The Bhopal Gas Disaster Court verdict on 7.6.10 highlights the following:
The following are major contributors to the disaster:
1. Gradual but sustained erosion of good maintenance practices.
2. Declining quality of technical training of plant personnel, especially its supervisory staff.
3. Depleting inventories of vital spares.
4. MIC is a highly dangerous and toxic poison, even then storage of huge quantity in large tanks was undesirable. The capacity and actual production in the Sevin Plant is not required such a huge quantity to be stored.
5. The VGS (vent gas scrubber)and refrigeration plant were not adequate to the need of hour and more so they were out of order at the relevant point of time.
6. The nitrogen pressure was not adequate for long before the incident, so it was not maintained and hardly cared about.
7. The Public Information System was failed, neither the State Govt. nor the UCC or UCIL took any steps to appraise the local public.
8. Other alarming systems were also failed.
Together these factors combined to cause the multiple failures that underlay the calamitous incident, causing a vast destruction of life.
In my various assignments of investigating incidents,some involving fatalities,one or more of the above similar causes keep repeating.Why do we NOT want to learn from mistakes? Its because of a human fallacy - the longer it gets, the more you forget about an incident!
Managements are shortsighted and are focussed to reach immediate goals. Any accident occurred is viewed as a part of the work. Though the experienced advise learning from the accidents,those in decision making view the lessons learned to be impractical to implement or time consuming and thus wrong practices are continued.
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