its own high temperature alarm, a level indicator and
high- and low-level alarms. It was recommended that the level in each tank did not
exceed about 50% of capacity. The safety valves between the tanks and the relief
valve pipe were accompanied by a ‘rupture disk’ which kept in gas until it reached a
certain pressure, then let it out. This could not be monitored from the central control
point, requiring manual readings from a pressure indicator located between it and the
safety valve.

A batch of MIC had been manufactured between October 7 and October 22 1984. At
the end of this period, tank E610 contained 42 tonnes of MIC, while E611 contained
20 tonnes. This represented a considerable inventory of the chemical. As noted by Dr
Varadarajan of the Indian Council for Scientific and Industrial Research, and
confirmed by UCIL manager S. Kumaraswami, UCIL stored ‘many times its own
requirement’ at Bhopal in order to be able to supply other chemical firms in India, and
to guard against the whole Sevin manufacturing process having to be closed down if
there were a failure in MIC production (Everest, 1985).

After the completion of production of this batch the flare tower was shut down so that
a piece of corroded pipe could be replaced. The flare tower was used for burning
normally vented gases from the MIC and other sections of the Bhopal plant; burning
neutralised the toxicity of these gases before they reached the atmosphere. However,
the flare tower was not designed to cope with large quantities of a chemical such as
MIC.

Unfortunately, other features of the plant’s safety systems were also shut down. The
vent-gas scrubber received gases from the tanks, neutralised the gases with caustic
soda (sodium hydroxide) solution, and released them into the atmosphere at a height
of 30 metres or routed them to the flare tower. The scrubber had been turned off to a
standby position a few weeks before the accident.

The plant refrigeration unit was a 30 tonne unit which used the CFC Freon to chill salt
water, the coolant for the MIC tanks. This system was shut down in June 1984 and
drained of Freon, thus rendering it unavailable for use during an emergency
(Diamond, 1985). There remained a set of water-spray pipes which could be used to
control escaping gases, but these were to prove ineffective (see below).

On October 21, the nitrogen pressure in tank E610 fell from the roughly normal 1.25
atmospheres to 0.25 atmospheres. This made it impossible to draw any MIC from this
tank, so MIC for the reactor was drawn from tank E611. However, on November 30
tank E611 also failed to pressurise, owing to a defective valve. Attempts to pressurise
E610 once again failed, however, and so the operators instead repaired the valve in
tank E611.

The Night of December 2/3 1984

In the normal course of operation in the plant, small quantities of MIC and water react
together in the pipes to produce a plastic-like substance which is a trimer of MIC (i.e.
three MIC molecules attached together). Periodically the pipes were washed with
water to flush out trimer that had built up on the pipe walls. Because MIC and water
react together, albeit slowly if the MIC is quite pure, during flushing out the pipes
were blocked off with a barrier disc known as a ‘slip blind’ to prevent water going
into the storage tank. Such a flushing was ordered to be carried out on the night of
December 2/3, and began at 2130.

Responsibility for carrying out the flushing operation lay with the supervisor of the
MIC plant. However, responsibility for fixing the slip blind lay with the maintenance
supervisor. Several days earlier the post of second-shift maintenance supervisor had
apparently been deleted, but nobody had been assigned the duty of inserting the slip
blind. Several overflow devices (‘bleeder lines’) were clogged, and so water began to
accumulate in the pipes. A valve used to isolate the various pipe lines was leaking (as
were many others in the plant), and so water rose past that valve and into the relief-
valve pipe.

The operator noticed that no water was coming out of the bleeder lines, and shut off
the flow with a view to investigating what was happening to this water. However, the
MIC plant supervisor ordered him to resume the process (ICFTU, 1985). Water now
flowed downhill from the relief-valve pipe towards tank E610. It then flowed through
the jumper system into the process pipe (which is normally open), and then to the
blow-down valve. This valve should have been closed. However, it is part of the
system responsible for pressurising the tank with nitrogen. It is likely that a fault in
this valve, or perhaps even that it had simply been left open, was the cause of the
problem which had prevented the pressurisation of tank E610 for the previous six
weeks, and had not been corrected. With the blow-down valve open, an estimated
500 kg of water flowed into tank E610 (through an ‘isolation valve’, which was
normally left open), and started to react with the MIC.

Because tank E610 had not been pressurised for six weeks, considerable quantities of
contaminants were able to leak into the tank which would normally have met a
pressure barrier. These contaminants included transition metal ions such as iron,
chromium, nickel and cadmium which act as powerful catalysts for the reaction
between water and MIC. (The iron probably originated in corroded carbon-steel
pipes; it had originally been recommended that stainless steel be used, but this was
not done, presumably for economic reasons.) As a result this reaction proceeded
much more rapidly than would have been the case in the absence of these
contaminants.

At 23.00, after a change of shift, the new control-room operator, Suman Dey, noted
that the pressure in tank E610 was about 0.7 atmospheres, well within the normal
range of 0.1 to 1.7 atmospheres (2-25 psi) (but considerably above the 0.25
atmospheres at which the tank had remained for some weeks since the failure of the
pressurising system).

At 23.30 a leak of MIC and dirty water was detected near the scrubber. The mixture
was coming out of a branch of the relief-valve pipe, downstream of the safety valve.
Workers examining the situation found that another valve (a ‘process safety valve’)
had been removed, and that the open end of the relief-valve pipe had not been sealed
with a slip bind for flushing.

By 00.15 on December 3 the pressure in tank E610 had reached 2 atmospheres,

outside the normal range; by 00.30 the reading had gone off the top of the scale (just
under 4 atmospheres, 55 psi). (It is indicative that some of the pressure dials in the
plant were in psi, others in the incompatible units of kg per cm2.)

There was a hissing sound from safety valve of tank E610, indicating that it had
opened. The local tank temperature and pressure gauges now showed values above
their scale maxima of 25 0C and 4 atmospheres (55 psi). There was a loud rumbling
and screeching from the tank. The operators tried to start the scrubber, but
instruments showed the caustic soda was not circulating. Clouds of gas were now
gushing from the plant chimneystack.

The plant superintendent was summoned, and immediately suspended operation of the
MIC plant. The toxic-gas alarm, designed to warn the community round the plant,
was turned on. Bhopal was a city containing many shantytowns and slums, two of
these large slum colonies containing several thousand people being literally across the
road from the plant. However, a few minutes later the toxic-gas alarm was switched
off, leaving just the plant siren to warn workers sounding.

The water-sprays were turned on to douse the stack (as well as the tanks and the
relief-valve pipe). However, the water sprays did not reach the gases, which were
being emitted at a height of 30 metres.

The safety valve remained open for two hours. During that time, through it passed a
complex mixture of gases, foam and liquid at a temperature of over 200 0C and a
pressure of 15 atmospheres (UCC, 1985).

It should have been possible to decant some of the MIC from tank E610 into E619, as
one tank should always have been kept empty against such emergencies. However,
E619 itself contained a considerable quantity of impure MIC, and there was some
evidence that this was starting to react as well, though there were no releases.

Chernobyl

Background

The Chernobyl Nuclear Power Plant is in the northern part of the now independent
former Soviet Republic of Ukraine, near the borders with Belarus and Russia, in the
eastern part of a large geographical region known as the Byelorusso-Ukrainian Poless
(woodland), on the River Pripyat which flows into the Dnieper. It is 15 km away
from the town that gives it its name, and some 130 km north of Kiev, in an isolated
area of the country with low population density (about 70 people per km 2). Apart
from the company town, Pripyat (population 45,000, evacuated in 1986) 3 km from
the station, there were no major centres of population near the plant (Figure 3).

Ukraine is a largely agrarian economy (‘the breadbasket of the Russias’), with a

population of some 52 million people, and an energy use of about 190 million tonnes
of oil equivalent per year. This represents a slightly lower usage of energy per head
than a country like the UK, though for a far lower industrial output. Electricity
accounts for about a quarter of Ukraine’s energy use. Coal is the most important
source of electricity providing 54% of the total, with nuclear power producing 38%
from thirteen nuclear reactors at five power stations.

Soviet interest in nuclear technology began during the Second World War, soon after
nuclear fission was first described in 1939. The USSR became the second nation to
test a nuclear device in August 1949, much to the surprise of the USA and the UK.
Nuclear technology became one of the highest priorities for the Soviet regime. In
June 1954, the small (5 MW) Soviet research reactor at Obninsk (which is still
operated) became the first nuclear station in the world to generate electricity for use in
an electricity grid. At that time a number of nations were at a similar stage in the
development of nuclear power; the USA had made the first nuclear electricity in 1952
(lighting five electric light bulbs), while the UK was to become the first nation to
operate a commercial-scale nuclear power station, at Calder Hall in 1956, the USA
following in 1957. The Soviets launched the world’s first nuclear powered icebreaker
in 1957.

Soviet scientists were to develop two principal types of commercial nuclear station (as
well as other systems, including two ‘fast reactors’). One, the VVER, is similar to the
western Pressurised Water Reactor, and in its three versions (the 440-230 series, the
440-213 series and the 1000 series) has come to dominate electricity production in the
former Soviet bloc (e.g. Bulgaria, Slovakia, the Czech Republic, Hungary, Slovenia,
as well as republics of the former Soviet Union (FSU), and East Germany, where the
reactors were closed on unification). However, there is another design, the RBMK,
based on the Obninsk reactor.

Naturally, all nuclear power stations in the FSU were built, owned and operated by the
state. In 1989, just before the breakup of the USSR, it operated 46 nuclear power
reactors with an installed capacity of 35.4 GW. Presently, there are fifteen
commercial RBMKs operating, all in the FSU, at St Petersburg, Smolensk and Kursk
in Russia, Ignalina in Lithuania and Chernobyl in Ukraine. In addition there are four
reactors at Bilibino, Siberia, similar to the RBMK and used for district heating and
power production, and RBMKs for weapons production at Krasnoyarsk and Tomsk.
The RBMK has proved to be a relatively reliable producer of electricity with high
availability.

The RBMK is different in principle from any other commercial reactor system in the
world, mixing water cooling with a fixed graphite moderator. (A moderator is
necessary to slow down the neutrons which cause nuclear fission to take place in the
reactor fuel.) Water passes through pipes which pass through the core where the
nuclear fission takes place. This water boils in the pipes, and the steam produced goes
to turbogenerators to create electricity.
The ratio of liquid water to steam (‘void’) in the pipes is important. At very low
power output the water in the pipes in the core would be almost entirely liquid. As
liquid water is a good absorber of neutrons, this regime could only be sustained if the
‘control rods’ (which control the level of nuclear activity by absorbing neutrons
themselves) were almost all removed from the core. If something should now happen
to cause the water to boil, there would be an increase in the number of free neutrons,
and hence in nuclear fission, and hence in heat production. This in turn would
promote further boiling, and a ‘vicious circle’ would ensue. This is referred to as a
‘positive power coefficient’.

The problem only affects operation at very low power (which was both forbidden in
operating instructions, and prevented by the presence of an emergency core cooling
system which would shut down the reactor at low steam levels), and the concept had
been used in the early weapons production reactors in the USA. It was for example
rejected by the British on safety grounds in 1947 (Arnold, 1992, p. 12), and has never
been pursued outside the Former Soviet Union.

The first commercial RBMK began operation at St Petersburg in 1974. The

Chernobyl Nuclear Power Plant was the third site to use RBMKs (the first reactor of
1000 MW rating entering full service in 1978) and the first nuclear power station in
Ukraine SSR. A second unit, which has been closed since a fire destroyed the roof of
the turbine hall and instrumentation equipment in 1991, began operating in 1979, a
third in 1982, and then unit 4 in 1984. It was unit 4 which exploded in 1986. Two
other RBMK units on the site were under construction in 1986 but were abandoned
soon afterwards.

Before the Accident

Ironically, one of the potentially more serious events that can occur at a nuclear power
station is a power cut. Though the nuclear fission processes themselves could be shut
off immediately, the same could not be achieved for the residual heating caused by
radioactive decay of fission products in the fuel. This heating would initially
represent some 7% of normal operating power. If emergency safety (cooling) systems
were unable to operate because of interruption in their power supplies, it is feasible
that considerable damage could be done to the reactor. For this reason back-up
emergency systems running on different energy sources such as diesel are fitted.

Chernobyl unit 4 was scheduled to come out of service for routine maintenance on
April 25, 1986. As the station came off line, it was proposed to carry out an
experiment to determine whether even in the event of a power cut, or some other
event which interrupted the flow of steam into the turbogenerators such as a major
pipe failure, there would be enough energy in the turbogenerators as they ‘coasted
down’ to operate the plant’s Emergency Core Cooling System (ECCS) for the 30 or
40 seconds required to get the diesel backup power supply working.

In fact, the ECCS itself could not be used in this experiment, as it would shut down
the reactor before the experiment could start. It was therefore decided to use the main
circulating pumps and the feedwater pumps (which keep the coolant in the core
circulating) to simulate the load on the turbogenerators which would be caused by the
ECCS.

The experiment was designed by an electrical engineer, who regarded it as something

which would not affect the nuclear side of the plant (as it could have been done with
the reactor switched off, using decay heat in the fuel). However, plant operators
decided to keep the reactor operating at low power so that the experiment could be
repeated in case of failure. Under such conditions, the effect of using circulating
pumps and feedwater pumps to simulate the load of the ECCS was highly relevant to
the nuclear side of the plant, as they would change the rate of flow and hence the
temperature of water passing through the core, and thence the neutron absorption
characteristics of that coolant.

From 01.00 on April 25 the reactor’s power was reduced from its normal 3 200 MW
(thermal), until by noon it was operating at half power. The experiment was to be
carried out at 700-1 000 MW (thermal).

Running the station on half power exacerbated one of the classic problems of nuclear
power generation, ‘xenon poisoning’. The element xenon-135, which is created as a
result of nuclear fission (both directly, and more importantly from radioactive decay
of another fission product, iodine-135), is a very good absorber of neutrons. If too
much of it builds up in the fuel, it can therefore prevent nuclear fission occurring. In
normal reactor operation the amount of xenon remains constant, as the rate at which it
is created is balanced by the rate at which it absorbs neutrons and turns into other
elements. However, if the reactor is brought down from full power to half power,
there will be a considerable period during which the rate at which xenon-135 is
created is greater than that at which it is destroyed. This is because iodine-135, and
hence the creation of xenon-135 through decay of this iodine, will be at full-power
levels, but destruction of xenon-135 will be occurring at only half-power rates. The
concentration of xenon-135 therefore increases.

At 14.00 the reactor Emergency Core Cooling System (ECCS) was disconnected from
the primary circuit. This system would have tripped (switched off) the reactor during
the experiment and prevented a repetition if necessary.

There was now an unexpected hitch in bringing a coal-powered station on line, and
the Ukrainian electricity authority, Kievenergo, demanded that Chernobyl-4 remain on
line for a further nine hours, until 23.10. The station was therefore run at half power
for this length of time with the ECCS disengaged, contrary to operating instructions,
though not directly relevant to the accident.

The Night of April 25/26,1986

At 23.10 the operators started to reduce power by inserting control rods (which absorb
neutrons) into the core. However, at 00.28 an operator failed to reset the power
regulation system to the desired 700-1 000 MW (th), and as a result the power kept
falling. Power slumped to below 30 MW (th). This led to greatly increased levels of
xenon in the fuel; xenon was still being produced (from iodine-135) at 1 600 MW
rates, but hardly being burned up at all by the very low neutron levels in the fuel at the
low power output.
The increase in xenon poisoning made it much more difficult for the operators to
reverse the mistake and bring power back up to what was required. The vast majority
of the total of 211 control rods had to be removed, and even then the power could
only be raised to 200 MW (th). At this relatively low power output most of the water
in the pipes passing through the core was liquid.

In this unstable (and forbidden) regime, several signals were sent from various parts
of the station, including the steam pressure monitors, ordering a trip of the reactor, but
these were overridden by the operators, who disabled that part of the automatic
control system.

At 01.19 the operators opened the main feed valve, thus increasing the levels of water
in the system. As this cold water passed into the core steam production fell further,
and power began to fall as more neutrons were absorbed by the water. To maintain
power at 200 MW (th) it was necessary to remove all but the last 6 to 8 control rods
from the core, something which was absolutely forbidden.

At 01.21.50 the operator sharply reduced the supply of cold water, and steam began to
be produced. Some automatic control rods started to reenter the core to compensate
for reduced neutron absorption in the water. Nonetheless, there were still fewer than
half of the design ‘safe’ minimum of control rods in the core, and less than a quarter
of what was demanded in the operating instructions.

At 01.23.04 the main steam valves to the turbogenerator were closed, simulating a
failure in power supply and initiating the experiment. As already stated, the reactor
could have been tripped at this stage, but was kept operating in case the experiment
had to be repeated.

The closing of these valves reduced the flow of main coolant and of feedwater,
increasing the temperature in the coolant and hence steam production. The number of
neutrons being absorbed by the coolant therefore fell, and an increase in reactor power
was noted at 01.23.31. Automatic control rods entered the core but were unable to
stop this increase in power.

At 01.23.40 the shift manager attempted to shut off the fission process by inserting the
manual control rods. However, these rods were inserted mechanically (rather than by
gravity), and took about 10 seconds fully to insert. In fact, a design fault meant that
the initial insertion of the rods actually increased the reactor power. Three seconds
later the power had reached 530 MW (th). A condition known as ‘prompt criticality’
now ensued, and two explosions were heard. It is believed that the first resulted from
an interaction between the fuel and the coolant once some of the fuel rods had been
destroyed by the increase in power, while the second may have resulted from an
explosion between hydrogen (formed when the very hot water came into contact with
the graphite moderator) and air which had entered the reactor space. The second
explosion is calculated to represent something like 480 times the normal operating
power of the reactor, which had been running at 6% of normal power just five seconds
earlier.
At least 3% of the 190 tonnes of fuel in the core were ejected from the building, and
over 30 fires were started. Highly radioactive material was strewn around the
wreckage of the reactor building. Emissions from the stricken reactor continued until
May 5, when in effect they ceased (Figures 5 and 6).

Causes of the accident

It has been common practice, until recent years, to regard accidents as being caused
either by ‘component failure’ or by ‘human error’. In fact, of course, these are not
mutually exclusive categories. Simple component or system failure, for example, can
often be traced back to human mistakes, for example in the original design of the
plant, or in the maintenance and monitoring function. Similarly, it can be argued that
a properly designed plant should be capable of ‘forgiving’ considerable deviation on
the part of the operators.

However, it is also clear that there is an intermediate class of errors between the two,
which can be referred to as ‘organisational’. Organisational inadequacies might
involve excess pressure on operators to ignore safety procedures (or indeed
inadequate safety procedures in the first place); poor management or other factors
leading to low morale; poor supervision of operation; poor flow of information
through the operating utility etc. Such organisational factors can result in operators
quite deliberately acting contrary to safety and other operating codes, or being
unaware of them. In such cases the term human ‘error’ would not seem to be
appropriate. Both accidents here under discussion exhibit many examples of this
phenomenon.

It is common now to carry out ‘HOT’ (Human, Operational and Technological)

analyses of the causes of major accidents.

HOT Analysis of Bhopal

Human Factors

Though the Bhopal plant’s technology was broadly similar to that used in UCC’s
other MIC manufacturing plant at Institute, West Virginia, it relied much more heavily
on manual, rather than computerised, control systems. This seems to have been as a
result of the Indian government’s insistence that the plant should provide as much
employment as possible. As a result, human involvement in the accident, both at
operator and at manager level, was considerable.

The plant, as discussed above, was losing money, and received a very low priority
from the Union Carbide Corporation; indeed, apart from the MIC unit the whole plant
was put up for sale in 1984. The Agricultural Products Division offered poor
promotion prospects. These factors had obvious effects on employee morale. Some
80% of workers trained in MIC technology in the USA had left the plant in the four
years before the accident, while many of those who remained had started their own
businesses on the side to supplement their wages. Furthermore, cost-cutting led to
reduction in staffing levels - between 1980 and 1984 the entire MIC unit work crew
was cut from twelve to six, while the maintenance crew was cut from three to one.
A 1982 safety audit revealed that there was a general carelessness and lack of safety
consciousness in the plant’s operations at all levels (UCC, 1982). Examples cited
include maintenance workers signing permits which they could not read (being
written in English); workers in prohibited areas without the required permits; fire-
watch attendants being called away to other duties.

A number of specific unsafe practices can be cited as being relevant to the Bhopal
accident.

The position of maintenance engineer on the second and third shifts had been
eliminated. This person had been responsible for fitting the slip blind which would
isolate the pipes from the MIC tanks during flushing out, and the task had not been
reassigned.

Staff reductions had an inevitable effect on the level of human back-up to safety
systems. Important instrumentation, e.g. the local pressure valves and dials for each
MIC tank, were not accessible to the central control site, and required an operator
physically going to the tank to check them. In addition, emergency communications
within the plant, and from the plant to the local community, depended on messengers
physically carrying messages from place to place.

Levels of staff safety training were poor; in particular, workers had no training on
how to deal with emergencies; indeed, there were no emergency plans. One
manifestation of this was the early switching off of the site emergency alarm designed
to warn the local community.

Top managers seemed to know very little about the possible health consequences of
MIC and other chemicals in use in the plant.

When, several weeks before the accident, storage tank E610 suffered a considerable
drop in pressure, nothing was done to rectify the situation. The lack of positive
pressure in tank E610 allowed small amounts of water containing contaminants to
leak into the tank and local pipes. This led to a blockage of those pipes with MIC
trimer, necessitating the flushing operation on the night of December 2/3, and allowed
catalysts to contaminate the MIC in the tank and so accelerate the reaction between
water and MIC during the accident.

When the worker who was carrying out the flushing procedure noticed that no water
was coming out of the far end of the pipes, he stopped the procedure. However, he
was ordered to recommence by the production supervisor who made no attempt to
discover where the water was going. This supervisor had been transferred to the MIC
plant from a UCIL battery plant a month before the accident and had little experience
of the MIC plant and its hazards.

Tank E610 was filled to 75-80% of its capacity, against the recommended 50%.
Further, neither of the other tanks was empty to transfer MIC into if necessary.
The Union Carbide Corporation claimed that the accident had been caused by
deliberate sabotage by a worker (investigation carried out by Arthur D. Little Inc,
May 10 1988, quoted in UCC, 1994) who attached a water pipe directly to the tank.
Even if this were true, the above contributions to the accident remain relevant; the
accident had involved simultaneous failures in plant, management and operation, and
other relevant failures had occurred some weeks before the accident (Adler, 1985).

Organisational Factors

The relatively low importance of Bhopal to Union Carbide starved the plant of both
resources and managerial attention. The whole of UCIL represented less than 2% of
UCC’s worldwide sales, and Bhopal, one of thirteen plants owned by UCIL, had
operated at less than 40% capacity for several years. (Indeed, the plant had been
established just as the pesticides market began to decline and competition increased,
and serious consideration was given to abandoning the plant even as it was being
constructed.)

In the fifteen years between the plant’s establishment and the accident there had been
eight different senior managers, many coming from outside the chemical industry
with little experience of the specific problems raised by the plant. This turnover of
top management brought with it frequent changes in operational procedures and
consequent uncertainty for operators.

Technology policies, operating and safety manuals and maintenance procedures were
all derived from UCC’s documents, but tended to be left to the local management for
implementation, with occasional safety audits from the parent company. The last of
these, in May 1982, detected inter alia the following weaknesses which were relevant
to the accident:

the potential for release of toxic materials in the MIC unit and storage areas
because of equipment failure, operating problems or maintenance problems;

lack of fixed water-spray protection in several areas of the plant;

potential for contamination, excess pressure or overfilling of the MIC storage

tanks;

deficiencies in safety-valves and instrument maintenance programmes;

problems created by high personnel turnover at the plant, particularly in

operations.

To these can be added the poor allocation of certain safety features, which allowed,
for example, responsibility for flushing the pipes and responsibility for fitting the slip
blind to rest with different functions within the plant.

The local plant management did develop an action plan to deal with these problems
(Mukund, 1982), but clearly this had not been entirely effected or effective.

A further failure in the organisation/operational system allowed the earlier shut down
of the refrigeration system. This could have cooled the tanks sufficiently to slow
down the reaction between the impure MIC and water, or at least reduced the
temperature so that fewer of the toxic by-products of the reaction would have been
formed.
There was no contingency plan to deal with major emergencies.
Reference to the Indian Government’s enthusiasm for the plant to create as much
employment as possible, which led to the installation of manual rather than
computerised control systems, should also be made under this heading.

Technological Factors

Broadly, technological contributions to an accident can be divided into those

associated with plant design, and those associated with component failure. The
preconditions for the Bhopal accident lay in the fact that large amounts of MIC were
stored in underground tanks in an operating environment which relied on manual
rather than computerised control systems, and hence had no reliable early warning
system. Alternatives (small drum storage; constant-flow production cycles which did
not require storage of MIC) were available. The design did not include a backup
system to divert escaping MIC into an effluent area for quick neutralisation. One of
the other tanks should have been kept empty for diversion of material in an
emergency, but at the time of the accident all three tanks contained significant
amounts of MIC.

Other relevant technological factors included:

Failure of the pressurisation system in tank E610. This allowed ingress of water,
containing contaminants that could catalyse the reaction between MIC and water,
which would otherwise have met a pressure barrier. In the absence of these catalysts
the 500 kg of water which entered the tank would have been insufficient to cause such
a violent reaction in such a short period of time.

Water approached the tank via the relief-valve pipe and the process pipe. This is
strongly implied by the high level of sodium ions in the tanks. (Alkaline water from
the scrubbers tended to accumulate in the relief-valve and process pipes.)

Water could only enter the tank through the blow-down valve or the safety valve. The
possibility of a malfunction in the blow-down valve was suggested by the failure in
the pressurisation system of tank E610, but was not investigated. Water could only
reach the blow-down valve from the process pipe, and could only reach the process
pipe from the relief-valve pipe through the jumper line, which had been retrofitted to
the plant without due consideration of this possibility.

The use of corrodible carbon steel rather than stainless steel for pipework was the
probable cause of the high concentration of iron ions in the small quantities of water
which entered the tank prior to the accident.

Gases released from the storage tank could not be neutralised or contained. The
scrubber was designed to deal with gases alone and not with a mixture of gases and
liquids, and anyway failed to operate, having been put on stand-by. The flare tower
was down for maintenance, though it is questionable as to whether it could have
coped with the volumes of releases. Water sprinklers could not throw water high
enough to neutralise the escaping gases.
The general standard of maintenance in the plant was poor, though it had only been
installed in 1981. Valves and pipes were rusted and leaking and instrumentation was
unreliable.

HOT Analysis of Chernobyl

Human Factors

The Chernobyl accident is remarkable in at least two respects. The first is that there
was no component failure of any description; all ‘technological’ factors apply purely
to the design of the plant. The second is that, with the (very important) exception of
the failure of the operator to reset the power regulation system to stabilise the reactor
power at 700-1 000 MW(th) which caused a dramatic slump in power, none of the
human actions can be described as ‘errors’. All of the other precipitating actions were
deliberate violations of operating rules, presumably made within the context of a
determination to carry out the experiment under all circumstances. This in turn may
have derived from the fact that the experiment could only be carried out once a year,
when the plant was coming off line for maintenance.

The first set of human factors relevant to the accident concern the conception of the
experiment itself. This experiment was designed by a consulting electrical engineer.
He appears to have regarded the test as a purely electrical one, in which the reactor
was not relevant, and indeed the reactor could have been tripped as soon as the
experiment started, or even earlier. However, presumably because the operators
wished to be able to run the experiment a second time should the first attempt prove
inconclusive, the reactor was kept running at low power. Now the importance of rates
of water flow through the core became crucial to the operating parameters of the
nuclear reactor.

It is reported that the director of the station was unaware of the experiment, while the
chief engineer and head of the reactor section seem to have approved the experiment
without properly acquainting themselves with the details.

The members of the state inspectorate, the Gosatomenergoadzor, had all gone to the
local clinic for medical inspections on April 25, so nobody was on site to prevent
breaches of the operating code (Ignatenko et al., 1989).

The sloppy drawing up of the test programme, without agreement with the station
physicists, the reactor builders, the RBMK designers or representatives of the
inspectorate may appear bad enough. Yet the operators then deviated very
significantly from this programme.

When the Kievenergo control centre demanded that Chernobyl-4 be run for a further
nine hours, the plant was run at half power with the Emergency Core Cooling System
switched off, in contravention to strict operating instructions. Though of itself this
was not relevant to the accident, it demonstrates the attitude towards operating
instructions on the part of the operators.

Of more relevance is the fact that the original test had been scheduled for the
afternoon of April 25, but the test as carried out occurred in the early hours of the next
morning, when most of the site’s professional scientists and engineers had left, and
perhaps also when operators were not at the peak of alertness.

After the dramatic dip in reactor power caused by the failure to enter a ‘hold power’
command at 00.28 (the ‘genuine error’ referred to above), operators fought to increase
the reactor power, but could only raise 200 MW (th), against the 700-1 000 MW
demanded by the test programme. To achieve this many more control rods were
removed than allowed in the instructions. (Out of 211 control rods, the instructions
recommend that an ‘Operating Reactivity Margin’, ORM, of an equivalent of at least
30 rods should be maintained at all times. The operator has discretion between an
ORM of 30 and 15 rods, but below 15 rods, in the words of Valery Legasov, head of
the Soviet delegation to the conference on the accident held in August 1986, ‘no-one
in the whole world, including the President of the country, can allow operation. The
reactor must be stopped.’ At the start of the experiment proper, 01.22.30, the ORM
was between 6 and 8 rods. Legasov says ‘the staff were not stopped by this and began
the experiment. This situation is difficult to understand’.) In this regime it was
impossible to shut down the reactor quickly.

The reactor was now operating at 7% of normal output, well below the 20% specified
as a minimum in the operating instructions, and the 22-31% envisaged in the test
programme. Under these conditions, a slight boiling in the coolant would reduce
neutron absorption, causing an increase in nuclear activity, and hence of heat, which
would further boil the coolant, resulting in a further reduction in neutron absorption,
and so on. This is referred to as a ‘positive power coefficient’ - if power increases this
causes a further increase in power.

The reactor was operating at a far lower power than expected, but the flow of coolant
through the core remained at levels demanded by the experiment programme. As a
result there was even less steam in the mixture in the core, resulting in an even more
unstable condition. The whole core was perhaps within 1 K of boiling, but no boiling
was taking place.

The operators overrode the many ‘trip’ commands coming from a variety of parts of
the plant. Indeed, the whole process of keeping the reactor at power, in order to
repeat the experiment if necessary, was not part of the test programme; the test could
in fact have been carried out soon after switching the reactor off, using the decay heat
of the fuel.

Organisational Factors

The remarkable actions of the operators - Legasov said they ‘seemed to have lost all
sense of danger’ - cannot be explained in terms of ‘error’, but must be seen against the
institutional background of the plant’s operation.

In many senses nuclear technology, along with the space programme, was the most
prestigious of the industries of the USSR. Chernobyl had been described as the
flagship of the Soviet nuclear fleet. Perhaps these factors contributed to the
complacency about safety that was endemic in the station’s operations. For example,
from 17 January 1986 until the day of the accident the reactor protection system had
been taken out of service on six occasions without sufficient reasons. Between 1980
and 1986, 27 instances of equipment failure had not been investigated at all, being left
without any appropriate appraisal of possible consequences being made (Ignatenko et
al. (1989)). The operators thought that ‘no matter what you did with the reactor an
explosion was impossible’ (Kovalenko, 1989). There were no RBMK control room
simulators for operator training anywhere in the FSU.

The kudos attached to nuclear power also affected the attitude of operators in a more
subtle way. Operators were selected not only for their technical ability (typically it
took a nuclear engineer seven years to get their first degree and four or five more for a
PhD, in a highly competitive system), but also for their loyalty to the Party - it was
not possible even to enter university without being an unswerving Party member.

Officially, operating procedures, derived more from the plant design than from
operating experience, were to be adhered to ‘by the book’; overtly to do otherwise
would be to invite instant dismissal and a return to a 25-year waiting list for an
apartment. In reality, though, operators were constantly being put into situations
which conflicted with this imperative, e.g. the local mayor, a high Party official,
demanding extra power during a cold spell, something which would be done if
possible whatever ‘the book’ said.

Thus the highly talented workforce was daily discouraged from using personal
initiative and taking responsibility for it, while they were quite used to bending the
rules covertly (Traves, 1995).

The experiment had originally been proposed for the similar reactors at the Kursk
station in Russia. However, there the plant manager, an experienced nuclear engineer,
apparently appreciated the dangers and refused permission. Further, A. Kovalenko
reports that a sequence of events similar to the early stages of the Chernobyl accident
had occurred at the Leningrad (St Petersburg) RBMK plant in 1982. It is not clear
whether these pieces of information reached the Chernobyl site management
(Kovalenko believes the Leningrad papers had probably been read by the Chernobyl
management, ‘but at the time of the tests they were all tucked up in bed’), but clearly
there were considerable communication problems within the Ministry for Power and
Electrification.

Technological Factors

As mentioned above, the Chernobyl accident occurred without any of the plant’s
components malfunctioning. In other words, though questions have been raised over
the standard of construction and maintenance at the station, the accident was the result
purely of poor plant design.

The central flaw is a feature called ‘positive void coefficient’. If the proportion of
steam in the steam/water mixture passing through the core should increase, this
reduces the number of neutrons being absorbed by that mixture, and hence increases
the amount of nuclear fission occurring. At normal operating temperatures this is
outweighed by a ‘negative Döppler (fuel) coefficient’ - hot uranium is better at
absorbing neutrons than is cold uranium. So if the power output of the reactor goes
up, the number of neutrons absorbed by the coolant reduces, but the number of
neutrons absorbed by the fuel increases by a greater factor, and the overall effect is to
return the reactor power to a lower level. At very low power, however, the positive
void coefficient is greater than the negative Döppler coefficient. Now, an increase in
power output will result in an overall reduction in neutron absorption, hence an
increase in nuclear fission, hence an increase in power output - a positive feedback
loop or ‘vicious circle’ which could cause the reactor to run away with itself. This is
the reason that very low power operation was forbidden.

Stations such as Pressurised Water Reactors, Boiling Water Reactors, Advanced Gas-
cooled Reactors and Magnox do not display a positive void coefficient, either because
the water acts as the moderator and so loss of coolant results in the cessation of the
fission processes (PWR, BWR), or because the reactor is gas-cooled and so no change
of phase (‘voiding’) is possible (AGR, Magnox).

The Emergency Core Cooling System (ECCS) served a number of safety purposes,
one of which was to prevent operation at very low power. However, this system could
be disabled manually, as could the various trip signals.

The station did not have a fast shutdown system independent of the operational
control rods.

The emergency control rods entered the core mechanically, taking up to about 18
seconds, rather than by gravity. These rods were unable to enter the reactor at all
during the accident, presumably because the initial release of power caused the
control rod channels to buckle.

A design fault in the control rods (the attachment of a graphite ‘rider’ on the bottom of
the rods) meant that insertion of the rods could initially lead to an increase in
reactivity, and hence in temperature production; this was especially important when
there was considerable xenon poisoning in the fuel and hence very low levels of
insertion of control rods.

The station also lacked an ‘outer containment’ which is regarded as being necessary in
water-cooled reactors in the West. It is likely that such containment would have
significantly reduced the release of radioactive materials in the course of the accident.

Discussion

The similarity between the two accidents was apparent almost immediately. For
example, Academician Valery Legasov, head of the Soviet delegation to the Vienna
conference on Chernobyl in August 1986, said (cited in Ignatenko et al., 1989):
‘Naturally, reactor design engineers studied all the accidents which have occurred at
nuclear power stations and have, if necessary, adopted additional safety measures.
But unfortunately they did not study accidents in other branches of industry. The train
of events at Chernobyl NPS, which led to the tragedy, was in no way reminiscent of
even one of the emergency situations at other nuclear power stations, but was very,
very similar, right down to the last details, to what happened at the chemical works at
Bhopal in 1984.

‘Right down to the last details. The Chernobyl accident occurred in the night from
Friday into Saturday. The accident in India happened on a Sunday. At Chernobyl
they switched off the emergency protection, in India they switched off the coolers and
absorber which perform a protective function. In India there was a technical fault
involving a gate valve, and passage of water resulting in an exothermic reaction,
which developed exponentially, with the coolers switched off, whilst here there was
an excess of steam and a rise in reactivity. The main thing was that both in India and
here, the staff had been able (in spite of this being strictly forbidden) to switch off the
protective devices.

‘If the reactor designers had drawn some conclusions from the Bhopal accident ... but
what use is there in talking about it now? To be fair I would just like to say that it was
precisely after Bhopal that chemists knocked on the “reactor doors”, but such words
as “methyl isocyanate”, “oxidation” and “chemical reactions” made the problem
uninteresting for physicists. The lesson of Bhopal went unheeded.’

While Legasov may push the technical details of his comparison to the edge of
usefulness, there is no doubt that a series of human, operational and technological
failures were common to both accidents.

Neither accident is characterised by ‘human error’ in the sense of inadvertent actions

by operators. At Bhopal it is not clear that any action clearly fits into this category;
even the failure to fit the slip blind which would have prevented water entering tank
E610 arose from organisational weaknesses. At Chernobyl, the failure to set a new
power level while bringing the plant power down in the early morning of April 26 was
a clear ‘error’.

But the rest of the human violations of operating instructions seem to be quite
deliberate. This is probably typical of major accidents; Howard (1983) analysed five
chemical industry accidents, and argued that only one could be assigned to human
error in the sense defined above. ‘Management error’, which of course impinges on
‘organisational failure’, and general matters of worker attitudes were more salient
features.

In both accidents, there seems to have been a remarkably cavalier approach on the
part of the operators to operating and safety instructions, insofar as these were
available to them. A number of examples are outlined in the text above.

Ironically, though, it seems that the causes of this laxity were almost diametrically
opposed to each other. In the case of Bhopal, overall morale was very low. The plant
was losing money and most of it had been put up for sale; there was a high turnover of
top management and of US-trained operations staff, coupled with drastic staff cuts.
The Agricultural Products Division was regarded as a career dead end. Against such a
background it is unlikely that the highest quality operators would have been attracted
to the plant. The general lack of awareness about the potential hazards of the plant’s
operations, and the observation that the operating instructions were generally written
in English which many of the operators did not speak or read are further evidence for
the poor state of what might be called the ‘safety culture’.

At Chernobyl the problem seems to stem from precisely the opposite vice, that of
overconfidence. The operators were among the most highly skilled workers in the
USSR, well paid and with good social standing. From management down there
seemed to be a feeling that ‘no matter what you did with the reactor an explosion was
impossible’.

These observations imply that safe plant operation flourishes when operators are
confident of their own value to the company, but are kept aware of potential hazards.
There would appear to be a desirable ‘morale envelope’, within which the operators
are neither too complacent about the possibility of serious accident, nor too depressed
about their own futures. In this context the constant vacillation over the last ten years
about the future of the Chernobyl plant is potentially very dangerous. It seems that
every three months or so it is announced either that the station will close as soon as
Western money is made available, or that refurbishment of the existing plant,
including Unit 2, is planned which will allow operation of the plant for the rest of its
planned lifetime (i.e. up to the year 2011) or even longer. The effects of such
uncertainty on staff morale can be imagined, and a comprehensive and consistent
approach to the future of the operators, including guarantees of alternative
employment if closure should be pursued, should be regarded as an integral element
in any attempt to improve safety.

Mosey (1990) categorises organisational factors as follows.

1. ‘Dominating production imperative’, institutional pressure to maintain

production, and also to ‘get the job done on time’. At Bhopal, this pressure was
considerable. The plant was losing money, and within a division which was losing
money, against a background of considerable divestment by the parent company. It
had been operating at 40% capacity for some time. Thus the flare tower had been
dismantled during a break in MIC manufacture, despite the fact that it might still have
been required in case of an MIC leak from the storage tanks; the Freon from the
refrigerator had not been replaced; and as an operational example, the plant supervisor
ordered that flushing of the pipes should continue before investigating why no water
was coming out of the relief-valve pipe.

At Chernobyl, it is difficult to understand why the operators should have continued

with the test despite the fact that so many of the preconditions (especially the required
700-1 000 MW (th) output from the reactor) could not be met unless they were
determined to get the job done whatever the circumstances. This would also explain
why the reactor was kept running rather than shut off at or before the start of the
experiment proper, thus allowing the possibility for a repeat of the experiment if it
should not work first time. However, the motivation would seem to be different from
that at Bhopal. There was no threat to the future of the Chernobyl plant itself, the
flagship of one of the most prestigious industrial fleets in the USSR. It seems rather
that loyalty to the Party, coupled with the above-mentioned belief that nothing could
go seriously wrong in such a technology, drove the operators to ignore the most
emphatic of safety instructions, if indeed they recognised the prohibition of operation
below 25% of normal output as such.

Legasov also refers to a number of examples where production considerations seem to

have overridden quality concerns. In one case of a shoddily welded pipe, ‘they began
to look into the documentation and found all the right signatures; the signature of the
welder, who certified that he had properly welded the seam, and the signature of the
radiographer who had inspected the seam - the seam that had never existed. All this
had been done in the name of labour productivity.’

2. ‘Failure to allocate adequate or appropriate resources’. This was a central

issue at Bhopal. The generally run-down state of the plant, with several valve
failures, clogging of bleeder lines, rusting pipes etc., was directly relevant to the
accident. The retention of obsolete technology and control measures (e.g. the lack of a
computerised control system) would not presumably have persisted had the plant been
resourced more fully. Wage levels were low, meaning that many operators had to start
their own businesses on the side, which will have contributed to fatigue in the early
hours of the morning. Further, the dramatic reduction in staffing levels led directly,
for example, to the failure to fit the slip blind to the relief-valve pipe which allowed
water to enter the tank.

It may also be noted that the Indian state provided very few resources for
environmental management and monitoring of environmental and safety standards. In
1983 the central government Department of the Environment, established only in
1980, had a budget of just $650 000, with instructions to concentrate on deforestation
and waste pollution issues (World Environment Centre, 1984).

This factor is less relevant at Chernobyl, where there was no component failure as
such. However, the RBMK design itself, and especially the positive void coefficient
problem, was arrived at for reasons of economy, though it was recognised by the
designers that under certain extreme operating conditions major failure could occur.
One can also note the lack of any RBMK simulators for training anywhere in the
USSR.

3. ‘Failure to acknowledge or recognise an unsatisfactory or deteriorating safety

situation’. The 1982 safety audit at Bhopal identified ten serious weaknesses in the
operating regime of the plant, at least five of which were relevant to the accident in
1984. However, there appears to have been little attempt by UCC to ensure that the
recommended improvements had been made. Certain maintenance problems, such as
that affecting nitrogen pressure in tank E610, seem simply to have been ignored.

In September 1984 an internal UCC report warned that a runaway reaction between
MIC and water could occur at UCC’s only other MIC plant, at Institute, West Virginia.
UCC responded by increasing the level of sampling at Institute, but the warning
seems never to have been passed on to the similar plant at Bhopal.

At Chernobyl, revelations that the reactor had operated six times with the Emergency
Core Cooling System uncoupled in the first four months of 1986, and that twenty
seven component failures had been ignored from 1984 to the time of the accident,
indicate a failure to recognise the flaunting of safety procedures.

4. ‘Lack of appreciation of the technical safety envelope’. This was a major

common factor in the two accidents.

At Bhopal, there was almost no knowledge among the plant operators or supervisors
about the potential toxic effects of MIC. (Research into the health effects of this
chemical was relatively rudimentary at the time, but information was available in the
academic and Governmental spheres which does not appear to have been made
available to plant officials.) There were no emergency procedures in the case of a
major release, and the disabling of many of the safety devices further suggests that
operators were not alert to the possibility of major leaks even between batch
manufacturing phases.

The depressurisation of tank E610 some six weeks before the accident should have
been addressed, but operators seemed entirely unaware of the consequent dangers of
allowing contaminants to enter this tank.

At Chernobyl, the ubiquitous impression among managers and operators alike was
that safety rules were made covertly to be broken (though the official position was
that they were adhered to literally). As well as the practice of simply crossing out
sections of the instructions which appeared inconvenient, Legasov also quotes a site
manager as saying, ‘What are you worrying about? A nuclear reactor is only a
samovar’.

5. ‘Failure to define and/or assign responsibility for safety.’ The most striking
example of this at Bhopal was the division of responsibility for carrying out the
flushing and for fitting barriers such as the slip blind between the MIC supervisor and
the maintenance supervisor. The abolition of the latter post some short time before
the accident was not accompanied by a reassignation of this duty, so the flushing was
carried out without it. Had responsibility for the whole process lain say with the MIC
supervisor this would not have been possible. There seemed to be no allocation of
responsibilities in the case of an emergency; it was not clear for example who was
responsible for alerting the local community, as a result of which the off-site alarm
was switched off soon after it was activated.

At Chernobyl it is still not clear how it was possible for an electrical engineer with
little experience of nuclear reactors in effect to take control of the plant during the
experiment, without the site director even being aware of the test. The frequent
violation of safety procedures in the period before the accident seems to have been
done with the knowledge of the deputy chief engineer; to whom was he responsible?
How was it possible for the test programme to be drawn up without any reference to
any review or approval process? What powers did the state inspectorate have, and did
they attempt to exercise them? (In an attempt to resolve such questions, the Soviets
created a new Ministry of Nuclear Energy after the accident.)

A further point arises. In his Memoirs, published after his suicide in 1988, Valery
Legasov reports that ‘the level of preparation of serious documents for a nuclear
power plant was such that someone could cross out something, and the operators
could interpret, correctly or incorrectly, what was crossed out and perform arbitrary
operations’. When taken alongside the comments by Traves (above), a worrying
model of one organisational source of poor safety performance emerges.

Operators at Chernobyl were under constant pressure to produce high output from the
reactors. In the course of normal operation, then, one can postulate that operators, as
they became more confident in operating the plant, began to identify sections of the
operating instructions which were not essential to the production of power, and
observance of which might well delay or reduce output. Some of these ‘short cuts’
may have been identified by accident during normal operation - an operator omitted a
procedure, and discovered that on that occasion no apparent detriment resulted. These
‘operationally unnecessary’ procedures were presumably among those which Legasov
discovered to be crossed out in the documentation.

In any complex technology, there will undoubtedly be a number of procedures which,

while desirable, can indeed be omitted with very low or zero risk of significant
adverse consequences. Others, however, will be absolutely mandatory. Others will
lie between the two extremes. In the case of operation of Chernobyl, one might
perhaps categorise continuing to run the reactor at half power for nine hours as a
‘trivial’ breach, running the plant with the Emergency Core Cooling System disabled
or over-riding trip commands as ‘serious’ breaches, and running the reactor at 6% of
power with Operating Reactivity Margin of only six rod-equivalents as ‘forbidden’.

However, as Traves describes, the official position was that operators always went ‘by
the book’, on pain of dismissal and disgrace. Hence it was presumably impossible for
operators to discuss openly which corners could ‘safely’ be cut, and which could not
under any circumstances.

The Soviet system was undoubtedly an extreme example of such pressures, but one
can assume that similar pressures must be felt by operators in all industries and
societies; there is some evidence of similar practices in the chemical industry, for
example (Jones, 1988).

There would seem to be two possible ways of reducing the likelihood of such
pressures leading to major problems. Either the regulatory and training regime is so
strict that operators are not tempted to cut corners however sure they are that the
measures in question are unnecessary or lead to inefficiencies; or operators are
encouraged to discuss more openly any violations in operating procedures which they
may have perpetrated, however involuntarily, and so to categorise them by
seriousness.

Clearly this latter course requires a great deal of confidence and the involvement of
any external regulator to which the industry in question may have to report. However,
unless the regulatory system and safety culture is so robust as to make the cutting of
corners organisationally impossible, greater openness over the real practice of
operation may be fruitful, and would certainly have been valuable in the case of
Chernobyl.

The technological causes of the accidents differ in one important respect. At

Chernobyl there was no component failure, while at Bhopal at least one important
component seems to have failed - the blow-down valve of tank E610 which caused
the depressurisation of the tank some six weeks before the accident. This allowed
ingress of contaminants into the stored MIC in the tank, and subsequently allowed the
entrance of water which had flowed into the process pipe via the relief-valve pipe and
jumper line.

However, both plants displayed a number of design errors, outlined above, which
made them especially vulnerable to violations of operational codes and procedures.
Perhaps principal of these were the storage of large volumes of MIC in tanks and the
backfitting of the jumper line at Bhopal, and the positive void coefficient of the
Chernobyl reactor which created a positive power coefficient at very low power, and
allowed the reactor to ‘run away with itself’. In addition, though both plants had
safety systems, these could be and were uncoupled by operators, either for
maintenance or so that the safety experiment could be carried out.

A contrast can be seen between the accidents at Bhopal and Chernobyl, and similar
accidents in the West. In the first half of this century there were a number of major
accidents in western countries involving chemicals. For example, explosions
involving the fertiliser ammonium nitrate (which is also used as a commercial
explosive) caused 560 deaths at Oppau, Germany in 1921, 200 deaths at Tessenderloo
in Belgium in 1942 and 530 deaths in Texas City in 1947 (the worst industrial disaster
in US history).

However, the second half of the century has seen a reduction of major accidents
involving chemicals in the West. Examples causing more than a hundred deaths are
rare;

Explosion of lorry (liquefied propene) Los Alfaques, Spain 216 deaths 1978
Collapse of an off-shore oil rig Norway 123 deaths 1980
Explosion of Piper Alpha oil rig UK 167 deaths 1987

Examples are far more frequent in eastern Europe and in the developing world.

Explosion of liquefied natural gas Xilatopec, Mexico 100 deaths 1978

Oil explosion at power station Tacao, Venezuela 145 deaths 1982
Petrol explosion Sao Paulo, Brazil 508 deaths 1984
Liquefied petroleum gas reserves explosion Ixhuatepec, Mexico 452 deaths 1984
Release of MIC Bhopal, India 3 800 deaths 1984
Train sparking explosion from leaking gas pipeline, Russia 500 deaths 1989

(From Shrivastava, 1987.)

(It should be noted that the demonstrable direct death toll from Chernobyl at the end
of 1995 was 33 - 30 during the accident itself, plus 3 among thyroid cancer sufferers
in Ukraine, Belarus and Russia - with perhaps one more among those who suffered
from Acute Radiation Syndrome. However, more deaths are predicted owing to long-
term effects of radiation.)

The most obvious Western event which can be compared to Chernobyl is the Three
Mile Island accident at Harrisburg, Pennsylvania, USA, in 1979. It is less easy to find
a direct comparison for Bhopal, but an example might be the leak of aldicarb oxime
from the Union Carbide plant at Institute, West Virginia in 1985.

Three Mile Island

The 959 MW reactor Three Mile Island 2 was destroyed on March 28 1979, when a
complete loss of feedwater led to severe core damage. Though it is not the intention
of this paper to provide a detailed account of this incident, a HOT analysis emphasises
a number of similarities between the causes of this accident and those of Chernobyl.
The accident, which started at 04.00, is often described in terms of ‘operator error’.
On the face of it, after the reactor had tripped for another reason (water entering a dry
line through a check valve which had stuck open) the operators misread the
information being presented to them (that a valve known as the Power Operated
Relief Valve (PORV) had stuck open). In their attempts to understand and respond to
the plant parameters they then made a number of errors, the most important of which
were to throttle the high pressure injection flow machinery (which was providing
cooling water to replace that which was escaping through the stuck valve), and then to
turn off the main circulating pumps. The result was that the core boiled dry and about
40% of the fuel melted before the situation was recognised and controlled.

However, further analysis once again indicates that these ‘errors’ should be seen
against a less than perfect organisational and technological background, and indeed it
seems harsh to blame the individual operators in any sense.

For example, in 1977, at the Davis Besse plant, which like TMI had been built by
Babcock and Wilcox, a PORV had stuck open, and operators again responded to rises
in pressuriser water levels by throttling water injection. Because the plant was at low
power (9%), and the valve closed after 20 minutes, no damage was done, but an
internal Babcock and Wilcox analysis concluded that if the plant had been operating
at full power ‘it is quite possible, perhaps probable, that core uncovery and possible
fuel damage would have occurred’. In January 1978 a Nuclear Regulatory
Commission (NRC) report concluded that if such a circumstance had arisen it was
unlikely that the operators would have been able to analyse its causes and respond
appropriately (Kemeny et al., 1979). Yet none of this information was passed on to
other plant operators either by Babcock and Wilcox or by the NRC. (This is strikingly
similar to the September 1984 internal UCC report on the dangers of a runaway
reaction at Institute which was not passed on to Bhopal.) Indeed, the failure of a
PORV valve was not one of the ‘analysed incidents’ with which operators were
familiarised during training.

The Kemeny Report also refers to a lack of staff and expertise in the area of nuclear
plant operation; for example, review of technical information from other plants was
carried out by people without nuclear backgrounds. This deficiency was felt both at
TMI itself and throughout the organisation. In addition, the apportionment of
responsibility for safety both within the operating utility and within the regulatory
authority was not clear.

One aspect of technological weakness was in the layout of the instrumentation. There
was an indicator light associated with the PORV, and this light went out 12 seconds
after the reactor was tripped. However, this merely reported that the signal to open
the PORV had been cancelled; it did not actually confirm that the valve had closed.

Just over three minutes later, the temperature of the water in the ‘reactor coolant drain
tank’ rose dramatically, suggesting that the steam generators had boiled dry (and
hence, indirectly, that the PORV was stuck open), but the relevant meter displaying
this information was located on the back of the main control panel, out of the sight of
the operators who were by now trying to cope with vast amounts of information.
Similarly, though there was an alarm sound associated with this message it was
undetectable under the audible alarms on the front panel, which were all sounding at
once.

This information was also sent to the alarm printer to be printed out, but by the time
that signal was sent the printer was receiving over 100 other alarm messages per
minute. It took several minutes for the printer to print it out, and then it was just one
alarm among several hundred. It took two hours and 22 minutes to identify that the
PORV was stuck open and to stop the loss of coolant from the circuit, but by then
several other problems had arisen, and it took another 13 hours to stabilise the
situation, by which time the reactor core had been destroyed. However, releases of
radioactivity from the station were minimal; for example, they did not breach the
plant’s weekly permitted discharge limit.

The principle conclusion that can be drawn, then, is that although the Three Mile
Island accident involved human and organisational weaknesses as severe as those at
Chernobyl, and also involved component failure (which was absent at Chernobyl),
key design features of the plant prevented radioactive leaks as a result of the incident
which might have caused significant damage to the environment or to human health.
Among these key design features include the physics of the plant which would cause
it to trip under any exceptional conditions, and prevent a power surge under any
circumstances. The containment of the plant was able to prevent releases of
significant amounts of radioactivity into the environment. In other words, the design
of the plant was ‘forgiving’, tolerating considerable violations by operators of
operating and safety codes without causing major releases of hazardous materials.

Institute

UCC operated an MIC plant at Institute, West Virginia. Immediately after the Bhopal
accident this plant was closed, and $5 million spent on additional safety features.
Public announcements were made that such a major accident could not occur in the
USA.

However, on March 28, 1985 there was a leak of mesityl oxide causing nausea to
eight people, followed on August 11 1985 by a leak of aldicarb oxime which caused
135 injuries, 31 of whom were hospitalised.

There is no consensus about the toxicity of aldicarb oxime. Dr Vernon Houk from the
Centre for Disease Control in Atlanta, Georgia, said that it was ‘less toxic than MIC’,
though he added ‘I am not saying this is an innocuous chemical - it is not’, while an
unidentified health consultant in the Charleston Gazette (14.8.85) claimed it was
seventy times more potent than MIC. In the same month, Rep. Waxman said that
internal UCC documents indicated that aldicarb oxime was given the same hazard
classification (Class 4) as MIC (Wilkins, 1987).

Subsequent investigations revealed several occasions over the previous five years in
which releases of chemicals had occurred, including one case a month before the
Bhopal incident in which over six tonnes of an MIC/chloroform mixture had been
released (US EPA, 1985).
These incidents were caused by failures in operating procedures, equipment
malfunctions, and human errors - the same factors that contributed to the Bhopal
accident.

‘In the period leading up to the leak [on August 11] high-pressure alarms were
repeatedly shut off and ignored. A high-temperature alarm was out of service. A level
indicator in the tank that leaked and was known to be broken was not fixed.
Meanwhile the unit’s computer, which silently recorded the rising problems for days,
was never asked for the information by operators ... a total of 32 people in the
sprawling plant had directed responsibility for the problem chemical unit in the days
before the 11 August leak. Contrary to plant procedure, the workers never checked
the tank and associated equipment before using it to make sure it was running
properly, which it was not. In addition, the workers assumed that tank was empty
because a pump being used to drain it had stopped a few days earlier. But the workers
never verified that assumption. Such a check would have been difficult in any case
because the tank’s level indicator was broken ...’ (New York Times, 24.8.85).

There were delays in sounding the off-site alarm, and local people had little
information about potential health hazards. In April 1986 the Occupational Health
and Safety Administration (OHSA) imposed a record $1.4 million fine on UCC for
221 health and safety violations. Nonetheless, it was recognised that the safety
systems operated quite efficiently, stopping the leak of aldicarb oxime after just
fifteen minutes, and though there were significant health implications there were no
direct deaths from the incident.

It is of course difficult, if not futile, to draw too many firm conclusions from two case
studies, or indeed from the relatively small number of major industrial accidents over
the last half century. It would seem possible to come to a number of quite different,
and perhaps even contradictory, conclusions from the available evidence.

The first is that despite weaknesses, the organisational structure of industries in the
West is generally more effective than of those in developing countries. Gladwin and
Walter (1985) of New York University wrote, ‘a tentative reading of the publicly
available evidence so far suggests that the Bhopal facility may have been operating
quite independently of UCC. Much of this relative autonomy can probably be traced
to the pattern of restrictive Indian regulations imposed on foreign investment and the
importation of products, know-how and managerial and technical skills’, suggesting
adverse local factors were relevant at least at Bhopal.

However, the above comparisons suggest that human and organisational weaknesses
are by no means limited to the developing world and the former eastern bloc, though
safety cultures may be worse in these regions. The similarities between the
organisational causes of Bhopal and Three Mile Island are especially stark.

Perhaps, then, the undeniably greater success of Western nations in preventing major
loss of life, especially among those off site, may derive from a more robust approach
to technological design factors, which runs across all industries. Broadly, the
engineered safety systems and fundamental design philosophies at Institute and Three
Mile Island worked to prevent major health problems, while those at Bhopal and
Chernobyl did not.
However, both of these explanations assume that there is a qualitative difference
between the course of accidents in the West and in the developing world. The relative
frequency of major accidents in the two regions does lend support to this, but it must
also be noted that the fact that no lives were lost as a result of the Institute incident
was a function not only of the speed with which the emissions were stopped, but also
of the low population density near the plant compared to Bhopal. If aldicarb oxime is
indeed comparable in its toxicity to MIC then a release of Institute proportions into a
population as dense as that of Bhopal would presumably have caused many deaths.
Indeed, the month before the Bhopal accident there had been a release of over 6
tonnes of an MIC/chloroform mixture from Institute (US EPA, 1985), representing
about a sixth of the Bhopal release. No deaths were caused, but a simple comparison
would seem to suggest that the same release would have killed more than 500 people
had it occurred in Bhopal.

A third possibility, then, would point to a difference between nuclear and chemical
technology. It can be argued that there were equivalent human and organisational
failures at Three Mile Island and Chernobyl; indeed, there was component failure at
Three Mile Island but none at Chernobyl. Nonetheless, the radiological consequences
of the two nuclear incidents were dramatically different. This may suggest that
nuclear power technology can be made ‘fail safe’, or ‘forgiving’ of mistakes made by
operators, while the considerable releases of chemicals from plants in the West as well
as in the developing world would suggest that this is not possible, or at least has not
been achieved, in the chemical case. This approach offers an explanation for the
safety record of the nuclear power industry in the West, with no established examples
of on-site accidents causing off-site deaths through the effects of radiation, in
comparison to the safety record of the chemical industry in the West. However, it is
less successful in explaining the difference in the major accident rate between the
West and the developing world.

Some combination of all three explanations may therefore be necessary to explain the
various differences noted above. This would seem to be an area in which further
research would be fruitful.

Consequences of the accidents

Both Bhopal and Chernobyl were defining events in the world’s perception of the
relevant industries. However, there are a number of key differences in those
consequences.

The immediate (‘early’) health effects of Bhopal were much more serious than
those of Chernobyl.

It is predicted that there will be considerable long-term (‘late’) effects as a result

of Chernobyl, while understanding of the long-term effects of MIC is much less
clear and so reliable predictions are more difficult to make. Chernobyl’s late
effects could in principle affect people who were not born at the time of the
accident but live in contaminated regions, as well as offspring of those directly
affected by the accident, while at Bhopal it is likely that those affected will be
limited to people alive at the time and their offspring.
 Fallout from Chernobyl is much easier to detect, and will be longer-lasting, than
fallout from Bhopal.

The releases from Chernobyl are quite well characterised, while those from
Bhopal are far less so, owing to the complex chemistry of the precipitating event.

Bhopal occurred in a densely populated city, Chernobyl in a sparsely populated

rural area.

Bhopal occurred in the developing world at a time when the West was quite used
to images of third world suffering (e.g. soon after the drought which led to the
‘Band Aid’ project); Chernobyl happened on the edge of Western Europe.

Health Effects (1) - Medical

Bhopal

Almost 40 tonnes of a complex chemical mixture were released in the course of the
Bhopal. This mixture was calculated to be about two thirds MIC and about one third
products of the reactions which occurred in tank E610 before release (UCC, 1985).

As mentioned above, it is striking how little information was available in the public
domain about the health effects of MIC, given the widespread use of the chemical in
the pesticides industry.

There are two broad theories about the health effects of MIC. The ‘pulmonary theory’
holds that, with the exception of irritation to the eyes, the other effects of MIC are all
associated with its effects on the lungs, leading to oxygen deficiencies (hypoxemia) in
other organs of the body. It seems unlikely that oxygen deficiency alone could
account for the wide range of symptoms reported after the accident. Victims did
suffer from breathlessness, dry coughs, chest pains, restrictive lung diseases and loss
of lung capacity, dry eyes and photophobia (12 000 cases of cornea damage). The
most serious and permanent damage was in the respiratory tract. Many victims died of
oedema (fluid in the lungs). MIC also damaged mucus membranes, perforated tissue,
inflamed the lungs, and caused secondary lung infections. Many survivors could not
be employed because they suffered from bronchitis, pneumonia, asthma and fibrosis.
These observations could be explained in terms of lung and eye disease only.

However, there were many other problems, including fatigue, blurring of vision,
muscle ache, headache, flatulence, anorexia, nausea, excessive lachrymation, tingling
and numbness, loss of memory, anxiety and depression, impotence and shortening of
the menstrual cycle (Medico-Friend Circle, 1985), as well as loss of appetite,
vomiting, diarrhea, abdominal pains and suppression of lactation in nursing mothers,
which could not so easily be assigned to lung and eye damage.

The alternative ‘enlarged cyanogen pool theory’ holds that the effect of released gases
on the patients was to increase the pool of cyanogenic chemicals in the body, leading
to chronic cyanide-like poisoning. The cyanide controversy is referred to below.
UCC reported that chronic-type, low level inhalation studies conducted in mice and
rats in 1980 had “found no carcinogenicity” (Chemical and Engineering News
3.3.86).

It is not known precisely how many people died as a result of the Bhopal accident. A
few months after the accident the Indian Government officially put the death toll at 1
754, a figure derived from (incomplete) morgue records, to which were added figures
reported from registered cremation and burial grounds and from out-of-town hospitals
and cremation and burial grounds (eliminating names previously counted). A year
later this figure was revised to 1 773, and to 2 200 a further eight months later.
Newspapers put the total at 2 000 to 2 500, while others - social scientists, eye-
witnesses, voluntary organisation, and figures gleaned from circumstantial evidence
such as shrouds sold and cremation wood used - produced estimates between 3 000
and 15 000.

Such degrees of uncertainty concerning large numbers of deaths are not unusual in
India. There was no systematic method to certify and count accurately the dead as
they were brought to government hospitals or crematoria and burial grounds. Further,
in the first few days after the accident all available medical personnel were engaged in
treating the living.

Though government officials stuck to the figure of 1 754 deaths, in private they would
admit that they did not believe this number, and that counting errors, when rectified,
could well raise the death count to around 3 000. In response, social activists claimed
that there was a conspiracy between the Indian Government and Union Carbide to
underestimate the death toll, and though there is little evidence that this is true, it did
receive considerable currency in the months after the accident. It can certainly be
argued that the Indian Government and UCC, by not providing better information in
the immediate aftermath of the leak, lay themselves open to erosion of their
credibility.

In 1988 it was reported that two people a week in the city were still dying from the
after-effects of the accident (Jones, 1988). Within one year, it was reported, the
number of stillbirths among 10 000 women exposed to MIC had doubled, and
spontaneous abortions trebled (Kurzman, 1987).

On November 16, 1990, the State Government of Madhya Pradesh submitted to the
Supreme Court of India its completed categorisation of the claims of all of the
victims. It determined that there had been 3 828 deaths.

However, the immediate deaths were by no means the only health effects of the
accident. Some 200 000 to 300 000 people suffered health problems of various
degrees; the 1990 Madhya Pradesh State estimate was 203 500, the bulk of whom
suffered only ‘temporary injury with no disability’.

There were also suggestions of possible genetic effects of MIC. For example, Roy
and Tripathi (1985) of Banaras Hindu University did tests on crops which they said
‘showed that MIC acted as a mutagen and changed the morphology and breeding
behaviour of the plants’. They advocated destruction of all standing crops and
keeping the land fallow until after the monsoons, though this was not done.
The picture was considerably complicated by the circumstances of the accident. The
release from tank E610 occurred at an estimated 250 0C and 15 bar pressure, and in
the presence of several impurities, including chloroform. Under these circumstances
a range of toxic chemicals were produced, including aminomethane, methylurea, 1,3-
dimethylurea, trimethylurea, 1,3,5-trimethylbiuret, 1,1,3,5-tetramethylbiuret,
ammonium chloride, dione, methyl-substituted amine hydrochlorides, MIC trimer,
dimethylisocyanate, chloroform etc. (UCC, 1985). Each of these substances has its
own potential health effects.

It was also suspected that the mixture released on December 3 included hydrogen
cyanide, which is produced when pure MIC is heated to 350 0C, and at lower
temperatures if the MIC is contaminated with such chemicals as dimethylurea, dione
or MIC trimer. Either of these routes could have been available during the accident.
UCC claimed that the (average) temperature in the tank did not exceed 250 0C before
the valves ruptured, but the possibility remained of localised ‘hot spots’ within the
tank against a lower average temperature.

This matter was of considerable importance; while MIC was not at that stage a
recognised and well-understood poison, cyanide was. Proof of considerable releases
of cyanide would have made UCC liable for much more serious damages.
Furthermore, since there is an antidote for cyanide (sodium thiosulphate), unlike for
MIC, it would have caused a considerable political scandal if state and central
governments had not identified the substance at once and issued antidote to affected
communities.

There was evidence that cyanide may have been involved. Hydrogen cyanide was
found in the vicinity of the storage tanks immediately after the accident (APPEN,
1986). Discolouration of organs, cherry-red blood and oedema of the lung and brain,
all known symptoms of cyanide poisoning, were detected in some autopsies, and the
‘enlarged cyanogen pool’ theory of the health effects of MIC raised the possibility that
cyanide could still be implicated in causing health problems even if it was not
released in significant amounts in the accident.

However, the issue was never resolved (Khandekar, 1985; Weisman, 1985), and
administration of sodium thiosulphate was actively discouraged by the authorities,
despite some apparently successful use of the substance.

The lack of certain information concerning what was released during the Bhopal leak
has made it extremely difficult to make predictions based on calculated doses received
by individuals. Ongoing study of the health of individuals in Bhopal has led to the
coining of a new phrase, ‘chemically-induced AIDS’, to describe gas-induced
breakdown of the immune system, making victims especially susceptible to
tuberculosis and respiratory problems. However, in 1995 the Indian government
wound up its official monitoring programme in the city (Ghazi, 1994).

It remains the case that little is known of the long-term effects of MIC exposure, or of
exposure to many of the other chemicals which were formed and released in the
course of the leak. Furthermore, there was no real attempt to track the released
material in the environment around the plant. For example, Dr J. Kaplan, one of the
two US Government doctors from the Centres for Disease Control who went to the
area, said, ‘as far as can be determined, the cloud in India dissipated within two hours’
(JAMA, 12.4.85). The Indian Council on Medical Research was later to contradict
this suggestion. Similarly, within a few days of the accident air and water were
declared safe without any great degree of monitoring, but a report by the Nagrik
Rahat aur Punerwas Committee (2.5.85) found a high level of thiocyanate in subsoil
lakes and filtered water in Bhopal 100 days after the leak.

Since the long-term effects of radiation dominate the concerns over the Chernobyl
accident, this makes direct comparisons difficult.

Chernobyl

About 6 tonnes of highly radioactive material was released from the core of the
Chernobyl reactor. 30 people died as an ‘immediate’ result of the accident at
Chernobyl, two from falling masonry, burns etc. during the accident itself, and a
further 28 from Acute Radiation Syndrome in the following few weeks. All of these
people were on site either at the time of the explosion or in the course of the
firefighting operation which immediately followed. A further 106 cases of Acute
Radiation Syndrome (ARS) were confirmed. All of these people recovered, though a
further 14 had died by the end of 1995. The survivors have a greater likelihood of
developing cancer in the future.

There were no immediate health effects among people off site at the time of the
accident. However, many people received measurable doses of radiation as a result of
the event. It is known that high doses of radiation are associated with an increased
risk of developing cancer, after a ‘latency period’ which differs for different forms of
cancer. (Leukaemia has a latency period of 2 to 10 years, thyroid cancer of 5 years
and above, most solid cancers of at least ten years.) This evidence arises from studies
of a variety of irradiated populations, principally the survivors of the atom bombs at
Hiroshima and Nagasaki.

Below very high doses of radiation, it is assumed that this risk is independent of the
rate at which radiation exposure is experienced, i.e. that radiation is proportionately
just as dangerous in small amounts as it is in moderate. (There is no corresponding
assumption concerning MIC. In practice there is a threshold for MIC workers of 0.02
parts per million, ‘the level to which it is believed that nearly all workers may be
repeatedly exposed day after day without adverse effect’ (Kinnersly, 1973).)

However, Fishbein (1981), considering carcinogenicity in general, says ‘since there

are so few data and so many interpretations, the view is widely held that continuing
arguments over thresholds are an exercise in futility’. This may be thought to be as
applicable to radiation as it is to chemical exposures.

In any case, concern over Chernobyl has focussed on the long-term health effects of
the accident. The World Health Organisation has set up the International Project on
the Health Effects of the Chernobyl Accident (IPHECA). The results of IPHECA’s
pilot projects, reported at a WHO conference late in 1995, are as follows (WHO
(1995)):
 There has been a very significant increase in thyroid cancer in the affected areas
of Belarus, Ukraine and Russia. By the end of 1995 over 600 cases had been
identified, three of whom had died. (Thyroid cancer, fortunately, is treatable
with a high degree of success given appropriate medical facilities.) Further
excesses are expected over the next few years. Dose reconstruction exercises
have been carried out, taking into account weather conditions at the time of the
accident and the observed iodine deficiency in the local diet which will have led
an increase in uptake of radioactive iodine from the accident in the thyroids of
affected individuals. These suggest that the levels of thyroid cancers being
observed are consistent with previous understanding of the dose-response
relationship for this disease.

There is no evidence of increased levels of leukaemia among the population in

contaminated areas.

There is an apparent increase in mental retardation and behavioural problems

among children who were in the womb at the time of the accident. This is
difficult to evaluate, and attempts are being made to identify adequate cohorts of
the relevant children for examination in the three Republics.

There is no evidence of increases in solid cancers.

IPHECA is now looking at the health of the ‘liquidators’, the estimated 800 000
people who were involved, in the months and years after the accident, in liquidating
its aftermath, including shovelling highly radioactive graphite and spent fuel into the
stricken reactor from the roof of the turbine hall, and also in decontaminating
buildings and land near the reactor and burying the waste. There have been
unconfirmed reports of deaths among this population owing to the accident, but as yet
no evidence that the death rate is higher than would be expected after ten years in any
similar population of this size.

In the longer term, calculations based on (unproven) assumptions that radiation

remains equally dangerous at low dose rates as at high suggest that cancer deaths in
Europe over the next 70 years will be increased by 0.01% (Lynn et al., 1988), and in
the northern hemisphere by 0.004% (Parmentier and Nénot, 1989). The United
Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) has
calculated that the total collective radiation dose to the population of the former
Soviet Union is about 226 000 person-sieverts (UNSCEAR, 1988). Applying current
estimates of the risk of radiation-induced cancer (ICRP, 1991), it can be estimated that
11 000 to 12 000 cancers may eventually result in the former Soviet Union (30 000
worldwide). With the exception of thyroid cancers discussed above, such numbers of
extra cases would be undetectable against the ‘background rate’ of cancer deaths from
other causes.

Health Effects (2) - Psychological

A common feature of the two accidents is the level of public concern, and associated
stress-related disease, which in the case of Chernobyl have come to be referred to as
‘radiophobia’. In both cases, there was an immediate failure on the part of the state
governments, and at Bhopal on the part of UCIL, to give full information about the
accidents and their possible health effects. It is not necessary to infer any sinister
motivation for this, though a number of commentators have done so. The important
point is the effect that this had on the local populations.

Bhopal

At Bhopal, the Indian Government was seen to be underestimating the death toll, not
only among humans (see above), but also for example among animals (the official
figure of 1 047 being well below that of 2 000 which was estimated by studies ‘on the
ground’ (Indian Council of Agricultural Research, 1985)). The controversy over
cyanide exacerbated the distrust that local people felt over the accuracy of
government information.

There were considerable pressures on the ‘government’, at both state and national
level, in the immediate aftermath of the accident, complicated by the fact that
elections were scheduled for just three weeks after the accident occurred. The ruling
Congress (I) Party had to demonstrate to local people that it was their champion
against UCIL and UCC, and hence distance itself from the companies. At the same
time it had to avoid blame for allowing the accident to occur, both as a significant
(23%) stockholder in UCIL, and as the regulator of industrial practice, including
environmental and safety issues. However, Prime Minister Rajiv Gandhi, and Arjun
Singh, Chief Minister of Madhya Pradesh State, also wished to attract multinationals
into India and into Madhya Pradesh, and did not wish to take measures which would
discourage such investment.

Two tactics were used by the government to fulfil these needs. First, it took control of
all information; at one stage, for example, the direction of the wind at the time of the
accident was classified information (Nanda, 1985). In this way the answers to critical
questions about blame for the accident, suitable punishments, future actions, the
organisation of relief efforts and compensation, could be shaped to minimise blame
attaching to government agencies. Secondly, a number of individuals were identified
as being to blame, and punished accordingly. The state Minister of Labour was asked
to resign for not ensuring action was taken after a previous accident at the plant in
1981; several officials were suspended pending investigation; operators and managers
of the Bhopal plant were arrested.

On the face of it these tactics were successful. In the elections, put off until late
January 1985, the Congress (I) Party won all 239 seats in the state legislature, and 27
of the 35 seats for the national government elected by Madhya Pradesh. Presumably
this also made it easier for the Indian Government to take powers to represent all the
victims in March 1985.

However, the tight control over information, and especially information about the
health effects of MIC, made design of an appropriate response to the accident
difficult. For example, the managers of the plant who had been arrested, though
allowed to supervise making the plant safe, were prevented from talking to UCIL or to
UCC, thus preventing outside expertise from coming to the aid of the situation.
Union Carbide was less successful in avoiding public condemnation. As operator of
the plant it could not distance itself from matters, and lack of information made its
early statement to the media rather vague. Its concentration on technical, legal and
financial issues made it appear heartless in the face of great human agony.

In March 1985 the sabotage theory surfaced. This was never fully accepted even
within the company - for example, Warren B. Anderson, Chairman and Chief
Executive of UCC, said at a news conference, ‘The amount of water that got into this
tank took a while to get in there. That is why we said that it might be deliberate. I
can’t impugn malice here. I can’t say it’s an act of sabotage’ (United Press
International, 20.3.85). However, it prompted UCC to say that it ‘accepted moral but
not financial responsibility’ for the accident. The protracted legal battle (see below),
in the course of which the company tried vigorously both to have cases tried in India,
where compensation could be expected to be lower than in the USA, and to keep total
compensation below its $240 million insurance ceiling, further gave the impression
that the company was uninterested in the suffering it had ‘caused’.

Many victims continued to view Government and UCIL as being in cahoots, and also
to distrust traditionally respected groups such as doctors (who failed to distribute free
milk, for example) and lawyers (from the US and India, who descended on the area in
the hope of finding lucrative business representing victims). Shrivastava (1987) cites
examples of vernacular songs and poetry expressing such cynicism over motives.
One runs;

What did Carbide do? What did doctors do?

It murdered thousands of people. They did not give us milk.
What did the government do? What did lawyers do?
It aided the murderers. They used us as pawns.

In addition, the government took steps to stifle public complaint, for example raiding
the homes of activists the night before a major protest planned for June 25, 1985, and
breaking the demonstration up when it went ahead. Distrust of the authorities was
exacerbated by the slow progress, and poor targeting, of the government’s
compensation programme.

The overall effect was to erode trust in the small amount information that was coming
from the authorities, and to add to the stress felt by people who perceived that nobody
was taking their suffering seriously. Psychological and emotional symptoms included
sleeplessness, anxiety, loss of libido, projection of guilt, increased family violence,
and impairment of learning in children (Madhya Pradesh Chronicle, 1985). ‘People
just won’t believe anybody anymore. They won’t believe the government. They
won’t believe the doctors, and they won’t believe Union Carbide’ (Tatro, 1984).

Another manifestation of distrust, which in itself added to the psychological damage

done by the accident, was the ‘evacuation’ which accompanied ‘Operation Faith’, the
neutralisation of remaining MIC in the plant. The problem of dealing with this
material, in the other two tanks, was of some urgency, and after a review of the
options it was decided that the best way of neutralising it was to convert it into Savin
in the normal industrial process.
Some 200 000 people had already fled during the accident, though there was no
formal evacuation, it being assumed that the material would have dispersed or
hydrolysed within a few hours. A further 400 000 left during Faith on December 18
and 19, despite assurances from UCIL and from the government that the operation did
not represent a threat and that another accident was unlikely (‘Second evacuation’
Times of India 18.12.84). It is possible that the operation was interpreted by local
people as ‘starting the plant up again’. Many of the evacuees pawned or sold all their
belongings at distress prices.

Chernobyl

There was no corresponding division between ‘state’ and ‘operating utility’ in the case
of Chernobyl, and the Soviet government therefore had even less success than the
Indian in distancing itself from the accident and its consequences.

After the accident there was an initial unwillingness on the part of the authorities to
accept that such a major accident could have taken place. The reasons for this are
presumably associated with the perception among operators, managers and
government departments alike that the technology (and indeed the whole Soviet
system) was incapable of such disaster. Against such a background, levels of distrust
among the local populations when news of the accident did emerge were unsurprising.
The first indication in the West that there had been a major incident was when fallout
was detected in Sweden.

The evacuation at Chernobyl, once started, was carried out systematically and
efficiently. Evacuation of Pripyat, the ‘company town’ of 47 000 people adjacent to
the plant, only began at noon on April 27 1986, 36 hours after the accident, when the
wind changed. However, it was completed in less than four hours. By May 6
evacuation of a 30 km ‘exclusion zone’ around the plant had been undertaken. At
least 116 000 people were evacuated in the course of this exercise.

However, people were concerned at the lack of information about the accident, and
the poor quality of what information was available.

‘Locals [in the 30 km exclusion zone] describe how young soldiers banged on their
door and said, ‘Out! You have got one hour, there’s the bus, you can take only what
you can carry and no pets’. All questions were ignored. Many towards the edge of
the zone didn’t even know anything had happened. And when they arrived at their far
destinations the inhabitants there didn’t know why they had come or from where.
Things were different in Pripyat as everyone worked at the station, and in daytime on
April 26 they had flocked down the road to a bridge 1 km from the reactor and stood
watching the firework display for hours’ (Dr Eric Voice, personal communication,
1996).

Evacuation itself caused problems. According to IPHECA:

‘When people are evacuated from their homes, they often suffer considerable stress
because they do not have full information about what is going on, they undergo
disruption in community infrastructure and social interaction, and they face
uncertainty about housing and employment. Many evacuees who move to new
settlements after the Chernobyl accident were particularly depressed in their new
homes because of financial difficulties, fear of isolation, and concern for the health of
their children. The tense situation caused considerable stress which, combined with
the constant fear of health damage from the radioactive fallout, led to a rising number
of health disorders being reported to local outpatient clinics. Although the
countermeasures following the accident reduced radiation doses, they increased
tension and the upheavals resulted in significant psychological stress in the affected
population’ (WHO, 1995).

Financial Effects

The direct financial consequences of the Bhopal accident were largely limited to those
associated with immediate damage. To an extent, this derives from the fact that MIC
and the other emissions during the accident cannot be detected at very low levels in
the environment.

Estimates of business losses in the immediate area range from $8 million to $65
million (De Grazia, 1985). The closure of the plant itself, announced in April 1985,
eliminated 650 permanent jobs and about the same number of temporary jobs. These
jobs were especially important to the local economy because of UCIL’s relatively high
wage policy. The redundant workers often found it very difficult to find alternative
work, partly owing to superstitious prejudice against them.

Family economies in the slum colonies were totally disrupted by the loss of income
and the addition of financial burdens. Apart from the loss of principal wage-earners,
after the accident many women and children had died or were incapacitated, forcing
other members of the family to give up wage-earning occupations in order to do
domestic work. The proliferation of local loan sharks added to the financial
difficulties faced by local families.

The Indian Government instituted a food relief scheme which by October 1985 had
cost an estimated $13 million, though reports of corruption among officials
administering the scheme raised questions as to how much reached the victims. Soon
afterwards the programme was cut, to be replaced by a $27 million scheme to
‘beautify’ Bhopal. Most of this money was to be spent on general infrastructure, only
10% to go on health measures. These schemes formed part of a general relief effort,
including medical treatment, job-training programmes and public works projects,
which by March 1987 had cost an estimated $150 million.

The issue of personal compensation claims was a difficult and frustrating one. Before
the elections of February 1985 (which had originally been scheduled to take place in
the month of the accident) the Government promised 10 000 Rupees ($800) to
members of the families of people who had died, and 2 000 Rupees ($150) per
survivor. After the election this latter sum was reduced to 1 500 Rupees, and was
restricted to families who earned less than 500 Rupees ($40) a month. Many of these
amounts were distributed as crossed cheques in an attempt to eliminate corruption
among officials distributing the money. However, as many of those entitled to
compensation did not have bank accounts, they had to cash these cheques with
moneylenders at high discounts (Kurzman, 1987).
Initial claims against the Union Carbide Corporation in the USA ran to some $100
billion, more than ten times the value of the company. Personal injury claims were
handled by the Indian Government, which in March 1985 took powers through the
Bhopal Gas Leak Disaster Act to represent all victims of the accident. There were
also claims from UCC shareholders against the company for not informing them of
the risks involved in doing business abroad, though these were dropped when the
GAF Corporation made a hostile takeover bid for UCC in June 1985, boosting the
share value.

In estimating a financial ‘cost’ associated with Bhopal, it is necessary to place a

financial value on a lost human life, and on disability caused in an industrial accident.
In this sense the question of whether Bhopal was an ‘Indian’ or an ‘American’
accident became crucial.

The price of a lost life was likely to be adjudged much higher in the USA. Though
the Indian legal system was sophisticated (India had 230 000 lawyers, more than any
other country apart from USA), the area of tort was not well codified. Punitive
damages were almost unknown, and compensation tended to be very low. The
estimated ‘cost of a life’ after the Gujerat dam collapse in 1979 had been about $250
(in money of the day), reaching $1 800 after a train crash killed 3 000 people in 1981
(Adler, 1985).

Much higher sums could be expected under USA legal practice. A report by the Rand
Corporation (Wall Street Journal Europe, 20.5.85) estimated that the ‘worth of a life’
in the USA was about $500 000. US payment to asbestos victims, who suffered a
variety of diseases loosely comparable to those injured as a result of Bhopal, averaged
$64 000. Against this, the equivalent figures for India were taken to be $8 500 for a
lost life and $1 100 for serious injury.

Assuming 3 800 deaths and 203 000 injuries, (the Madhya Pradesh State estimates
from 1990) simple calculation yields figures of almost $15 billion for ‘human injury’
on US ‘values’ (1984 money), but little over $250 million on Indian ‘values’, the
figures being dominated by the ‘value’ put on a personal injury rather than that on a
death. (The 1995 Intergovernmental Panel on Climate Change report puts a value of
$1.5 million on the life of a US citizen, and $100 000 on that of a life in the
developing world (China).)

The meaningfulness of such figures is not clear, and is probably very limited. Indeed,
the very public discussions of such matters which continued for five years after the
accident must have added considerably to the distress of affected families, whose
perception was of being regarded as the subjects of awkward financial calculations,
rather than as individual human victims of a tragedy. Such calculations led to
protracted wrangling over where (which ‘forum’), and under what legal conditions,
the claims should be heard.

The Indian Government had in March 1985 taken on powers to act as the sole
representative of the victims in their cases against Union Carbide. For the Indian
Government there were several attractions to having the cases heard in the USA.
UCC was a majority shareholder in UCIL, and the Bhopal plant had been designed in
the USA and run by US-trained engineers. Much higher damages were likely to be
awarded by a US court than in India. UCC internationally had assets of some $9 or
$10 billion, while UCIL’s assets stood at less than $200 million, much reducing the
scope of damages. Furthermore, US law would allow the Indian Government
considerable powers of discovery of information from UCC concerning issues such as
the known health effects of MIC and studies of the health of people after the accident.
In addition, the portrayal of the accident as an ‘American’ one would assist the Indian
Government to sidestep questions about its own role, both as regulator and as
substantial stockholder in UCIL, which would be more awkward if the accident were
to be perceived as a local one.

In August 1985 UCC filed for dismissal of the suits in the USA, on the grounds that it
was an inappropriate forum for the litigation. The event had occurred in India and
most of the material evidence, witnesses and victims were in India. UCIL was an
independent company, not controlled by UCC despite its majority stockholding.

However, Judge John Keenan, appointed by the Reagan administration to rule on the
matter, allowed partial discovery to the Indian Government before deciding the forum
issue, as a result of which it was claimed that UCC, rather than UCIL, did indeed take
major decisions relating to Bhopal plant, e.g. the decision to store MIC in large tanks.

Vigorous attempts were made by both sides to reach an out of court settlement. In
1985 UCC offered first $100 million, then $230 million, a sum for which it carried
insurance. Both offers were rejected by the Indian Government. The Indian
Government also refused offers of interim payments from UCIL and UCC, e.g. $10
million in January 1986. This seems in part to have been because UCC demanded
considerable information about the immediate health effects of the accident which the
Indian Government would use in the trial, as a condition of making the money
available. There may also have been a wish not to be seen to be ‘consorting with the
devil’ at a time when for political reasons it was important for the Indian government
to be seen as quite separate from Union Carbide. In February 1986 UCC raised its
offer to $350 million. This offer was secretly accepted by US lawyers working on the
case, but was again rejected by the Indian Government.

Eventually, in May 1986, Judge Keenan decided that the cases should be heard in
India. However, he imposed three conditions on UCC; that it must agree to be bound
by Indian jurisdiction; that it must pay any damages decided by the Indian courts; and
that UCC (but not the Indian Government) would provide pre-trial disclosure under
the stricter American laws on the matter. In July 1986 UCC appealed against the last
of these conditions, arguing that both sides should face the same laws of disclosure.
Keenan’s decision represented a partial victory for both sides. For UCC, the case
would not be heard in the US against the background of higher personal injury
settlements. For the victims, all of the assets of UCC would be available for payment
of damages (though UCC divested itself of considerable assets through 1985 and
1986), and full disclosure of information would help to establish the culpability of
UCC as well as UCIL.

By the time such matters were sorted out, almost five years had passed since the
accident. In February 1989 the Supreme Court of India ordered UCC and UCIL to
pay $470 million to the Indian Government as a final settlement for claims on behalf
of the victims. UCC contributed a further $20 million towards the construction of a
hospital in 1992, selling its shares in UCIL to finance it.

Financial consequences arising from the health effects of the accident were limited to
India. It was believed that MIC hydrolysed rapidly under atmospheric conditions, and
so no attempts were made to monitor the spread of the chemical, or others released in
the accident. In addition, little was (or is) known of the long-term effects of low-level
exposure to such chemicals.

The main financial effects of Bhopal elsewhere in the world arose from higher
expenditure on plant safety and regulatory structures, obstacles to continued operation
of existing plants and establishment of new ones, and increased insurance premiums.
The perhaps ironic example of the extra $5 million spent on safety at UCC’s other
MIC manufacturing plant at Institute has been mentioned above. In the USA two
initiatives were launched by the Chemical Manufacturers’ Association; CAER
(Community Awareness and Emergency Response) and the National Chemical
Response and Information Centre (NCRIC). The Environmental Protection Agency
instituted the Chemical Emergency Preparedness Programme.

Another immediate effect of the Bhopal accident was the refusal of planning
permission to UCC to build a $66 million plant to manufacture industrial gases in
Livingston New Town, Lothian, in February 1985, despite unemployment rates in the
town running at 26%. When a tantalum production plant in Phuket, Thailand, which
used the highly corrosive chemical hydrogen fluoride and the radioactive compound
thorium dioxide, was burned down in June 1986 it was reported that videos
suggesting the plant could be another Bhopal or Chernobyl were circulating in the
town beforehand (Asiaweek, 6.7.86).

Available insurance coverage for toxic water sites was immediately reduced and
premiums increased, with some sites threatened with closure (Nolan, 1984).
However, even before Bhopal the chemical industry was facing difficulties in the area
of insurance, especially in the USA. In the early 80s the sudden and accidental
pollution insurance market had reduced individual companies’ coverage from $300
million to $50 million, with even this lower figure unavailable to large chemical
companies, while the environmental-impact liability insurance market had all but
evaporated, with only one major carrier, American International Group, offering such
cover by February 1985 (Jones, 1988). This may have been in response to an
increasing number of multi-million dollar verdicts against chemical companies (from
1 in 1962 to 251 in 1982 and 401 in 1984), and/or to the low pricing of such insurance
cover in the past.

Not only did prices rise, but it became increasingly difficult to get any cover for a
number of risks, forcing many companies to set up their own insurance companies to
avoid directors becoming personally liable for claims after adverse events.

Chernobyl

The direct financial consequences of the Chernobyl were more significant. Within the
FSU, it was reported that by 1990 over 200 billion roubles had been paid for direct
and indirect material losses. These included the destruction of the reactor itself, the
subsequent measures taken to make the site safe, including the construction of the
‘sarcophagus’ (Figure 4), and the abandonment of the partially completed Units 5 and
6 at Chernobyl and others around the Former Soviet Union. Another 2.5 billion
roubles were spent on compensation and concessions to victims (OECD/NEA, 1994).

However, the fact that radioactive materials, and especially caesium, can be detected
in very low quantities resulted in a number of countries taking their own measures to
reduce exposure. For example, in January 1996 in the United Kingdom some 300 000
lambs on 200 farms were still restricted owing to caesium levels in the flesh (MAFF
and Welsh Office Press Releases, 1996). Compensation to farmers in Wales, where
most of these farms were located, had reached almost £8 million ($12 million) by
1996 (Welsh Office, 15.2.96). There were restrictions on reindeer in Nordic
countries, and on fish in Sweden.

The USSR was not a signatory to the Vienna or Paris Conventions whereby all
liability for a nuclear accident is channelled through the operator. As a result
countries and companies in the West who were affected by the accident were unable
to seek recompense from the USSR. This makes a direct comparison with the costs of
Bhopal more difficult, but it is clear that the realised losses are much greater.

However, it does not seem likely that the greater cost of the Chernobyl accident
reflects a greater toll in human life or health or environmental damage. The above
analysis demonstrates that the short-term effect of Bhopal were much more severe
than those of Chernobyl, though the picture is less clear when it comes to examining
long-term effects.

Public perceptions

Despite their common role as ‘defining events’ in the campaigns against their
respective industries, Bhopal has been largely forgotten among the population of the
UK, while Chernobyl remains the subject of much public concern and media
attention, for example prompting three TV documentaries in Britain in the week of the
fifth anniversary in 1991.

It is unlikely that this difference can be explained in terms of the objective seriousness
of the two events. The demonstrable effects of Bhopal on human health are greater
than those of Chernobyl, and though long-term consequences of Chernobyl are
expected they can only be the subject of conjecture, as with certain very clear
exceptions such as thyroid cancer they will be indistinguishable from background
levels of the diseases, principally cancers, involved.
However, the following factors may be relevant.

Location

It is likely that the respective locations, and consequent media coverage, of the two
accidents were important in forming the public response to the events.

The Bhopal accident received a great deal of media attention in the USA. It was front
page news in the New York Times for two weeks (Shrivastava, 1987), and
developments were covered and analysis offered for some months, though coverage
fell after about two months (Wilkins, 1987). It became the second biggest story of
1984 after the reelection of President Reagan.

US Media coverage of the Bhopal accident tended to portray Indians, including

doctors and others working to mitigate the effects, as helpless victims of the accident,
while Americans who had gone out to help tended to be depicted as ‘powerful figures’
(people capable of doing something to improve the situation) more than twice as often
as their Indian counterparts. ‘The overall effect - which was probably unintentional -
was to portray Indians as something less than competent, responsive human beings’
(Wilkins, 1987). It was rare, for example, for the media to discuss the similarities
between the Bhopal plant and its MIC-manufacturing sister in West Virginia.

The coverage of the Chernobyl accident, on the other hand, tended to concentrate
more on similarities between the technology and the level of industrial development
of the USSR and the West. ‘Could it happen here’ was a more frequently asked
question, and there was less (though still considerable) emphasis on comparing the
technologies and organisational structures of the West and the country in question
than there had been in Bhopal.

It is unlikely that these observations alone could explain the continuing differences in
perceptions of the two events. Most obviously, they cannot explain the fact that the
media have been more interested in Chernobyl than in Bhopal for some years.
A more promising suggestion derives from the old US media adage that ‘1 000 deaths
in the Third World’ is equal to ‘100 deaths in Europe’ is equal to ‘one death in the
USA’.

Though the TV pictures of deaths at Bhopal were graphic and memorable (Wilkins,
1987), they occurred in a distant country, and of course to people of a different race to
the majority in countries like USA and UK. Further, it is possible, though this can
only be conjectured this long after the event, that the pictures of the Ethiopian drought
and famine which had become headline news around the world only two months
earlier, and had prompted the ‘Band Aid’ fund-raising movement, had to an extent
induced ‘compassion fatigue’ among the populations of the West.

Chernobyl, by contrast, happened in an ostensibly ‘developed’ country (though the

largely peasant nature of the region in which the station was sited has been described
above), and one relatively similar in racial background and in ‘customs and cultures’
to the West. The impression that something has happened to (and/or has been
perpetrated by) ‘people like us’ presumably increases newsworthiness.

Risk Perception

A further likely clue to the difference is to be found in work which has been done on
the factors which mediate between ‘real’ and ‘perceived’ risk, especially by the
Oregon researchers (Slovic et al., 1980). The application of this work to these two
accidents assumes that the key difference is that one was a nuclear accident while the
other was a chemical accident.

In essence, there are three relevant ‘factors’ in this mediation process.

First, if a risk appears to be ‘new’, ‘unknown to those exposed’, ‘not observable’ and
with ‘delayed effects’, it will be perceived as being more serious than a risk of
equivalent magnitude which appears to be ‘old’, ‘known’, ‘observable’ and with
‘immediate effects’. This is often referred to as ‘fear of the unknown’.

Both radiation and chemicals such as MIC are unfamiliar to the general public, and
generally regarded as ‘new’ risks. The end-product of a nuclear power station -
electricity - is if anything more familiar than the end-product of the Bhopal plant (a
pesticide).

However, radiation cannot be detected by human senses, whereas it seems to be

widely believed that toxic chemicals can be detected, especially by smell but also by
sight. The smells of MIC and phosgene were a familiar feature of the Bhopal plant
for workers and local people alike. The clouds which passed over Bhopal, and over
Seweso nearly a decade earlier, could be seen, and the crystalline fallout of dioxins at
Seweso was also very obvious (Fuller, 1977). (However, a number of toxic chemicals
cannot be detected in such a simple way.) Fallout from Chernobyl, by contrast, was
not observable without instruments. The fact that the fallout from a nuclear accident
may be affecting people without their knowing it adds to the perception of radiation as
a severe hazard.

It is known (by researchers and by the public) that the health effects of radiation can
often be delayed for a decade or more, while there is no clear evidence of
carcinogenicity associated with MIC. However, Wilkins (1987, p. 121) reported that
72% of (US) respondents did believe MIC caused cancer, and so the ‘delayed effect’
parameter may be common to both accidents.

The second factor refers to ‘controllability’, ‘voluntariness’ and also ‘catastrophe’. If

a risk appears to be one which is run voluntarily by affected individuals, who can
therefore control it to some degree, then it will be perceived as being less severe than
a risk of a similar magnitude which is regarded as being uncontrollable and outside
the choice of those involved.

Again, both nuclear and toxic chemical industries score badly against this parameter.
Decisions about the siting of plants, or even about whether such technologies should
be developed or not, tend to be taken at a level far removed from the local community,
or indeed sometimes from the wishes of the people of a nation as a whole.

Factor 2, however, also includes such parameters as ‘dread’ (‘fate worse than death’),
‘global catastrophe’ and ‘risk to future generations’. (Slovic’s justification for
grouping these parameters with the apparently unconnected ones of voluntariness and
controllability is that their perceptual effects are well correlated.) Here there seem to
be relevant differences between the nuclear and chemical industries.

The safety record of the nuclear power industry worldwide has been impressive.
Chernobyl is the only accident in a civil nuclear power station which has had
demonstrable radiation-induced health effects among people who were not on site at
the time. By contrast, on October 3 1985 the United States Government released a
consultant’s report stating there had been at least 6 928 chemical accidents in the US
since 1980, killing 135 and injuring 1 500 (Wilkins, 1987).
However, the image of the atom bomb (much more closely linked with nuclear power
in the public mind than in reality), and possibly of many films and other
entertainments depicting ‘nuclear war’ and other hazards of radiation, imply that a
major nuclear accident could be on a different scale from any other conceivable
industrial accident. Once this idea had become established in people’s minds, it
became difficult for them to reject it in the face of the evidence from the FSU
showing that, with the exception of thyroid cancers, no radiation-induced health
effects have been detected among the general population of the region. This
presumably created a ready market among readers and viewers, and hence within the
media themselves, for some of the more exaggerated claims about health effects of the
accident. One example was the initial reports in the British press claiming that 2 000
deaths had been caused.

‘Seeking a comparison with events outside the nuclear industry [for Chernobyl], the
press most often settled on a 1984 disaster at Bhopal, India, where a chemical cloud
had escaped from a pesticide plant. That cloud had killed outright not a few dozen
people but over two thousand, the long-term damage to the health of another ten
thousand or so was not hypothetical but visible; yet to the press and most of the
public, the Chernobyl accident seemed the more serious. That was largely because
reactor worries centred on faint but widespread radioactivity, whereas in Bhopal the
hypothetical long-term effects of dispersed chemicals for a wide population were
hardly mentioned. As an emblem of contamination, the radioactive atom remained
supreme. It was not pesticides but nuclear power that Newsweek (12.5.86) announced
to be a “bargain with the devil”’ (Weart, 1988, p 370).

Though concerns about the use of chemicals certainly go back as far as the use of gas
warfare in the First World War, and have been strengthened by books such as Rachel
Carson’s Silent Spring (1962) and events like Seweso (1976), there does not seem to
be the same image of a single catastrophic chemical event which could potentially
threaten human life on earth.

The fact that radiation is associated, at least in the popular mind, with the possibility
of genetic effects (‘mutation’), while such beliefs do not seem to be as prevalent with
environmental chemicals, brings the ‘risk to future generations’ into play.

Slovic’s third factor reflects the number of people exposed to the hazard in question.
The impression of the Bhopal accident, like car and mining accidents (much larger
causes of death than either chemical or nuclear accidents), was that one knew who the
victims were. It is believed that MIC hydrolyses quite rapidly in the environment, it
cannot be detected at very low concentrations, and there is no clear evidence of its
carcinogenicity in small amounts. Though relatively few people died at Chernobyl,
the releases of radioactive material are still detectable over a large area, and though
the likelihood of any individual, certainly outside of the FSU, developing cancer
because of exposure to such materials is extremely small, it might affect anyone.
Hence a person in the UK, say, will feel more at threat because of Chernobyl than
because of Bhopal, though in practice they may not be in any real risk from either.

Conclusions
Study of the causes and effects of the accidents at Bhopal and Chernobyl yields
remarkably similar pictures. Both involved considerable weaknesses in human,
organisational and technological weaknesses. Both occurred in plants which were
especially susceptible to violation of operating codes. Both were exacerbated by a
lack of credible information in the immediate aftermath.

The exercise points to a number areas in which further research would be fruitful.

The first refers to perceptions of the two events. Ten years after the events, the health
effects of releases from Bhopal have been much more serious than those from
Chernobyl. For example, Bhopal caused 3 800 deaths by official estimates, whereas
so far the established death toll from Chernobyl would appear to be 33.

Yet Chernobyl has had a far more long-lasting effect on public consciousness, both in
the region and in the West. While part of the explanation for this may arise from the
location of Chernobyl against that of Bhopal, part of it is undoubtedly because of
psychological factors in the perception of different risks. It seems clear that the
psychosocial effects of the Chernobyl accident vastly outweigh the effects caused
directly by radiation; this was also the case at Three Mile Island. (This being said, the
psychological detriment caused by Bhopal to the local population should not be
underestimated.)

A major question, then, is how can the psychological effects of such accidents be
minimised?

Some commentators (e.g. Shrivastava, 1987) have analysed major accidents in terms
of a plurality of stakeholders. It is argued that ‘official’ bodies such as the operators
of the installation involved and the State in its role as regulator, tend to concentrate on
objective, statistical information, which is assessed rationally rather than emotionally.
While such an approach may win the support of the scientific community and
potentially lead to apparently ‘appropriate’ responses to prevailing conditions, it can
also lead to the institutions involved appearing callous and unconcerned about the
plight of individuals, viewing people as mere elements in the statistical analysis. In
turn this can lead to the growth of mistrust of the official view among those most
affected, and therefore make it more likely that such people will believe any scare
story in circulation, or at least remain unreassured by information provided and
remedial action taken by the authorities.

Other stakeholders, principally the victims themselves and pressure groups (local,
national and international) seeking to achieve policy changes as a result of the event
in question, tend to approach events from a different frame of reference. Such groups
invest greater credibility in personal experiences and anecdotes (which of their nature
tend to be limited), and to seek to undermine trust in the official bodies.

Clearly neither of these paradigms is adequate, and in conjunction both work to

increase the level of psychological damage to the affected population. This in turn
can lead to ‘overreaction’ on the part of the authorities, often after some time delay,
creating further concern and mistrust. Ways should therefore be developed of
synthesising these frames of reference to create a ‘statistics of the individual’ which
values the widespread gathering of information while remaining sensitive of the needs
of individual victims. An essential component of this would be meaningful and public
dialogue between the two communities representing the two paradigms. Such
dialogue was conspicuously absent at both Bhopal and Chernobyl, with both ‘sides’
having to bear some of the blame for this.

Secondly, Chernobyl appears to represent an extreme case of a common human

experience. Under the rigidity of the Communist regime, operators were officially
expected to do everything ‘by the book’. In reality, however, pressure on them to ‘get
the job done’ seems to have led to routine disregard for ‘the book’, to the extent that
sections of the operating manual at Chernobyl were actually crossed out.

Ideally one would expect operators always to follow instructions precisely. However,
it seems likely that any experienced operator will become aware of possible ‘short
cuts’ which will allow the required outcome to be achieved more quickly, more
cheaply, etc.

In part the curbing of the temptation to employ such short cuts can be achieved by a
robust safety culture, as the success of the nuclear industry in the West in avoiding
major incidents demonstrates. However, it would seem absolutely essential that any
short cuts which are employed should be properly discussed with colleagues at all
levels, and ideally with the safety regulators as well. The Soviet industrial structure
seems to have made this impossible, with terminal consequences for the Chernobyl
reactor. Consideration should be given to methods of quasi-institutionalising any such
deviations from official procedures.

Thirdly, the difference in severe accident rates both between the developed world and
less developed countries including the former Communist bloc, and between the
chemical and nuclear industries, needs to be explained. Considerable human and
organisational failings were implicated in all four accidents considered above
(Bhopal, Institute, Chernobyl and Three Mile Island), implying perhaps some
technological explanation for any differences.

Had leaks of the magnitude of those occurring at Institute happened in areas as

densely populated as Bhopal it can be presumed that considerable numbers of deaths
would have resulted. The same observation cannot be made when comparing Three
Mile Island and Chernobyl. Does the key difference involve some difference between
technological standards in the developed world and those elsewhere? Or is it possible
to make nuclear technology ‘failsafe’ in a way which cannot be achieved in the
chemical industry (unless a particular process can be carried out without the storage
of significant quantities of hazardous intermediates)? Consideration of a small
number of case studies alone can do no more than raise the questions.

BIBLIOGRAPHY

Much of the information here presented about the course of the Bhopal accident has
been derived from Shrivastava, P., 1987, Bhopal - Anatomy of a Crisis, Ballinger
Publishing Company, Cambridge, Mass..
The course of the Chernobyl accident is outlined in Collier. J.G. and Davies, L.M.,
1986, Chernobyl, CEGB, Gloucester, UK; and in Ignatenko, E.I., Voznyak, V. Ya,
Kovalenko A.P. and Troitskii, S.N., 1989, Chernobyl - Events and Lessons (Questions
and Answers), Moscow Political Literature Publishing House.

Other references.

Adler, S.J., 1985, ‘Union Carbide plays hardball in court’, American Lawyer,
November 1985.
Asian Pacific Peoples’ Environment Network (APPEN), 1986, The Bhopal Tragedy -
One Year After, an
APPEN Report, Sahabat Alam, Penang, Malaysia.
Arnold, L., 1992, Windscale 1957 - Anatomy of a Nuclear Accident, MacMillan,
London.
Business Week, 1979, ‘Union Carbide: its six business strategy is tight on chemicals’,
24.9.79.
Central Water and Air Pollution Control Board, 1986, ‘Report of the Central Water
and Air Pollution Control Board (Gas leak episode at Bhopal)’ in APPEN, The Bhopal
Tragedy - One Year After (op. cit.).
De Grazia, A., 1985, A cloud over Bhopal, Kalos Foundation, Bombay.
Delhi Science Forum, 1985, Bhopal Gas Tragedy, Delhi Science Forum, Delhi.
Diamond, S., 1985, ‘The Bhopal disaster: how it happened’, New York Times, 28.1.85.
Environmental Protection Agency, 1985, Multi-Media Compliance Inspection Union
Carbide Corporation, Institute, West Virginia, EPA-RIII, Environmental Services
Division, Philadelphia.
Everest, L., 1985, Behind the Poison Cloud: Union Carbide’s Bhopal Killing, Banner,
Chicago.
Fishbein, L., 1985, ‘Overview of some aspects of quantitative risk assessment’ in
Occupational Cancer and Carcinogenesis, Hemisphere, Washington DC.
Fuller, J.G., 1977, The Poison that Fell from the Sky, Random House, New York.
Ghazi, P., 1994, ‘Bhopal struck by wave of “chemical AIDS”’, Observer, 20.11.94.
Gladwin, T.J. and Walter, I., 1985, Wall Street Journal Europe, 21.1.85.
Government of Madhya Pradesh, 1985, Bhopal Gas Tragedy, Relief and
Rehabilitation - Current Status, Government of Madhya Pradesh, Bhopal.
Hiltzik, M.A., 1985, ‘Carbide has a long history of difficulty’, Los Angeles Times,
19.8.85
Howard, H.B., 1983, ‘Efficient time use to achieve safety of processes or “How many
angels can stand on the head of a pin?”’in Loss Prevention and Safety Promotion in
the Process Industries vol. 1, Institution of Chemical Engineers Symposium Series,
London.
Indian Council of Agricultural Research, 1985, The Bhopal Disaster; Effect of MIC
Gas on Crops, Animals and Fish, Indian Council of Agricultural Research, New
Delhi.
International Commission on Radiological Protection (ICRP), 1991, ‘1990
Recommendations of the International Commission on Radiological Protection’,
Annals of the ICRP 21 no. 1-3.
International Confederation of Free Trade Unions (ICFTU), 1985, The Trade Union
Report on Bhopal, International Confederation of Free Trade Unions, Geneva.
Jones, T., 1988, Corporate Killing: Bhopals Will Happen, Free Association Books,
London.
Khandekar, S., 1985, ‘Painful indecision’, India Today, 31.1.85.
Kemeny, J.G. et al., 1981, Report of the President’s Commission on the Accident at
Three Mile Island, Pergamon Press, New York.
Kinnersly, P., 1973, The Hazards of Work: How to Fight Them, Pluto, London.
Kovalenko, A., 1989, Soviet Weekly, 19.8.89.
Kurzman, D., 1987, A Killing Wind: Inside Union Carbide and the Bhopal
Catastrophe, McGraw-Hill, New York.
Lynn, R. et al., 1988, ‘Global impact of the Chernobyl reactor accident’, Science 242.
Madhya Pradesh Chronicle, 1985, ‘Psychological effects on gas victims?’, 21.5.85.
Medico-Friends Circle, 1985, The Bhopal Accident Aftermath: An Epidemiological
and Socio-Medical Survey, Medico-Friends Circle, Bangalore, India.
Minocha A.C., 1981, ‘Changing Industrial Structure of Madhya Pradesh: 1960-1975’,
Margin 4 no. 1, pp 46-61.
Mosey, D., 1990, Reactor Accidents: Nuclear Safety and the Role of Institutional
Failure, Nuclear Engineering International Special Publications, Sutton, Surrey, UK.
Mukund, J., 1982, Action Plan - Operational Safety Survey May 1982, Union Carbide
(India) Ltd., Bhopal.
Nanda, M., 1985, ‘Secrecy was Bhopal’s real disaster’, Science for the People 17 no.
6. NEA/OECD, 1994, Liability and Compensation for Nuclear Damage: An
International Overview, OECD, Paris.
Nolan, J., 1984, ‘Bhopal likely to alter dramatically how insurance is written abroad’,
Journal of Commerce, 31.12.84.
Parmentier, N. and Nénot, J-C., 1989, ‘Radiation damage aspects of the Chernobyl
accident’, Atmospheric Environment 23.
Roy, S.K. and Tripathi, D.S., 1985, Madhya Pradesh Chronicle, 16.3.85.
SFEN, 1991, Proceedings of the International Conference ‘Nuclear Accidents and the
Future of Energy’, SFEN, Paris.
Slovic, P., Fischhoff, B. and Lichtenstein, S., 1980, ‘Facts and Fears; Understanding
Perceived Risk’ in ed. Shwing, R.C. and Al Albers, W., Societal Risk Assessment:
How Safe Is Safe Enough?, Plenum, New York.
Smyth, H.F., 1980, Current state of Knowledge about the Toxicity of Methyl
Isocyanate, unpublished paper, Mellon Institute, Carnegie-Mellon University,
Pittsburgh.
Town and Country Planning Department, 1975, Bhopal Development Plan, Municipal
Corporation, Bhopal.
Tatro, E.F., 1984, ‘Life in gas-stricken city gradually returns to normal’, Associated
Press 24.12.84.
Traves, A. 1995, University of Birmingham, personal communication.
Union Carbide Corporation, 1982, Operating Safety Survey CO/MIC/Sevin Units,
Union Carbide India Ltd, Bhopal Plant, Union Carbide Corporation, Danebury,
Conn..
Union Carbide Corporation, 1984, Annual Report, Union Carbide Corporation,
Danebury, Conn..
Union Carbide Corporation, 1985, Bhopal Methyl Isocyanate Investigation Team
Report, Union Carbide Corporation, Danebury, Conn..
Union Carbide Corporation, 1994, Bhopal Chronology, Union Carbide Corporation,
Danebury, Conn..
United Nations Scientific Committee on the Effects of Atomic Radiation
(UNSCEAR), 1988, Sources, Effects and Risks of Ionising Radiation, United Nations,
New York.
U.S. District Court, Southern District of New York, 1985, Memorandum of law in
opposition to Union Carbide Corporation’s Motion to dismiss these actions on the
grounds of forum and non convenience, MDL Docket no. 626 Misc., No. 21-38 (JFK)
85 Civ. 2696 (JFK).
Varadarajan, S., et al., 1985, Report on Scientific Studies in the Factors Related to
Bhopal Toxic Gas Leakage, Council of Scientific and Industrial Research, New Delhi.
Weart, S.R., 1988, Nuclear Fear - a History of Images, Harvard University Press.
Weisman, S., 1985, ‘Doctors in India disagree on drug’, New York Times, 10.4.85.
Wilkins, L., 1987, Shared Vulnerability - the Media and American Perceptions of the
Bhopal Disaster, Greenwood Press, Westport, Conn..
World Environment Centre, 1984, The World Environment Handbook, World
Environment Centre, New York.
World Health Organisation, 1995, Health Consequences of the Chernobyl Accident -
results of the IPHECA pilot projects and related national programmes (Summary
Report), World Health Organisation, Geneva.