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2 Bhopal and Chemical Process Safety INTRODUCTION No discussion of inherent safety processes (ISPs), process safety manage - ment (PSM), and methyl isocyanate (MIC) is complete without a discussion of the history and legacy of the Bhopal incident and the lessons learned. In what has been described by many as the “world’s worst industrial disaster”, over 40 tons of MIC was released at a Union Carbide India Limited (UCIL) plant in Bhopal, India on December 2, 1984 (Dhara and Dhara, 2002; Broughton, 2005). Much has been written on the disaster, and this report does not endeavor to repeat or evaluate that work but rather to provide an overview of the event and a discussion of the key lessons of process safety learned from the disaster as necessary con - text for the report. Chapter 3 discusses the use of MIC at the Bayer CropScience facility in Institute, West Virginia. METHYL ISOCYANATE The UCIL facility in Bhopal, India was a manufacturing facility for carba- mate pesticides that had a design similar to the plant in Institute, West Virginia, and it had been manufacturing MIC on site since 1980. As an intermediate step to the production of these pesticides, the facility stored a large quantity of MIC on site, although it was not actively manufacturing the material at the time of the incident. MIC itself is a volatile, colorless liquid with a pungent odor. It is extremely flammable, potentially explosive when mixed with air, and reacts exo- thermically with water to form methylamine and carbon dioxide. The liquid and vapor are toxic when inhaled, ingested, and if eyes or skin are exposed. Its vapor 31

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32 USE AND STORAGE OF METHYL ISOCYANATE (MIC) AT BAYER CROPSCIENCE pressure is high at 54 kPa at 20oC, its boiling point is 39oC, and the vapor density is greater than that of air, meaning that the liquid volatilizes readily and the vapor will stay near ground level. When stored, the liquid is kept between –10°C and 0°C in order to maintain a low vapor pressure and to prevent exothermic self-polymerization. THE BHOPAL DISASTER On the night of the incident, December 2, 1984, at 11:00 p.m. local time, while many of the Bhopal residents were asleep, it was reported that a plant operator noticed a small MIC gas leak and increased gas pressure inside a stor- age tank. This leak and pressure were due to water that had entered the storage vessel. At the time, critical refrigeration for the storage system had been moved to another area in the plant, and without refrigeration to slow the reaction of MIC with water, the temperature and pressure rapidly rose within the storage vessel. As the temperature rose, the MIC began to self-polymerize, adding to the heat and pressure. The vapor was first routed to a scrubber for the vent gas that should have neutralized at least some portion of the vapor, but this unit was not active. 1 The vapor should then have passed to a flare tower to be destroyed, but the tower was out of service for maintenance because of pipe corrosion. Shortly after midnight, a safety valve opened, sending a MIC gas plume into the air (Broughton, 2005). An emergency water curtain intended to react with the MIC in case of such a release was not designed to manage a release of that scale and was also suffering from corrosion, which likely reduced its efficacy. More than 40 tons of MIC was released into the impoverished commu- nity that surrounded the facility. As the plume traveled through the area, the severe acute irritant effects caused residents living nearby to become disoriented and anxious. In their attempt to escape from the chemical, residents ran out of their homes directly into the gas cloud, which resulted in increased exposure to the chemical. Reportedly, close to 3,800 residents were killed immediately. Thousands more, with estimates of up to 100,000-200,000 people in and sur- rounding that community, have experienced significant morbidity and mortality, including being partially or totally disabled, and experiencing premature death (Andersson et al., 1990; Beckett, 1998; Hood, 2004; Broughton, 2005; Mishra et al., 2009). From reports on the event, it is clear that the Bhopal facility was operating with reduced safety standards and equipment. Specifically, the unavailability of the refrigeration, scrubber, flare tower, and water curtain, led Broughton (2005) to conclude that the Bhopal facility operated with “safety equipment and proce - 1 The caustic in the scrubber was warm the next morning, indicating that some of the MIC could have actually reacted with the system despite being offline, but it was not sufficient to control the release.

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33 BHOPAL AND CHEMICAL PROCESS SAFETY dures well below the safety standards found at its sister plant in Institute, West Virginia”; and “the local government, although aware of some of the safety prob - lems”, was reluctant to enforce stronger safety and air pollution standards for fear of losing a large employer. Multiple reports on the incident (ICFTU-ICEF, 1985; Shrivastava, 1987; Broughton, 2005; Mannan, 2005) have identified root causes for the disaster that are tied to human and management factors in addition to the technical factors described above. Specific concerns include a lack of responsive- ness to safety concerns identified during inspections, poor management of change in response to new procedures, reduced staffing on site and high turnover among employees, and deficiencies in equipment maintenance and operation, including emergency equipment and procedures. RISKS ASSOCIATED WITH MIC The health risks of MIC exposure involve injuries to the ocular, respira- tory, gastrointestinal, reproductive, and nervous systems (Beckett, 1998; Dhara and Dhara, 2002; Broughton, 2005). Autopsies performed on 300 victims of the disaster showed lesions that were severely necrotized on the upper respiratory tract lining, the lung capillaries, alveoli, and bronchioles. In addition, the autopsies revealed edematous and enlarged lungs, hemorrhages, bronchopneumonia, and acute bronchiolitis (Dhara, 2000; Broughton, 2005). The acute health effects, par- ticularly those reported and observed in residents 0 to 6 months after the Bhopal disaster, were primarily injuries from the intensely irritating effect of MIC on the cornea and included severe ocular burning, persistent watery eyes, pain, ulcers, and photophobia. Lesions related to respiratory tract toxicity were seen in both the upper and lower respiratory tracts, and included chest pain and pulmonary distress, pneumonitis, pulmonary edema, and pneumothorax. Gastrointestinal problems included persistent diarrhea and persistent abdominal pain (Dhara and Dhara, 2002; Broughton, 2005). Genetic health effects included increased chromosomal abnormalities. Acute psychological health effects included neuroses, anxiety, and adjustment reactions; and acute neurobehavioral effects reported and observed were impaired audio and visual memory, psychomotor coordination, reasoning and spatial coordination (Broughton, 2005). Chronic and long-term health risks of MIC exposure, particularly 1 to 25 years after the Bhopal incident, also involved injuries to the ocular, respi - ratory, and other organ systems, including reports of long-term injuries to the reproductive and nervous systems. In published reviews and clinical studies of the health effects from exposure to MIC during the early and late recovery periods of the Bhopal incident, scientists reported persistent watering of the eyes, eyelid infections, corneal opacities, chronic conjunctivitis, tear secretion deficiency, and cataracts (Andersson et al., 1990; Dhara and Dhara, 2002; Broughton, 2005; Mishra et al., 2009). Decreased lung function, restrictive and obstructive airway disease, chest pain, dyspnea, wheezing, and allergic bronchoalveolitis were also

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34 USE AND STORAGE OF METHYL ISOCYANATE (MIC) AT BAYER CROPSCIENCE identified as the chronic and long-term respiratory health symptoms related to MIC exposure (Andersson et al., 1990; Beckett, 1998; Dhara and Dhara, 2002; Broughton, 2005; Mishra et al., 2009). Long-term reproductive health risks include increased spontaneous abortions, increased perinatal and neonatal mortality, menstrual cycle alterations, decreased placental weights, and increased chromosomal alterations (Beckett et al., 1998, Dhara and Dhara 2002, Mishra et al., 2009). Neurological symptoms include depression, impaired associative learning, motor speed and precision, and muscle aches (Dhara and Dhara, 2002; Mishra et al., 2009). LESSONS FROM BHOPAL Process Safety Management Although equipment failures increased the severity of the Bhopal disaster, these failures and the poor emergency response to the incident are indicative of serious flaws in the management of the facility, and these flaws are considered a root cause of the incident. These factors will not be discussed in detail here as they have been the topic of many previous papers and reports (for example, Bowander et al., 1985; Shrivastava, 1987), but the recognition of these organizational and human factors concerns has contributed to the response of the chemical commu- nity described here. The incident served as a catalyst for the chemical industry, government, chemical engineers, professional organizations, and various stake- holders to develop and adopt stronger and improved standards and practices for chemical process safety. As described by one process safety expert: “A significant impact of Bhopal was to make everybody—corporate management, government, communities—aware of the potential magnitude of a chemical accident” (West et al., 2004). It is in this context that the widespread use and acceptance of the concept, “process safety,” and later, chemical process safety, was embraced and adopted as a standard practice in the industry. The heightened awareness resulted in new regulations for process safety; best-practices initiatives, such as Responsible Care;2 and an increased concern about the potential to export the risk as well as the benefits of technology to developing countries as the chemical industry expanded around the globe. The goal of process safety is to develop a systematic and comprehensive approach to safety that involves the proactive iden- tification, evaluation, and mitigation or prevention of chemical releases that might occur as a result of failures in the process, procedures, or equipment (Kletz, 1998). In 1990, two major developments in U.S. process safety occurred: the publication of a proposed standard from the Occupational Safety and Health 2 Responsible Care is a global program initiated by the Canadian Chemical Producers’ Associa - tion in 1985 as a voluntary, industry-driven program to support improvements in health, safety, and environmental practices in the chemical industry.

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35 BHOPAL AND CHEMICAL PROCESS SAFETY Administration (OSHA), titled “Process Safety Management of Highly Haz- ardous Chemicals,” and the passage by the U.S. Congress of the Clean Air Act Amendments (CAAA) of 1990. The CAAA provided regulatory oversight of process safety in the chemical industry to OSHA and the U.S. Environmental Protection Agency (EPA). In particular, CAAA identified 14 minimum elements that the OSHA Process Safety Management Standard must require of employers (see Box 2.1). The final PSM standard was promulgated in 1992 by OSHA and is enforced by that office in coordination with EPA. The standard emphasizes the management of hazards through a comprehensive program that integrates management technologies, practices, and procedures and includes 14 mandatory elements that correlate to the CAAA requirements (see Box 2.2). Under CAAA, EPA has responsibilities relating to the prevention of accidental release, inven - tories of chemicals, and development of risk management plans (RMP), among other things. EPA, as directed by the CAAA, established its risk management program rule requiring companies that use toxic and flammable substances to develop and submit an RMP that must be revised and resubmitted every 5 years. A third major provision of the CAAA was the creation and establishment of the U.S. Chemical Safety and Hazard Investigation Board (CSB), an independent federal agency patterned after the National Transportation and Safety Board, to investigate major chemical accidents at fixed facilities (P.L. 101-549§ 304, 104 Stat. 2576 [1990]). The Bhopal disaster also resulted in changes from within the chemical engi - neering and chemical industry communities. The American Institute of Chemical Engineers (AIChE) launched a major initiative in February 1985 to improve and bring attention to the practices of process safety (Bollinger et al., 1996). AIChE focused on becoming a resource for information about process safety, providing training and education, advancing the state of the art in process safety, and pro- moting process safety as a key industry value. An AIChE task force was formed in March 1985, and its members proposed initial objectives to establish guidelines for hazard evaluation procedures; guidelines for bulk storage, handling, and trans - portation of toxic and/or reactive materials; and good plant operating procedures and training. As a result of these objectives, the AIChE Council officially approved the establishment of the Center for Chemical Process Safety (CCPS). The CCPS was fully established as a separate organization from AIChE in September 1985, with a director, part-time staff consultants in the industry, and close to 40 charter corporate members. In 1989, CCPS outlined 12 elements of process safety man- agement in its book Guidelines for Technical Management of Process Safety, and these have been serving as the foundation for process safety programs, standards and regulations throughout the chemical industry in the United States, and around the world (Mannan, 2005). These elements are listed in Box 2.3. In the chemical process industry, managing risks through the use and imple - mentation of these program elements of process safety management and the

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36 USE AND STORAGE OF METHYL ISOCYANATE (MIC) AT BAYER CROPSCIENCE BOX 2.1 CAAA Process Safety Management Standard Requirements (P.L. 101-549§ 304, 104 Stat. 2576 [1990]) 1. Develop and maintain written safety information identifying work­ place chemical and process hazards, equipment used in the pro­ cesses, and technology used in the processes; 2. Perform a workplace hazard assessment, including, as appro­ priate, identification of potential sources of accidental releases, identification of any previous release within the facility that had a potential for catastrophic consequences in the workplace, estima­ tion of workplace effects of a range of releases, and estimation of the health and safety effects of such a range on employees; 3. Consult with employees and their representatives on the develop­ ment and conduct of hazard assessments and the development of chemical accident prevention plans and provide access to these and other records required under the standard; 4. Establish a system to respond to the workplace hazard assessment findings, which shall address prevention, mitigation, and emergency responses; 5. Review periodically the workplace hazard assessment and response system; 6. Develop and implement written operating procedures for the chem­ ical processes, including procedures for each operating phase, operating limitations, and safety and health considerations; mandated requirements of OSHA and EPA generally assumes that the chemical hazard risk already exists and is accepted. The assumption is that once the risk is accepted, it does not go away. Unless the management system is actively moni - toring company operations and taking proactive approaches to correct potential problems, the opportunity for an unwanted event to occur will manifest. The “best practice” methods for managing risks are found in the elements and components of PSM, which are widely accepted and used worldwide. Community Right-to-Know Another important regulatory impact of the Bhopal disaster was the passage of the Emergency Planning and Community Right-to-Know Act (EPCRA, also

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37 BHOPAL AND CHEMICAL PROCESS SAFETY 7. Provide written safety and operating information for employees and employee training in operating procedures, by emphasizing hazards and safe practices that must be developed and made available; 8. Ensure contractors and contract employees are provided with appropriate information and training; 9. Train and educate employees and contractors in emergency response procedures in a manner as comprehensive and effective as that required by the regulation promulgated pursuant to section 126(d) of the Superfund Amendments and Reauthorization Act; 10. Establish a quality assurance program to ensure that initial process­related equipment, maintenance materials, and spare parts are fabricated and installed consistent with design specifications; 11. Establish maintenance systems for critical process­related equip­ ment, including written procedures, employee training, appropriate inspections, and testing of such equipment to ensure ongoing mechanical integrity; 12. Conduct pre­startup safety reviews of all newly installed or modi­ fied equipment; 13. Establish and implement written procedures managing change to process chemicals, technology, equipment and facilities; and 14. Investigate every incident that results in or could have resulted in a major accident in the workplace, with any findings to be reviewed by operating personnel and modifications made, if appropriate. SOURCE: OSHA, 2000. known as SARA Title III because it is Title III of the Superfund Amendments and Reauthorization Act of 1986). This bill came about as a result of both the Bhopal disaster in 1984 and a release of aldicarb oxime that occurred at the Union Carbide plant in Institute, WV in 1985. The release in Institute resulted in the hospitalization of approximately 100 individuals, and occurred shortly after the re-start of production following a hiatus in response to the Bhopal release. EPCRA, managed by EPA, defines the community right-to-know obligations of government, industry, and Tribal authorities with respect to emergency response planning and hazardous and toxic chemicals in the area. The Act has three subtitles: Emergency Planning and Notification, Reporting Requirements, and General Provisions. Some important elements of the Act follow:

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38 USE AND STORAGE OF METHYL ISOCYANATE (MIC) AT BAYER CROPSCIENCE BOX 2.2 Elements of OSHA’s Process Safety Management Standard • Process safety information. Employers must complete a compilation of written process safety information before conducting any process haz­ ard analysis required by the standard. Process safety information must include information on the hazards of the highly hazardous chemicals used or produced by the process, information on the technology of the process, and information on the equipment in the process. • Process hazard analysis. Employers must perform an initial process hazard analysis (hazard evaluation) on all processes covered by this standard. The process hazard analysis methodology selected must be appropriate to the complexity of the process and must identify, evaluate, and control the hazards involved in the process. • Operating procedures. Employers must develop and implement writ­ ten operating procedures, consistent with the process safety information, that provide clear instructions for safely conducting activities involved in each covered process. Activities to be covered include initial startup, normal operations, temporary operations, emergency shutdown, emer­ gency operations, normal shutdown, and startup following a turnaround, or after an emergency shutdown. • Employee participation. Employers must develop a written plan of action to implement the employee participation required by PSM. Under PSM, employers must consult with employees and their representatives on the conduct and development of process hazard analyses and on the development of the other elements of process management, and they must provide to employees and their representatives access to process hazard analyses and to all other information required to be developed by the standard. • Training. Each employee presently involved in operating a process or a newly assigned process must be trained in an overview of the process and in its operating procedures. The training must include emphasis on the specific safety and health hazards of the process, emergency opera­ tions including shutdown, and other safe work practices that apply to the employee’s job tasks. • Contractors. Contract employers involved in maintenance, repair, turnaround, major renovation or specialty work, on or near covered pro­ cesses are required to train their employees to safely perform their jobs. The contract employers must document that employees received and understood training, and assure that contract employees know about potential process hazards and the work­site employer’s emergency ac­ tion plan, assure that employees follow safety rules of the facility, and

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39 BHOPAL AND CHEMICAL PROCESS SAFETY advise the work­site employer of hazards that contract work itself poses or hazards identified by contract employees. The facility employer must obtain and evaluate information regarding the contract employer’s safety performance and programs. The employer also must inform contract employers of the known potential fire, explo­ sion, or toxic release hazards related to the contractor’s work and the process; explain to contract employers the applicable provisions of the emergency action plan; develop and implement safe work practices to control the presence, entrance, and exit of contract employers and contract employees in covered process areas; evaluate periodically the performance of contract employers in fulfilling their obligations; and main­ tain a contract employee injury and illness log related to the contractor’s work in the process areas. • Pre-startup safety review. A safety review is mandatory for new facili­ ties and significantly modified work sites to confirm that the construction and equipment of a process are in accordance with design specifications; to ensure that adequate safety, operating, maintenance and emergency procedures are in place; and to ensure that process operator training has been completed. Also, for new facilities, a process hazard analysis must be performed and recommendations resolved and implemented before startup. Modified facilities must meet management­of­change requirement. • Mechanical integrity. Employers must establish and implement written procedures to maintain the ongoing integrity of process equip­ ment, including pressure vessels, piping systems, relief and vent sys­ tems, emergency shutdown systems, controls, and pumps. Employees involved in maintaining the ongoing integrity of process equipment must be trained in an overview of that process and its hazards and trained in the procedures applicable to the employee’s job tasks. • Hot work. Hot work permits must be issued for hot work operations conducted on or near a covered process. • Management of change. Employers must establish and implement written procedures to manage changes (except for “replacements in kind”) to process chemicals, technology, equipment, and procedures, and change to facilities that affect a covered process. Employees and contract employees who operate a process and maintenance must be trained in the change prior to startup of the process or the affected part of the process. • Incident investigation. PSM requires the investigation of each inci­ dent that resulted in, or could reasonably have resulted in, a catastrophic release of a highly hazardous chemical in the workplace. The investiga­ tion must be initiated as promptly as possible, but not later than 48 hours continued

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40 USE AND STORAGE OF METHYL ISOCYANATE (MIC) AT BAYER CROPSCIENCE BOX 2.2 Continued following the incident. The investigation must be by a team consisting of at least one person knowledgeable in the process involved, including a contract employee if the incident involved the work of a contractor, and other persons with appropriate knowledge and experience to investigate and analyze the incident thoroughly. • Emergency planning and response. Requires employers to develop and implement an emergency action plan. The emergency action plan must include procedures for handling small releases. • Compliance audits. Employers must certify that they have evalu­ ated compliance with the provisions of PSM at least every three years to verify that the procedures and practices developed under the standard are adequate and are being followed. The compliance audit must be con­ ducted by at least one person knowledgeable in the process and a report of the findings of the audit must be developed and documented noting deficiencies that have been corrected. The two most recent compliance audit reports must be kept on file. • Trade secrets. Employers must make available all information neces­ sary to comply with PSM to those persons responsible for compiling the process safety information, those developing the process hazard analy­ sis, those responsible for developing the operating procedures, and those performing incident investigations, emergency planning and response, and compliance audits, without regard to the possible trade secret status of such information. The employer may require from those persons to enter into confidentiality agreements not to disclose the information. SOURCE: Adapted from OSHA (2000). • the creation of local and state emergency planning committees (LEPC and SERC, respectively), • the requirement for plant operators to notify local and state officials in the event of a significant release of toxic materials, • the requirement for plant operators to report inventories of all onsite chemi- cals for which an MSDS exists to state and local officials and local fire departments, • the requirement for plant operators to submit a Toxic Release Inventory Form annually, and • the protection of “trade secrets” contingent on approval by the EPA. EPCRA, Responsible Care, and the continuing evolution of PSM systems

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41 BHOPAL AND CHEMICAL PROCESS SAFETY BOX 2.3 12 Elements of Process Safety Management Defined by CCPS 1. Accountability: Objectives and Goals 2. Process Knowledge and Documentation 3. Process Safety Review Procedures for Capital Projects 4. Process Risk Management 5. Management of Change 6. Process and Equipment Integrity 7. Human Factors 8. Training and Performance 9. Incident Investigation 10. Company Standards, Codes and Regulations 11. Audits and Corrective Actions 12. Enhancement of Process Safety Knowledge are manifestations of another, less-well-defined legacy from Bhopal: the change in community and industry perceptions of hazardous and toxic materials and the risks they pose to personnel onsite and the local population surrounding chemical facilities. The effects of the MIC release in 1984 are still felt in Bhopal, India, and by the Dow Chemical Company, which purchased the facility from Union Carbide in 2001. Within Institute, WV, it would be naive to not recognize the impact the Bhopal release had, and continues to have, on the area, and it is clear that the release and its aftermath have affected local community relationships with the current and former owners of the facility. The nature of the relationships between a chemical company and its sur- rounding community and onsite personnel can and do influence the range of busi - ness decisions that a company can make. This relationship is discussed in greater detail in Chapters 6 and 7 in the context of external factors that affect decision- making. To emphasize the importance of these relationships, the committee notes here that in 1985, the DuPont facility in LaPorte, TX actually began onsite production, although not storage, of MIC. In describing the implementation of this process, Mr. John Carberry stated that its success was due in part to the site manager’s “long standing, strong, broad community and governmental relations” and because the company recognized that it needed to, “[m]anage community and governmental relations to insure a smooth acceptance of the new process” (Carberry, 2011). To address this need, DuPont pro-actively involved the com- munity in discussions about the change in procedures at multiple points during the decision-making process. This engagement with the community was credited with creating a relationship where objections could be voiced and addressed without community protest.

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42 USE AND STORAGE OF METHYL ISOCYANATE (MIC) AT BAYER CROPSCIENCE REFERENCES Andersson, N., M. K. Ajwani, S. Mahashabde, M. K. Tiwari, M. K. Muir, V. Mehra, K. Ashiru, and C. D. Mackenzie. 1990. Delayed eye and other consequences from exposure to methyl isocyanate: 93% follow-up of exposed and unexposed cohorts in Bhopal. Br. J. Ind. Med. 47(8):553-558. Beckett, W. S. 1998. Persistent respiratory effects in survivors of the Bhopal disaster. Thorax 53(suppl. 2):S43-S46. Bollinger, R. E., D. G. Clark, R. M. Dowell, R. M. Ewbank, D. C. Henershot, W. K. Lutz, S. I. Meszaros, D. E. Park, and E. D. Wixom. 1996. Inherently Safer Chemical Processes: A Life Cycle Approach. New York: Center for Chemical Process Safety of American Institute of Chemical Engineers. Bowander, B., J. X. Kasperson, and R. E. Kasperson. 1985. “Avoiding Future Bhopals.” Environment. 27:6-13; 21-27. Broughton, E. 2005. The Bhopal disaster and its aftermath: A review. Environ. Health 4(1):6. Carberry, J. 2011.Transition to Just-in-time Production of MIC, February 9, 2011, Washington, DC. Dhara, V. R. 2000. Health effects of the Bhopal gas leak: A review. Pp. 15-67 in The Bhopal Gas Leak: Lessons from Studying the Impact of a Disaster in a Developing Nation. Ph.D. Disserta- tion, University of Massachusetts [online]. Available: https://webdrive.service.emory.edu/users/ vdhara/healtheffects/dissertation/ch2.pdf. Accessed: Sept. 27, 2011. Dhara, V. R., and R. Dhara. 2002. The Union Carbide disaster in Bhopal: A review of health effects. Arch. Environ. Health 57(5):391-404. FABIG (The Fire and Blast Information Group). 2009. Major Accidents: Bhopal [online]. Available: http://www.fabig.com/NR/rdonlyres/803AA0DA-87BF-4A60-AAD0-71D0842F3775/2603/ Bhopal.pdf. Accessed: Sept. 27, 2011. Fortun, K. 2001. P. 259 in Advocacy After Bhopal: Environmentalism, Disaster, New Global Orders. Chicago: University of Chicago Press. Hood, E. 2004. Lessons learned? Chemical plant safety since Bhopal. Environ. Health Perspect. 112(6):A352-A359. ICFTU-ICEF. 1985. The Report of the ICFTU-ICEF Mission to Study the Causes and Effects of the Methyl Isocyanate Gas Leak at the Union Carbide Pesticide Plant in Bhopal, India, on December 2-3-1984. Available: http://bhopal.bard.edu/resources/research.php?action=getfile&id=445521. Accessed: April 16, 2012. Kletz, T. A. 1998. Process Plants: A Handbook for Inherently Safer Design. Philadelphia, PA: Taylor & Francis. Mannan, S. (ed.). 2005. Lee’s Loss Prevention in the Process Industries, 3rd Edition. Oxford, UK: Elsevier Butterworth-Heinemann . Mishra, P. K., R. M. Smarth, N. Pathak, S. K. Jain, S. Banerjee, and K. K. Maudar. 2009. Bhopal gas tragedy: Review of clinical and experimental findings after 25 years. Int. J. Occup. Med. Environ. Health 22(3):193-202. OSHA (Occupational Safety and Health Administration). 2000. Process Safety Management. OSHA 3132. U.S. Department of Labor, Occupational Safety and Health Administration, Washington, DC [online]. Available: http://www.osha.gov/Publications/osha3132.html. Accessed: Feb. 14, 2012. Public Law 101-549, title III, Sec. 304, Nov. 15, 1990, 104 Stat. 2576. Shrivastava, P. 1987. P. 184 in Bhopal: Anatomy of a Crisis. Cambridge, MA: Ballinger Publishing. West, A. S., D. Hendershot, J. F. Murphy, and R. Willey. 2004. Bhopal’s Impact on the Chemical Industry, Process Safety Progress 23(4):229-230.