University of Colorado Denver
The disaster in Bhopal, India presents a case more horrifying than any fiction writer could have imagined. Shortly after midnight on December 3, 1984, a storage tank at a Union Carbide pesticide factory in Bhopal began to leak methyl isocyanate gas (MIC). A runaway chemical reaction was underway in the tank—a reaction that would cause over 40 tons of lethal gas to shoot into the atmosphere around the plant. As the poisonous gas enveloped the densely populated city, a tragedy unparalleled in industrial history began. People began to die, especially throughout the shanty settlements that bordered the Union Carbide plant. No alarms sounded from the Union Carbide plant, and city residents—even those living in the shadow of the plant—had not been forewarned about the toxic chemicals stored, used and manufactured at the plant. No public address system advised Bhopal residents what to do. They ran away from the Union Carbide plant, but unknowingly followed the path of the lethal plume, which would eventually cover over 15 square miles (Everest 1985).
By morning, bodies were found in homes, streets, in the countryside and at local hospitals. In the span of a few days, 3,787 people would die in the world’s worst industrial disaster, later described by the Indian government as a “holocaust” and by others simply as the “night of the gas” (Hanna, Morehouse, Sarangi 2005). Within a few years, roughly 4,000 more deaths were directly attributed to the leak, according to the Bhopal Gas Tragedy Relief Department. By 2003, over 15,000 death claims had been processed by the Indian government, noting the cause of death due to that one night’s exposure. Some estimates suggested that many more residents died from the night of the gas, perhaps as many as 30,000, but were not accounted for in government records. An estimated 200,000 people were injured, and by the official reckoning, 578,000 people were affected in some way by the catastrophe (Waldman 2002). Many of these survivors would face a horrifying catalog of debilitating symptoms caused from exposure to the deadly poison, including impaired vision or blindness, respiratory illness, neurological issues, depression, and birth defects. The tragedy disproportionately affected the poor who lived around the plant—who had limited resources to recover from the health and economic costs of the catastrophe. And the tragedy continues, as the toxic remains of the pesticide factory have yet to be cleaned up, contaminating groundwater—the only source of drinking water supply for many in Bhopal (Sengupta 2008). By any measure, Bhopal is a tragedy—the enormity of which is hard to fathom.
“Normal” accident or environmental villainy
Tragedies occur and always will, especially in our high-tech, fossil fuel and chemical-driven society. After all, one might argue: accidents happen. Charles Perrow (1984; 1999) argued that complex enterprises engaged in high risk activities will always have catastrophic potential. Accidents in these complicated systems should be expected, and are therefore “normal.” Because of the system's interactive complexity and tight coupling events quickly surge out of control, creating a cataclysmic outcome.
While the “normal accident” framework focuses largely on technological systems and processes employed by organizations, what is the role of humans involved in operating these systems? Why do organizations depart from their own goals, act in unethical ways that harm the public, or engage in criminal conduct? The answers to these questions focus research on organizational culture and the intent of individuals responsible for the organization, as well as external pressures on the organization. Failures in complex systems should be understood within an organizational context and also within the political, economic, societal and cultural situation in which they operate (Perrow 1999; Reason 1990; Shrivastava 1994; Vaughan 1999).
Many advocates of environmental regulation point to this economic maxim that businesses (and people) act in their own self-interest. With an eye toward their bottom line, in the absence of sanctions, businesses will ignore or disregard environmental consequences of their activities, preferring to exclude the costs of pollution from the cost of production. Laws such as the Clean Air Act and Clean Water Act were designed in part to force the costs of pollution into the cost of doing business. Laws establish permitting requirements and emission limitations, followed by regulatory standards set by the states and the EPA. This is a way of accounting for the otherwise predictable behavior of businesses and individuals to be rational actors (Reagan 1987). Absent regulation, businesses have little or no incentive to control pollution or to use natural resources efficiently. On the other hand, many businesses are increasingly willing to go beyond legal compliance, generating calls for newer, more collaborative forms of regulation (Fiorino 2006).
Even with regulation, companies may engage in a compliance calculus. “Command and control” systems such as those found in most major U.S. environmental laws work best as long as the regulations have a reasonable expectation of being implemented, and businesses sense that either on-site inspections or self-reporting requirements could lead to sanctions. If company executives perceive a small probability that they will be caught violating regulatory requirements, they may choose to ignore them. The extent to which they are willing to engage in illegal behavior or criminal misconduct may, in part, be explained by this kind of compliance calculation.
However, this does not fully address why large, highly-profitable companies engage in misconduct. Struggling companies on the brink of failure arguably have a much stronger incentive to cut corners due to competition and the desire to survive. Well-heeled corporations with healthy balance sheets, on the other hand, are the ones that are best able to include the costs of complying with environmental and/or safety regulations into their costs of doing business. They should, therefore, be less likely to misbehave. But that is not always the case. Tyco, Enron and WorldCom were darlings of Wall Street whose executives committed crimes or were indicted for fraud in 2001 and 2002. So, some highly profitable companies decide to go to the “dark” side, even though they can afford to comply with safety and environmental regulations. Why? The answer to this puzzle can be found in studies of organizations, and involve organizational culture, power, structure and hubris.
Organizational culture creates the “rules of the road” for organizations. Culture helps determine whether employees feel that the organization is sincerely interested in complying with regulations, protecting the environment, or putting the health and safety of its workers first. Alternatively, culture can create the space into which normalization of deviance, or routine nonconformity, is accepted, and even encouraged (Vaughan 1996; 1999). For example, the Challenger disaster was caused by both a technical problem (the failure of the O-rings to seat properly in low temperatures) and an organizational culture problem, where engineers were aware that voicing concerns was not tolerated in an atmosphere where getting the shuttle launched was highest priority (Vaughan 1996; Heimann 1993).
When top-level managers suggest to workers that safety and environmental regulations are overblown or costly, it establishes an expected kind of conduct from front-line personnel. So, too, does internal performance pressures to deliver products and services as quickly and efficiently as possible. In turn, this may affect individual actions and foster the development of an internal culture that implicitly supports achieving organizational goals illegitimately. Such expectations are unlikely to support worker positions that run contrary to the organizational way of thinking. Ultimately, top administrators may place performance pressures on staff indirectly, by establishing out-of-reach goals or not providing sufficient resources necessary to attain goals, or directly by setting a climate that supports misconduct as a way of reaching the goals of the organization. Either kind of pressure (or both) sets the tone for an organization to shift to the dark side. Reason (1990) noted that the most grievous errors in high-technology enterprises come not from the front-line operators but from the “blunt end” of the system, that is to say, high-level decision makers. He went on to suggest that the further these individuals are from front-line activities and potential accidents, the greater their potential danger to the system.
Nor are they immune to the external pressures of an organization, including the high expectations placed on them. Mishina et al (2010) found that high-performing, prominent companies may be more likely to turn to illegal activity, because the market has ever-increasing expectations on the future returns of the company. The prospect of poor future relative performance may compel high performing firms to engage in illegal activities in order to maintain their prominence in American and international business venues.
In sum, accidents and tragedies are part of the human experience. Unanticipated consequences are woven into our societal fabric, and we should expect that bad things will happen, especially in complex systems and high-risk enterprises. At the same time, it is appropriate to consider the values, intent, use of power, and external motivations that individuals inside of organizations bring to their organizations. Exploring the culture and power permeating an organization may help us understand the difference between normal accidents and accidents waiting to happen.
Bhopal as a case of environmental villainy
Who is to blame for this “Hiroshima of the chemical industry,” as it was later described by the Citizens Commission on Bhopal? (Morehouse and Subramaniam 1986). Was this an unavoidable accident that could have happened to any pesticides manufacturer anywhere? From the beginning of the investigations surrounding the tragedy, Union Carbide has steadfastly maintained that the processes and procedures it mandated for the Bhopal plant were sound and safe. Warren Anderson, CEO for Union Carbide, observed shortly after the accident that the Bhopal plant had the same safety procedures as at any other Carbide facility. Thus, according to Union Carbide, corporate practices were not at fault. The company’s official explanation was that a disgruntled employee committed sabotage. This saboteur, never identified by Union Carbide, knew enough about the process to infuse water into the storage tank, subsequently prompting a deadly release of gas. From this point of view, the “night of the gas” in Bhopal is best described as an act of sabotage in a complex system, and largely outside of company control, thus absolving the corporation from moral responsibility and leaving any legal responsibility to be determined by the courts. In other words, this was a “normal” accident within a tightly coupled, complex, high-risk system.
Was there villainous culpability on the part of the parent company, Union Carbide? For this to be the case, one would look for a chain of bad decisions, most of which were made with a lack of regard for on-the-ground safety or environmental protection. To put it another way—one could look at the extent to which management practices at Union Carbide consistently deviated from acceptable business practices and embrace riskier operations. Moreover, villainy might be present in the attitudes of key decision makers at Union Carbide. One might look to the extent to which the company was willing to ignore its own safety standards regarding the treatment and storage of dangerous chemicals, assuming that any accidents could be controlled. Bravado about the invulnerability of the company to serious accidents, coupled with the patent disregard for safety systems or the environment would set the conditions for villainy to occur. The next paragraphs briefly overview the factors that suggest this was not a normal accident.
As one of the first U.S. companies in India, Union Carbide had an early and powerful presence. When it established Union Carbide India Limited (UCIL) in 1934, Indian government welcomed the new business. In the 1960’s India’s Green Revolution prompted high demand for fertilizers and pesticides, and Union Carbide took this opportunity to build a pesticides plant in Bhopal. However, as the market for pesticides declined in the late 1970s, Union Carbide decided to cut costs at the Bhopal plant by reducing the O&M staff by half, placing a heavy reliance inexperienced operators and supervisors, and shutting down the refrigeration unit. (The refrigeration unit may have been able to contain the exothermic reaction in the tank.)
These cost-cutting measures resulted in warnings that should have been heeded by Carbide. No fewer than five chemical accidents at the Bhopal plant occurred in the three years before that fateful night. On December 25, 1981, a leak of phosgene gas killed one worker. Less than two weeks later, 25 workers were hospitalized as a result of another leak at the plant. A MIC leak affected 18 workers in February 1982. Perhaps most villainous, instead of taking a hard look at the cause of these leaks, the company responded by turning off the alarm systems in order to not unduly concern the public or its workers.
In April 1982, UCIL expressed concerns about the on-going issues with leaks at the plant to Union Carbide. Union Carbide responded by sending U.S. experts to the UCIL plant to conduct an audit in May 1982. The team identified a host of issues, including 30 leaking valves, nearly half of which were located in the MIC and phosgene units (Hanna, Morehouse and Sarangi 2005). Despite this adverse audit, no safety improvements were made (Reason 1990). During the night of the gas, safety devices such as the flare tower, scrubber and water sprays were inadequate or nonfunctional. This despite the fact that the plant was located in a densely populated area, and stored the deadly components of its Temik and Sevin pesticides in quantities ten times larger than that at any other Carbide facility. Facing unprofitability, Union Carbide decided to close its Bhopal facility in November 1984, just one month before the deadly explosion. Based upon a litany of poor response to known safety issues, Bhopal was a tragedy waiting to happen. As Perrow notes, accidents may be commonplace, but disasters are hard to arrange (1999, p. 360).
If evidence suggests Union Carbide executives had gone to the dark side, others are also responsible. Union Carbide argued that the tragedy rests solely with UCIL, the Union Carbide subsidiary that operated the plant in Bhopal. Certainly, the plant managers were in the best position to oversee what was happening in the production lines. UCIL, not surprisingly, maintained that primary responsibility for the accident rested with Union Carbide. After all, the design of the plant, the decisions made at the plant regarding storage of deadly chemicals, and the decisions to minimize costs by reducing the number and sophistication of employees were all products of the corporate office. Moreover, Union Carbide owned the controlling stake in its subsidiary (50.9 percent), and therefore controlled the culture at the plant, if not the daily operations.
The Indian government, in its desire to attract multinational corporations, was willing to locate a pesticides plant in an urban area with little regulatory oversight. Local municipal officials initially rejected Union Carbide’s plans to install the MIC production unit in an area zoned for light industry and commercial activity, but Madhya Pradesh state officials intervened on behalf of the company. The rapid growth of Bhopal with haphazard industrialization and urbanization policies of the state government created a situation where thousands of poor people lived legally around the Carbide facility.
Aftermath and conclusions
The aftermath of the tragedy resulted in years of litigation. Union Carbide settled with the Indian government for $470 million in 1989. This amounted to a settlement for victims of about $1,000 for every life lost and $600 for debilitating injuries. It took decades for criminal charges to be brought against eight UCIL executives. The case was decided in 2010, and seven executives were given two-year sentences and fined $2,100 after the court reduced charges from culpable homicide to negligence. UCIL was fined $10,600. After public outcry over the reduced charges, the Indian government announced additional compensation packages for victims of $163 million.
India’s Supreme Court agreed to reconsider the reduced charges against UCIL executives later in 2010, but dismissed the petition in 2011 saying that the material presented did not rise to a charge of homicide. Warren Anderson left the country under government escort in the days following the accident and has to this day refused to obey the summons of the Bhopal court to answer charges of culpable homicide. As of 2012, requests to extradite him to face criminal charges have not been honored by the U.S. government.
Meanwhile, the tragedy continues. Union Carbide made little effort to clean up the facility after the accident, and the government of Madhya Pradesh took over running the site in 1998. In 2001, Dow Chemical acquired Union Carbide as a wholly-owned subsidiary. Dow has resisted calls to remove toxic materials on-site or to clean contaminated ground water, suggesting that victims look to the state government to clean-up the site. As of 2008, 390 metric tons of waste was at the defunct site awaiting safe disposal, the solution to which has not been found by the Indian government. In 2010, India’s attorney general Goolam Vahanvati asked the country’s Supreme Court to force Dow Chemical to pay $1.1 billion to compensate Bhopal victims. Meanwhile, the families of victims organized and continue to fight for what they believe is just compensation and to clean up the site. On the 27th anniversary of the “night of the gas” (December 3, 2011), protests during a “rail roko” led to 17 arrests. In 2012, Dow’s involvement as a sponsor of the Olympic Games in London prompted protests and a formal demand by India’s Olympic body to remove Dow as a sponsor of the London games.
After Bhopal, both the U.S. and Indian governments passed new environmental laws. Nine “Bhopal” bills were introduced in the Congress in the six months after the tragedy. The U.S. passed the Emergency Planning and Community Right to Know Act as part of the reauthorization of Superfund in 1986. The Indian government passed the Environmental Protection Act in the same year.
Some accidents reach crisis proportions. Following Shrivastava (1987; 1994), industrial crises have three characteristics. First, their scope expands beyond the triggering event to disrupt political, economic and community processes. Second, industrial crises bring about changes in technological, organizational and societal systems. Finally, industrial crises prompt urgent responses to mitigate harm, provide for long-term recovery and prevent, to the extent possible, similar future crises. Thus, industrial crises have the magnitude to change policies, laws, regulations and business practices in a way that simple accidents do not. Bhopal was, and continues to be, the epitome of an industrial crisis.
Opportunities for additional research abound. Further exploration into the cause of crises and resultant policy responses is warranted, as is the legacy effects of industrial crises on citizens, communities, governments and culpable organizations (Birkland 2004 and 2006; also see the WOPPR workshop on the meaning and implications of crises on policy processes, June 2011).
Bhopal Gas Tragedy Relief and Rehabilitation Department, Bhopal, Madhya Pradesh. “Profile.” http://www.mp.gov.in/bgtrrdmp/profile.htm May 5, 2010. Accessed 10/4/2010.
Birkland,Thomas A. “Learning and Policy Improvement after Disaster: The Case of Aviation Security.” American Behavioral Scientist, 48, no. 3 (2004): 341-364.
Birkland, Thomas A. Lessons of Disaster: Policy Change after Catastrophic Events. Washington: Georgetown University Press, 2006.
Everest, Larry. Behind the Poison Cloud: Union Carbide’s Bhopal Massacre. Chicago: Banner Press, 1985.
Fiorino, Daniel J. The New Environmental Regulation. Cambridge, Mass: MIT Press, 2006.
Hanna, Bridget, Ward Morehouse, and Satinath Sarangi. The Bhopal Reader: Remembering Twenty Years Of The World's Worst Industrial Disaster. New York: Apex Press, 2005.
Heimann, C. F. Larry, “Understanding the Challenger Disaster: Organizational Structure and the Design of Reliable Systems,” The American Political Science Review Vol. 87, no. 2 (1993): 421-435.
Mazmanian, Daniel and Paul Sabatier. Implementation and Public Policy. Glenview, IL: Scott Foresman and Co, 1983.
McKendall, M.A. and J.A. Wagner, “Motive, Opportunity, Choice, and Corporate Illegality,” Organization Science 8 (1997): 624–647.
Mishina,Yuri, Bernadine J. Dykes, Emily S. Block and Timothy Pollock. “Why "Good" Firms Do Bad Things: The Effects Of High Aspirations, High Expectations, And Prominence On The Incidence Of Corporate Illegality,” Academy Of Management Journal, Vol. 53, no. 4 (2010): 701-722.
Morehouse, Ward and M. Arun Subramaniam. The Bhopal Tragedy: What Really Happened and What it Means for American Workers and Communities at Risk. Preliminary Report for the Citizens Commission on Bhopal. New York: Council on International and Public Affairs, 1986.
Perrow, Charles. Normal Accidents: Living with High-Risk Technologies, New York: Basic Books, 1984.
Perrow, Charles. Normal Accidents: Living with High-Risk Technologies, Updated Edition, Princeton University Press, 1999.
Reagan, Michael D. Regulation: the Politics of Policy. Boston: Little, Brown and Company, 1987.
Reason, James. Human Error. Cambridge, UK: Cambridge University Press, 1990.
Sengupta, Sominin. “Decades Later, Toxic Sludge Torments Bhopal,” New York Times, July 7, 2008.
http://www.nytimes.com/2008/07/07/world/asia/07bhopal.html. Accessed on October 4, 2010.
Shrivastava, Paul. Bhopal: Anatomy of a Crisis, Cambridge, Mass: Ballinger, 1987.
Shrivastava, Paul. “Societal Contradictions and Industrial Crises,” in Learning from Disaster: Risk Management after Bhopal, ed. Sheila Jasanoff (Philadelphia: Univ. of Pennsylvania Press, 1994):248-267.
Vaughan, Diane. “The Dark Side of Organizations: Mistake, Misconduct, and Disaster,” Annual Review of Sociology 25 (1999): 271-305.
Vaughan, Diane. The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA, University of Chicago Press: Chicago, 1996.
Waldman, Amy. “Bhopal Seethes, Pained and Poor 18 Years Later,” New York Times, September 21, 2002. http://www.nytimes.com/2002/09/21/world/bhopal-seethes-pained-and-poor-18-years-later.html?fta=y. Accessed July 12, 2010.