Case Studies

Ann Rodriguez and Viney Chadha

In this chapter we will walk through several case studies, providing detailed fact patterns that preceded a significant risk event. We will isolate possible root causes and reference key risk indicators that, if monitored, might have mitigated these events either entirely or partially. Note that for some of the cases there may not be agreement as to the definitive root cause, so there may be some interpretation of the known facts.

CASE STUDY 1: UNION CARBIDE, CHEMICAL RELEASE IN BHOPAL

On December 3, 1984, Union Carbide India Ltd (UCIL), a chemical plant in Bhopal, India, majority owned and operated by a subsidiary of Union Carbide Corporation (UCC), released 40 tons of methyl isocyanate (MIC) gas, resulting in significant loss of life immediately and over time, causing lingering and serious health impact.¹¹ Approximately 4,000 men, women and children died that first night. Estimates of those injured or disabled are as high as 400,000. Within three days, estimated fatalities had risen to between 7,000 and 10,000 people. As many as 15,000 more have reportedly died since from residual exposure. The gas affected an area of more than eight square miles populated by nearly 900,000