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Jan 29, 2024

From the India Today archives (1984)

Sayed Khan, resident of a one-room tenement in Bhopal's Jayaprakash Nagar, had

Sayed Khan, resident of a one-room tenement in Bhopal's Jayaprakash Nagar, had come home from a film show at 12:30 that night. "I'd just got into bed," he recalled, "when my eyes started to hurt, as if someone had flung chillies into a fire." He went out to investigate but he irritation got worse, and the last thing he remembers of his family, before he fled, frightened out of his wits, towards new Bhopal is all of them coughing, sputtering and vomiting.

Zaheer Ahmad, whose compact jhuggi is just across the road from the Union Carbide factory on Bhopal's outskirts, was on duty as a watchman at the military recruitment centre. When he returned shortly after 6:00, his home stood unlocked, and inside lay the bodies of his wife and two sons, 13 and 9. Only a daughter, Shabnambee, 8, and his eldest son, Raeez, 16, survived.

M.L. Garg, retired brigadier and general manager of the paper factory, Straw Products Ltd, was asleep that night when the telephone rang at 1:15 a.m. It was the factory calling to say four people had fainted. "We are suffocating, sir," the voice said. Just then, Garg recalls, his eyes began to water and he himself felt suffocated. The windows of his home were open and he soon saw a "yellowish gas" waft in. "I then realised it was a very serious matter," he said, and ordered his factory closed and evacuated.

Shezad Khan, a tanker driver aged 30, too was asleep with his wife and four young daughters in Jayaprakash Nagar which also borders the factory. "Main jaga aur ankhon mein ek dam jalan mahsoos hui, jaise ki koi nazar utaar raha ho," he said. (He awoke, his eyes smarting, as if someone had flung chillies into a fire to ward off the evil eye.) In blind panic, Shezad fled from his room. He can't explain why, but he jumped onto the first passing vehicle and was deposited some 40 kms away at Kurawal. It was the last time he saw his family alive.

Ram Sewak Piasi was luckier because he works in Bijawar near Khajuraho. The news of the gas leak from the Union Carbide plant alarmed him because he knew his brother and his family lived in Chola Kenchi next to the factory. Catching the first train to the state capital, Ram Sewak reached his brother's home 48 hours after everyone had fled from it. It took him five days to find his sister-in-law and niece in Hamidia Hospital. And he didn't learn of the fate of his brother and two nephews until the authorities pasted pictures of the unidentified dead all over the city.

The night of December 2/3, a night that Bhopal and its 700,000 citizens can never forget. A Monday of macabre death, a killer cloud of gas that silently settled on an unsuspecting city and converted a pleasant, mild winter's night into a nightmare of misery, panic, sickness and, for at least 2,500 people, babies and children, fathers and mothers, siblings and grandparents, a slow, painful, unnecessary snuffing out of life. That it was the worst ever industrial accident in history, taking an unprecedented and still uncounted death toll and leaving no fewer than 50,000 affected, was quickly dwarfed by the tidal wave of human suffering that spread quickly across the city like the poison cloud that caused it.

Methyl isocyanate (MIC) a product that few in Bhopal knew even existed, which Union Carbide, its makers, describe in their manuals as "an extremely hazardous chemical", a poison against which "stringent precautions must be observed to eliminate any possibility of human contact." Yet it was this lethal substance, a highly volatile chemical that is used by Union Carbide to manufacture pesticides, that vapourised silently into Bhopal's night air.

As people fled their homes, as hospitals overflowed with tens of thousands unable to breathe, unable to see, unable to eat, as doctors battled to contain the unending flow of the sick, as the administration reached out to restore a broken down city, as an appalled prime minister interrupted his campaign tour to investigate at first hand, as the president of Union Carbide's American owners flew into India to offer help, as the state Government ordered a judicial inquiry, as the city slowly limped back to normal, the question that nagged most persistently was, did the accident have to happen? Tragically, as the fortnight wore on, INDIA TODAY's own investigations revealed that the answer to that question was turning out to be a resounding 'No'.

The countdown to the Bhopal disaster started shortly before the change in the night shift that Sunday, December 2. About 75 of the 950 employees at the plant were on duty on the shift that was to end at 10:45 p.m. Less than half an hour before the change-over, the supervisor on duty—who was new to the MIC unit—routinely asked an operator to wash the inside of a length of piping near the MIC reactor. This is a time-consuming procedure—the pipes have to be washed out thoroughly—and because safety valves may at times leak, it is standard procedure for the maintenance department to insert a metal sheet called a slip blind near a valve to seal off the rest of the system from the tube being washed. The seeds of the Bhopal tragedy are suspected to lie in this: sources believe that the slip blind was not inserted when the operator connected the water hosepipes to the tubes he was required to wash.

The shift change a few minutes later brought a new set of operators into the plant. If, indeed, water leaked into the system and made its way to MIC storage tank 610, it would easily explain subsequent events. Only a detailed inquiry will establish why the MIC began to heat up, but it is clear that by this time, unknown to the new shift a potentially violent chemical reaction was already under way in tank 610.

The Union Carbide manual on 'Standard Operating Procedure' warns that if water leaks into the system, it "results in the evolution of a lot of gas (thereby increasing equipment pressure) and liberation of a lot of heat (thereby raising temperature)". This, in retrospect, is precisely what happened. The sequence of events, as reconstructed with approximate timings, went as follows:

* 11:00 p.m. The pressure in tank 610 is noticed to have risen from the normal 3 pounds per square inch to 10. As it happens, the pressure in neighbouring tank 611 has been increased deliberately (by injecting nitrogen into it) to move the MIC into the pesticide manufacturing unit. Consequently, the new staff pays little heed to the pressure rise in tank 610 possibly believing that this tank too has been pressurised by the earlier shift to transfer MIC to the pesticide unit.

* 11:30 p.m. The operating staff in the utility area sense a little irritation in the eyes because of a small MIC leak and ignore it because tiny leaks are not unusual. Around midnight, the operators around the MIC unit also sense the leak, and they report it to Production Assistant Shakil Ibrahim Qureshi. At the same time, the MIC control room operator reports to Qureshi that the pressure in tank 610 is high.

* 12.00 a.m. A few minutes after midnight, Qureshi and an operator check tank 610 and find that the rupture disc, a device that bursts when the pressure reaches 40 pounds per square inch, has indeed burst and the safety valve, which is the next check point, has popped.

* 00.30 a.m. The water washing the tubes is hurriedly turned off, but it is already too late to save the situation.

* 1.00 a.m. Untreated MIC vapour is seen escaping through the nozzle of the 33-metre high atmosphere vent line out into Bhopal's cool night air.

It must have been a chilling sight. Worse, it was confirmation that at least five elaborate fail-safe systems designed precisely to prevent such an occurrence had failed just when they were most needed. Not that this was unknown to the management of Union Carbide: some of the systems were under repair and had been so for some time. According to experts, the management had no business to be operating the MIC unit without at least two preventive devices in perfect working order.

The systems that failed were:

* Vent gas scrubber. From the outside, the vent gas scrubber resembles a tall metal rocket. Its function is to detoxify the lethal vapours by spraying them with a caustic soda solution. In theory, the MIC vapour would have passed through the scrubber and escaped through the vent line as relatively harmless gas. But tragically enough, it didn't happen that way.

It escaped as lethal MIC vapour because though regulations state quite clearly that the scrubber must always be functional when MIC is in the system, the unit had actually been shut down for maintenance. As it happens, even when it is under maintenance the scrubber can be turned on, but its effectiveness is reduced. Under emergency conditions, the scrubber could have neutralised over four tonnes of liquid MIC in the first 30 minutes and then, with the caustic soda solution weakened and temperature inside rising, a little less than one tonne in every subsequent half hour period. In the two hours that the MIC vapour escaped into the air, the scrubber could have accounted for seven of the 40 tonnes and shared considerable load.

According to sources, the scrubber was turned on but the caustic soda solution was already weak and in the panic the flow of fresh caustic soda solution was not turned on.

* The flare tower. A few dozen metres from the MIC unit is the flare tower, a 30-metre high pipe which is used to burn toxic gases high in the air without posing danger to people. A pilot flame is supposed to be kept lit at all times so that it can quickly ignite any gas that is fed through the flare tower. On Sunday night, one part of the piping leading to the flare tower was corroded so the flare tower too was under maintenance and unavailable to the operators to divert at least some of the escaping MIC vapour into it.

* The water curtain. The Carbide factory has an extensive network of water outlets which can shoot a jet of water some 12 to 15 metres into the air to drop like a curtain around sensitive areas where gas leaks are possible. Water "knocks down" MIC vapour to form either dimethylurea or trimethylbiuret, depending on the quantity of water. Both of these are comparatively safe. The water spouts were, indeed, operational and were turned on shortly after 1:00 a.m., but they weren't designed to reach a height of 33 metres at which the MIC was gushing into the air. They were, consequently, of no use.

* The refrigeration system. The MIC storage tanks are connected to a 30 tonne refrigeration system which uses Freon 22, which keeps the coolant, brine, at between -15C and -10C. The refrigeration system circulates the liquid MIC and keeps it down to under 15C though its ideal storage temperature is said to be 0C. At the time the MIC escaped into the air, the refrigeration system was closed. Had it been working, the MIC could have been cooled and the pressure brought down. But, as one source put it: "The refrigerant, Freon 22, had been removed for utilisation elsewhere. It couldn't have been started for hours."

* The closure of the refrigeration system was particularly appalling because the Carbide manual of 1976 on MIC itself makes clear its vital role: "...The pressure in the tank will rise rapidly if methyl isocyanate is contaminated This reaction may begin slowly, especially if there is no agitation, but it will become violent... bulk systems must be maintained at low temperature... The low temperature will not eliminate the possibility of a violent reaction, if contamination occurs. It will, however, increase the time available for detection of the reaction and safe disposal of the material before reaction reaches a dangerous speed."

* The spare tank. Of the three tanks in the unit, each with a 60-tonne capacity, one is always kept empty for contingencies such as the one on that night. Tank 610 held 40 tonnes the maximum permitted for safety reasons, tank 611, then under use, had 15 tonnes and 619 was empty as required. A pipeline did, indeed, connect 610 to 619 through a suction pump and if only the valves had been open the sheer build up of pressure and the higher level of liquid in 610 would have moved the MIC into 619. The operation of opening the valves, according to one company source, would have taken no more than three minutes. In the confusion, the valves weren't opened.

Had the systems been working, had the employees kept their wits about them and reacted the way they have been taught in emergency drills, most of the MIC escaping into the air could have been rendered harmless. Systems do fail, and accidents do happen, but Union Carbide's past record, even by admission of its US principles, is far from exemplary.

Last fortnight, the state government revealed that there had been at least three previous accidents, in October and December 1982 and February 1983, concerning leaking chemicals and gases. In one, Ashraf Khan, a worker, died as a result of accidental exposure to phosgene gas, another ingredient in the making of pesticide. Speaking about these accidents, Chief Secretary Brahma Swarup told INDIA TODAY that there was no pattern to them. He said: "I am quite clear that none of the earlier accidents could lead anyone to anticipate that this (the large-scale leak of MIC) would happen."

Previous accidents that came to public notice may not have indicated this, but there were other, far more ominous pointers. At a press conference last fortnight, Chairman Warren Anderson of Union Carbide in the US released a report prepared in mid-1982 by three American experts who studied the Bhopal plant's safety measures and equipment. The report was startlingly critical saying that "the plant represented either a higher potential for a serious accident or more serious consequences if an accident should occur"—words that have proved all too correct in retrospect even though it was claimed that most of the defects had been put right by June this year.

The experts' report is almost portentous in some of the lapses it points out. Among other things, it says quite clearly that:

* "Filter cleaning operations are performed without slip blinding process lines. Leaking valves could create serious exposures during this process."

* "Leaking valves have been fairly common... A considerable number of valves were replaced in March 1982 but the problem still exists though to a lesser degree. Team members observed one case in which an MIC shut off valve was leaking so severely that even evacuation of the line above the valve was not adequate to prevent MIC release when a blind flange was removed. Valve leakage would appear to be a situation that requires continuing attention and prompt correction."

* "A number of factors make the MIC feed tank at Sevin (the pesticide plant) a source of concern.... It appears that it would be possible to contaminate the tank with material from the vent gas scrubber."

* "The pressure gauge on the phosgene tank was bad, showing no pressure even though the tank was in service."

According to Anderson, the report and the accompanying recommendations were sent to the Bhopal management in September 1982 but it is a matter of controversy how far the recommendations in the report were implemented.

It isn't clear what purpose Anderson intended to serve in releasing the report. Anderson arrived in India on December 6 and was arrested the next day along with Union Carbide Chairman Keshub Mahindra and Managing Director V.P. Gokhale when they reached Bhopal. (Union Carbide's factory management had been arrested the first day after the accident.) The arrest itself was a fiasco, drawing widespread criticism since within hours Anderson had not only been freed on bail after a brief detention in the company guest house, a state plane was provided to ferry him to Delhi. "The letter and the spirit of the law have been observed," declared Chief Minister Arjun Singh after the event. But few people remained convinced, especially the Ministry of External Affairs which had earlier given assurances through the Indian Embassy in Washington that Anderson was free to visit India unimpeded.

On his return to the US, Anderson affirmed that he had been treated well, but his act in releasing the internal assessment report could well have been interpreted as passing the buck. The American chief executive has accepted responsibility for what happened in Bhopal but appeared to be trying to deflect the criticism from the US parent company to the Indian subsidiary. Since the Danbury, Connecticut-based parent owns 50.9 per cent of the Indian unit's equity, it had veto power over the policies and practices in Bhopal. Quite clearly, this authority wasn't used even in the face of the glaring lapses the Americans themselves pointed out. Worse, it is now remarkably clear that although identical in all other respects, the Indian unit lacked the computerised early warning and fail-safe systems used in the US factory.

Sources admit that in addition to all this, other practices at the factory had become lax. In 1977-78, when work on the MIC plant started, only first class B.Sc. graduates or those with a diploma in engineering were taken as operators. They were subjected to six months' theoretical training and then trained on the job. That is no longer true, and there are cases of operators without an academic science background and, what is more, they no longer have to undergo the same rigorous training as before. Some operators are matriculates from other plants or units. Worse still, the number of staff has been cut down because of financial problems. In the past there were a dozen operators in the MIC unit, three supervisors, two maintenance supervisors and a superintendent in each shift.

Today that number has been reduced to six operators on each shift and one supervisor. There is no maintenance supervisor on the night shift. Earlier, there was a separate plant superintendent on each shift for each of the two phases of the factory; now, both phases have only one plant superintendent on each shift.

Union Carbide, with its top management in detention was unable or unwilling to comment. But a former senior employee found it hard to believe that such lapses could occur in a concern believed to be as safety-minded as Union Carbide. Kamal Pareek, 35, who handled MIC over 10 years at the Bhopal plant till he left last year for a better job, says: "I just can't believe it. If, and I repeat if, the newspaper reports are correct and all the safety systems were bypassed, that is unprecedented. I find it difficult to believe that Union Carbide would ever endanger human life by compromising on safety. The whole thing is particularly stunning because the safety equipment as well as the operating staff in Bhopal was among the best in the country. How could it happen in Carbide of all places?"

The state government too gave Union Carbide a clean chit not so long ago. Confronted with doubts expressed in the state Assembly about the plant's safety the then labour minister, Tara Singh Viyogi, told the Assembly on December 21, 1982 that: "It is not as if a great danger is posed to Bhopal by the factory." Dealing with demands to remove the factory, Viyogi said: "It is a Rs 25 crore investment. It is not a small stone that can be picked from one place and put at another."

Others weren't so sanguine. Raajkumar Keswani, 34, a local journalist had done a series of reports showing the dangers posed by the factory in a Hindi weekly, Saptahik Report, that he ran for four years till the end of 1982. The reports on the Union Carbide factory, published in the issues of September 17, October 1, and October 8, 1982 carried prophetic headlines: 'Save, please save this city'; 'Bhopal on the mouth of a volcano'; and 'If you don't understand, you will be wiped out'. The weekly reports may not have received attention, but Keswani wrote a long article along the same lines in the June 16, 1984 edition of Jansatta, the Hindi daily of the Indian Express group. He says he wrote to the chief minister as well, adding: "It is not as if the Government did not know about the danger; it did not want to act."

The action, when it came, was far too late. In the early hours of Monday, December 3, even as the lethal fumes began to spread over the shanty towns of Jayaprakash Nagar and Chola Kenchi, it was still only the staff at Union Carbide that knew something was very seriously wrong. For an hour, some workers struggled to contain the damage. An INDIA TODAY correspondent who gained entry briefly into the Union Carbide factory late last week saw abandoned footwear and gas masks lying scattered near the MIC unit. He also noticed that the concrete bed in which tank 610 lay had large cracks, testifying to the violence of the reaction that occurred in it. Obviously, there had been considerable confusion in the factory at the time. A public announcement alerted all workers in the factory of the wind direction and they all fled in the opposite direction. This saved them all though production assistant Qureshi fell, broke some bones and inhaled some of the dangerous gas.

The factory has two sirens: a loud, continuous one for the public and a muted one over the public address system meant for factory workers alone. The public siren was put on around 1 a.m., but only for a few minutes, and after that the muted siren took over. This was as per Carbide procedure which was evolved to avoid alarming the public around the factory over tiny leaks. But in the present case it was gross negligence that the continuous siren was put off although it was already known by then that MIC was escaping in huge quantities. It was not until 2.00 a.m., one hour later, that the public siren was sounded once again, full blast, to alert the already terrified, injured and dying in the city.

The siren was heard by Sayed Khan as he ran away leaving his family coughing and sputtering. By the time he returned in the morning, his father, mother and two brothers were dead. Only a sister survived. Shezad Khan of Jayaprakash Nagar, who had fled in blind panic leaving his wife and four daughters to the vapours returned to find all but two girls dead. Shiv Narang, a machine operator at the Straw Products factory lost a three-month-old boy. But seven of his 12 neighbours, all of whom shared a four-room, 'L'-shaped hut, died. Among the dead were Nathu Ram Kuswa, the owner of the hut, his wife and two children. Kuswa died because he couldn't leave his wife's side: she had just delivered their second child a few hours earlier.

The gas leak became official knowledge just after 1:00 a.m. when Chahat Ram Singh, a town inspector on patrol near the factory, sent a wireless message to the police room that something had gone wrong at the factory. At 1:15, the control room told the city superintendent of police, Swaraj Puri who reached the control room just before 1:30 a.m. Puri later told INDIA TODAY that the main problem seemed to be that no one knew precisely what had happened: there was MIC in the control room but a telephone call to Union Carbide at 1.30 a.m. failed to elicit any positive information.

Bhopal Commissioner Ranjeet Singh recalls that he was rung up from the control room at about that time by a policeman who was gasping for breath. "It was Kafkaesque that night," he remembers, "people running all over, chappals and shards of glass on the road". The commissioner telephoned the director of health services, Dr M. N. Nagoo who alerted the hospitals. Some 15 minutes later, Nagoo took his son and drove off towards the old city. He had gone only 1.5 km when he ran smack into a massive exodus heading in the opposite direction. "They were running, they were in tempos, in buses - anything that could get them away from the factory", some 5 km away. He turned the car around and immediately some 40 people climbed on it, on the bonnet, inside, on the roof and in the boot. It was with the greatest difficulty that he was able to move it and head to the Jayaprakash Hospital.

Another person in considerable difficulty was Brigadier Garg of Straw Products. Having closed down the factory, Garg had the task of evacuating 176 of the factory's 1,200 workers on duty that night. Garg reached for the one source he knew he could rely on: the army. A telephone call to the sub area commander, Brigadier N. K. Maini, resulted in the despatch of several cars and closed trucks. The staff was evacuated to the military hospital—but not before 14, including Garg's personal assistant, Chacko, had died or were fatally stricken.

There was no dearth of tales of heroism. Alerted by the commissioner, the army swung into action. Major G.S. Khanuja of the Electrical and Mechanical Engineers Centre made repeated trips to the factory area setting up a continuous evacuation to the Military Hospital as well as Hamidia Hospital. Khanuja was reported to have looked for victims going from house to house - and ended up being hospitalised, suffering from exposure to MIC fumes.

At the Union Carbide plant, meanwhile, every conceivable system seems to have collapsed. The company's Bhopal chief, Works Manager J. Mukund, was told of the accident - not by a company employee but by the city's additional district magistrate. Worse, though the gas leak was confirmed by 1:00 a.m., it wasn't till 45 minutes later that he came to know of it. Why the employees did not ring him during these minutes is a mystery. According to informed sources, Carbide also had a system of walkie-talkies that can be used to inform higher management if any emergency occurs at the plant.

It is supposed to be operative round the clock but even this doesn't seem to have been used. Mukund told a reporter the same morning that the leak had been plugged within minutes of his being informed. In fact, the leak was never plugged. The MIC continued to escape into the air until all 40 tonnes had been exhausted shortly before 3.00 a.m. At about that time, a retired major who worked with a private security outfit employed by Union Carbide came to the police control room to tell them that the leak had been plugged. But according to Carbide sources, when the Central Bureau of Investigation (CBI) wanted to take a sample of MIC from tank 610 for its investigations all that it was able to get was vapour.

It wasn't just Union Carbide where systems had broken down. No administration could possibly have coped with what was happening that night. At least 1,00,000 people living in the vicinity of the factory had fled their homes. Bhopal's rudimentary public transport, even when it was pressed into service, was in no shape to cope. Said Garg: "I didn't see any official help coming that night with the exception of the army." The popular anger was fuelled by news that many ministers and officials had fled town with their families in government vehicles. Said Puri: "The anger is understandable, but the police did press into service whatever vans and trucks were available, and took people out of Bhopal. But don't forget, at that point we ourselves didn't know the nature of the gas leak."

While it is true that the magnitude of the tragedy was awesome, it nevertheless exposed the state government machinery: its centralisation, lack of initiative and collapse under stress. This was particularly evident in the first few days of the disaster. True, individuals within the administration worked themselves to their physical limits but all was on a piece-meal basis with no overall planning. The first coordination meeting of secretaries and heads of departments was called only on the night of December 4, more than 40 hours later.

Initially, the doctors didn't know quite what to do. It was a mad rush to simply keep track of what was happening and administer first aid, and dispose of the dead who were brought in increasing numbers from early that night, as one doctor recalls. Common complaints included irritation in the eyes, nausea and vomiting, chest pains, difficulty in breathing. When patients in their tens of thousands started streaming into Bhopal's hospitals one doctor said, "We are dealing with something that is quite unknown."

There was no precedent. All that is known is that MIC destroys the lung tissue leading to pulmonary oedema, or an accumulation of fluids. The victim, in effect, drowns. Dr. N.R. Bhandari, superintendent of the Hamidia Medical College and Hospital, said that if lung tissue was destroyed, death occurred in a matter of minutes. But others died of subsequent complications including anoxia, or insufficient oxygen to the blood, and cardiac arrest brought upon by the weakening of the pulmonary system.

Doctors were able to treat other symptoms—difficulty in breathing and burning eyes—using bronchodilators, steroids and eye medicines. There was no shortage of medicines, says Nagoo, because there were enough eye medicines stocked under the national programme to combat blindness. But there was a shortage of oxygen - some cylinders came from the Bharat Heavy Electricals Ltd unit and some was brought from Delhi in a pressurised AN 32 of the air force. There was a terrible shortage of hospital beds: some 50,000 patients passed through Bhopal's seven hospitals. Hamidia Medical College and Hospital pitched scores of tents to accommodate the 2,500 patients who clamoured for its 750 beds. Jayaprakash Hospital's 125 beds were unequal to the task of treating a total of 12,000 patients who passed through its doors for treatment.

And, there was a shortage of doctors. Nagoo estimates that in addition to Bhopal's 350-400 doctors and 150 interns, at least another 250 doctors came to the city from other parts of the state and country. Toxicologists and experts were sent by the World Health Organisation while the Centre despatched a high powered team led by Dr S.R. Saxena of Safdarjang Hospital. Saxena said that two irritants appeared to have been at work. "The reaction to one came within a couple of hours and to the other after a passage of 48 to 72 hours," he said. This could be medical evidence of the existence of phosgene in the MIC vapours but Saxena wouldn't comment.

But INDIA TODAY has learnt that MIC is stored to a purity of 99.5 per cent and that upto 0.1 per cent of phosgene, which was used in World War I to annihilate tens of thousands of soldiers, is permitted as an impurity. This means that if 40 tonnes of MIC vapourised that night, as much as 40 kgs of phosgene would have as well.

At a Doctors Club clinic in Chola Kenchi, one of the worst affected areas, Dr R.K. Jain said: "The complaints are changing each day." He and his team of six other volunteer doctors encountered respiratory and eye problems on the first day. Two days later it was coughing and then cough and fever and severe expectoration. A week after the accident there was blood in the sputum. "We can't predict what will happen tomorrow," he added morosely.

Dr Madan Mohan, head of the Opthalmic Centre at Delhi's All India Institute of Medical Sciences, examined some 300 to 400 patients in the two days that he was in Bhopal and felt that "there may be a visual impairment of up to 20 per cent in some of the worst cases I have seen but in none of them does blindness seem a possibility." To counter sudden widespread fears of blindness - some triggered off by the use of atrophine in treating eye disorders, a drug which causes temporary vision impairment—Madan Mohan was obliged to issue a statement.

In fact, the Bhopal accident is the first time that doctors have seen the effect of MIC on human beings. Professor Heeresh Chandra, a leading forensic expert and head of Hamidia's medicolegal institute, led a team conducting autopsies on the hundreds of corpses brought into Hamidia. Those who died on the first day had lungs two to three times their normal weight. Those brought in on the second day had pink blood. Bodies examined seven days after the accident had dark red blood and heavily congested organs. The autopsy team suffered gas poisoning and they also inhaled the gases trapped inside the bodies they had to cut open.

Five days after the accident, a relieved superintendent of the Hamidia Hospital said: "The worst is over." Doctors, dealing with a gas they didn't know, weren't sure of the long term implications.

Although the National Toxicology Programme in the United States has ruled out cancer as a result of tests carried out last year, there is scant information available on other possible diseases. "I also want an answer," says Madhya Pradesh's Director of Health Services, Dr. M.N. Nagoo, "I'm trying to collect information."

He hopes that the Indian Council for Medical Research will fund a research project to follow up the victims of the Bhopal disaster. Such a project would be costly but worthwhile. It will mean keeping tabs on more than one lakh people who live in the vicinity of the factory and who were exposed to MIC in varying degrees. They would have to be observed for anything up to five years to see what complications, if any, turn up as a result of their exposure to the gas.

A related problem was the removal of more than 1,600 animal carcasses that, two days later, still littered streets and houses and posed a real danger of an outbreak of cholera. Finally 20 dumpers and six cranes - four of them from the army and two from Bharat Heavy Electricals - were detailed to carry out this bizarre but essential task of removing 790 buffalos, 270 cows, 483 goats, 90 dogs and 23 horses. Says Laxmi Narayan, an IAS official in charge of the task: "I don't know how much a buffalo weighs but when it's dead it looks like an elephant." In fact, in the course of lifting one, the coil of one of the smaller army crane's snapped. In another instance the walls of 32 houses had to be broken because the buffalos had bloated so much they could not be pulled out through the narrow door.

Even after they were buried there was a danger of their bodies bursting, sending out the toxic gases they had inhaled. Finally the carcasses were carried five km away where 10 bulldozers made a pit 10 feet deep over more than one acre. On the advice of experts, four trucks of salt, two trucks of bleaching powder, 10 trucks of lime and half a truck of caustic soda were first emptied into and then evenly spread out in the pit before covering up the mountain of carcasses. This area is now considered safe.

Predictably, the world's worst industrial disaster is being seen by some American lawyers as potentially the biggest ever damages bonanza to have dropped into their laps. Already a clutch of them has descended on Bhopal. Leading the pack was well known trial attorney Melvin Belli who had detailed discussions with Attorney-General K. Parasaran in Delhi and Arjun Singh in Bhopal. One suit in particular has already made headlines, a US $15 billion (Rs 18,000 crore) suit for damages filed on behalf of two victims in West Virginia.

Rehman Patel, 53, a power controller in the railways, lost his wife Mehrunissa, 48, and son Farooq, 13. Sheela Bai Dawani lost her husband. Lying in a private nursing home, Patel is in a mentally troubled state though he is progressing physically after suffering severely from MIC inhalation. His elder son, Navid, a marine engineer and a daughter, Fehbida, survive. Says Navid: "We don't know who filed the case on behalf of my father." Patel was on duty from midnight on Sunday to 8:00 a.m. on Monday morning, and was found unconscious on a small grass patch outside his office at 3.30 a.m. In the railway colony of 1,700 close to the factory, as many as 73 died.

It isn't at all clear how the compensation battle will go. Union Carbide is sparing no effort to put up a stout defence and has retained the services of some of the top lawyers in the Supreme Court, including J.B. Dadachandji and Co. What is yet to be assessed is Union Carbide's criminal culpability, if any, and the damages that the victims can expect to get if the trial comes to an Indian court. A member of the Law Commission, P.M. Bakshi, says that there is no specific law or statute in India under which action for compensation can be taken. A civil suit can be filed under the law of torts (civil wrongs) but there is only case law to go by. Says he: "Civil liability including compensation is to a large extent the product of a series of judicial decisions handed down by the courts."

A class action, or a case on behalf of each and every one of those affected who wishes to associate with it, can be filed, but with the exception of aircraft or railway accidents, "the amount is normally decided by the judge on the basis of such factors as the nature of injury, the expenditure incurred in medical treatment, loss of earning capacity and the pain suffered." Middle class motor accident victims have been of late awarded damages of up to Rs 2 to 3 lakh and lawyers seem to concur that if the cases are filed in Indian courts, Indian case law—that is, previous decisions on the subject—will apply.

There is no provision for punitive damages in Indian law. Harvard Law School graduate Kapil Sibal says US courts normally grant punitive damages in accident and negligence cases to "sufficiently recompense" the individual who is wronged. Lawyers in such cases can take a "contingency fee" of up to 30 per cent of the total amount awarded in damages. But noted jurist Nani Palkhivala told INDIA TODAY that if the Bhopal cases come up for trial in US courts the main beneficiaries would be American lawyers "unless, of course, they charge only a reasonable fee and give up the rest of the damages to the actual victims of the tragedy."

Leading lawyer Frank Anthony points out that criminal charges under Sections 120 and 302 of the penal code relating to conspiracy and murder could be pressed if evidence can be obtained but it would be necessary to prove mens rea—a criminal mind—which is always a difficult proposition. He feels that Union Carbide may offer substantial out-of-court settlements to avoid the damaging publicity of a long-drawn court case.

There is speculation in the US that the company may be willing to settle at between US pound 15,000 (Rs 1.8 lakh) and pound 20,000 (Rs 2.4 lakh) each, and in spite of the presence of Belli and company, some American lawyers feel that the case will have to be heard in India, not the US. Raymond Battochi, a prominent Washington attorney, feels that if the victims and their lawyers decide not to accept the Carbide out-of-court offer, the cases can only be tried in Indian courts and Indian - not American - compensation law will apply. Battochi admits that some American lawyers will want to bring the case to the US "but the chances of them being tried in American courts are slim or none," he says. The operating principle is that the damages or injuries have to occur on American soil, to American residents or dependents of American residents. The only device that may bring the Bhopal victims to US courts is the last one which applies if dependents of any victim happen to be resident in the US.

Atul Setalvad, a leading Bombay lawyer, believes that the American parent company can be held responsible if it is proved that there was a design defect. But if it is established that the gas leaked because of poor maintenance, the parent company wouldn't be liable. And. in the Indian company, individuals working in responsible positions could be named in civil suits, but only those directly involved in the mishap would be liable in a criminal action. Setalvad feels that the company chairman could almost certainly not be held liable though others like the managing director and plant manager could possibly be named in civil suits. Those charged in a criminal case would face stringent punishment: under Section 304(A) of the penal code, causing death by a rash and negligent act, the maximum imprisonment is two years. Under Section 304, culpable homicide not amounting to murder, it is a life term.

Inevitably, next to Union Carbide, it is the state Government that has much to answer. Interviews with survivors indicate that none of them had any notion that they were living a road-width from disaster. Said one: "I did not feel concerned. If the Government permitted the factory, they must have made sure of it." It was a common reaction, and it explains why beneath the fear and anguish that characterise the popular mood in Bhopal. There is the beginnings of an anger, not just against Union Carbide, but against the local authorities as well. Says Madan Mohan Joshi, the Nai Duniya bureau chief in Bhopal, who was a long-time critic of the Union Carbide factory and whose newspaper published several critical articles about the plant's potential safety hazards: "It is the bureaucrats who are responsible for all this."

Spokesmen for the Union Carbide point out that when it came up, there was empty land all around the factory and that this was settled by jhuggi dwellers and unauthorised construction over the years with political connivance. There is a certain inevitability to such creeping urbanisation. Factories provide jobs, and workers prefer to live near their source of work. It was only in May this year that a large number of the unauthorised tenements and settlements were regularised by the Arjun Singh Government.

The real failure of urban policy in Bhopal is reflected in the Bhopal Development Plan, better known as the Master Plan for 1975-1991. The plan lists "obnoxious industries" insecticides among them and says that all such industries must be located on the north-eastern side of the city. Union Carbide was, indeed, in the correct part of the city but the plan assigned all the area around it to commercial premises and residential accommodation. Planners can hardly plead that they didn't know that toxic substances would be in use at the plant: according to one Carbide source, all drawings of the factory submitted to the various authorities in Bhopal, including the Industry Department, the town and country planning office and the municipal corporation, clearly indicated that the intention was to manufacture MIC-based pesticide.

Nor do the state authorities seem to have effectively monitored the factory's operation. After the death of Ashraf Khan in December 1982, the head of the chemistry department of a local college was asked by the Government to investigate the incident and INDIA TODAY inquiries reveal that it was indeed handed in to the Labour Department. But Labour Minister S.S. Patidar maintains that no report was submitted in the 16 months that he has been minister. Patidar says that the Government is checking the records "to see if regular inspections were carried out. If they are guilty, departmental action will be taken" against the inspectors.

The problem is that the authorities are ill-equipped to make proper inspections. The Indore-based director of industrial health and safety has two deputies, one at Indore and one at Bhopal, and only about two dozen inspectors for the whole state of Madhya Pradesh. One Carbide source says that in all his years he has never seen an inspector seriously checking the plant and machinery. "All the 'inspection' meant was signing forms that everything was all right," he said.

Chief Secretary Swarup affirms the problems, saying that state governments are not equipped to formulate regulations and carry out proper inspections. Environmental boards deal with various aspects of air pollution and do, indeed, monitor coal dust pollution from thermal power stations. But as far as gas emissions are concerned, they lack the know-how and the relevant instruments.

Ironically enough, at the time of the accident, the Central Insecticides Board, which registers all pesticides and declares them fit for use, was considering a list of 25 highly toxic pesticides it was planning to derecognise. The list includes the names of carbaryl, which is marketed as Sevin, and Aldocarb, two MIC-based products made by Union Carbide.

After the Bhopal accident, the Ministry of Industry has also enlarged the list of what it describes as high polluting industries which require prior approval for factory sites, a guarantee to install safety equipment and a commitment that factory effluents will not pollute the air, water and soil around the plant. With hindsight, other chemical companies such as ICI say that they have "doubled and trebled" their safety checks. Moreover, the Cabinet has ordered a review of safety procedures at most plants where dangerous or toxic chemicals or gases are used.

The dead in Bhopal are beyond help, and none of this will make much difference to the survivors either. As the fortnight drew to a close, city folk were caught up in yet another dilemma.

When the Government announced plans to restart the pesticide unit for a while to use up the MIC remaining in tank 611, well over a lakh citizens decided to take no chances. Shops downed shutters, cinema houses closed, and some banks suspended work as people fled.

Most clearly did not find the 11 government-run camps around Bhopal adequately safe. The poor left in and on top of buses and trains while some of the rich begged for seats on outgoing flights. The army helped with evacuation and set up mobile rescue teams with gas masks in danger areas as the administration tried to inspire confidence. But people seemed to have lost all faith in the Government.

For people so recently ravaged by a silent, invisible killer from the sky it was the unkindest cut, memories suddenly jostled of a nightmare that had barely ended. But it wasn't the immediate suffering that alone has left an indelible black mark in Bhopal's collective conscience. It is the unanswerable questions that will continue to haunt its population for generations to come, as survivors tell their children, why Bhopal? In part the answer has to do with the ethic of industrialisation and the demands it makes on a still largely feudal rural society.

But, the greater part of the question can't be answered, and will not vanish easily from the conscience of those guilty of negligence, whether in Union Carbide or in authority. The guilty will undoubtedly be taken to task, but there can be no retribution just enough, nor any turning back of the clock. Bhopal holds out lessons that have to do with basic human concerns, for safety, for standards and for good sense. If the lessons are lost then it is all too possible that accidents such as this may be repeated in another factory in another city in another way.

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