Podcast: Butterflies of Bhopal -- Lessons Written in Blood

Ramin:  First, Trish and Traci, thanks for the invitation. It's great to be here with you. And yeah, I mean, since I was a kid, like many kids, I was into drawing and making up stories and superhero comics was a combination of art and crazy stories. I was very much into those. As an adult, creating comic books became my hobby, one of my hobbies. And so something happened about 10 years ago that kind of inspired this more focused work on generating these safety comic books. That's when the small company I was working with, and we had designed and built this plant and we were helping with this operation, had a fire incident with a few burn injuries. And that accident affected our small team and inspired me to create a graphic novel to raise awareness about process safety. The book was called Nylon Years, and it dramatized the Flixborough disaster.

After Nylon Years was published, a couple of articles appeared in the Chemical Engineering Progress that gave me more focus to this work. One was a safety beacon about the importance of storytelling and safety communication. And then another article appeared written by T J Larkin that showed how organizations forget accidents just three years after they occur on average. And his article showed that if those lessons were communicated with a dramatic illustration, they would be remembered about eight times longer. His article had a few studies that supported those numbers. Of course, graphic novels combine those two elements of storytelling and dramatic illustrations. So learning the potential impact that this communication style could have inspired me to create more graphic novels since then. And like you said, I've been posting them on LinkedIn for free access.

Importance of Storytelling in Many Forms

Traci:  Now, Trish and I have talked many times on this podcast about the importance of storytelling, and Trish is certainly a weaver of stories and can bring something to the table for process safety. And Trish, obviously, this podcast is one way to do it. Articles and webinars are another way to do it. And now with these graphic novels, can you explain the importance of the work like Ramin's to process safety?

Trish:  Yeah. I love storytelling as you know. I love to tell a good story. And in fact, just this week I was delivering a workshop to people on how to do storytelling in science and engineering to try and communicate means more effectively. And so I'm doing a lot more of that storytelling coaching and training into the future now. And one of the things that I talk about in that storytelling is the recognition that people have different learning styles. And so we all prefer to take information in different ways. Some of us are very visual people. We like to draw, we do mind mapping when we need to come up with ideas. We like to see the thoughts that we are thinking about. Other people are very much auditory learners. They are typically the people that love listening to podcasts as an example. Other people are reading, writing.

They will take lots of notes, they will underline, they'll write in the margins of their pages. Other people are kinesthetic; they need to feel and have an experience. And one of the reasons why I really love Ramin's graphic novel style is that it combines three of those styles, and that means that there's something for at least three types of learners in that. It is the visual because we've got the pictures, the amazing artistry that he does. We've got the words because there is still a story in the words as well as in the pictures. So for the reading people, there's something for them and for the kinesthetic people, there's action, there's activity, they can get engrossed into the story. For me, I think the graphic novel style, whilst it won't be for everybody, so if you are a traditional reading style person and you really are a reading style person, you've got no sort of visual tint at all on you, then you probably just want to read it more as a written story or no pictures.

But for a lot of people it appeals to something in their learning style, which means they take that information in. And Ramin's right, we remember stories. There's been a lot of research done about it, but history goes back millennia in this area. If I look at the indigenous population in Australia, so they have continuously been surviving and thriving in this country for 65,000 years, and they did that with no written language. So how do they communicate to each other? They had a verbal spoken language. They had many languages actually, because there were many nations that lived in this country, but they also had cave paintings, and they drew pictures.

They drew what was safe to eat in certain areas. They drew what needed to be wary of. They drew maps on where to find fresh drinking water. They told stories so that people would remember the locations by the different landmarks so they would get where they needed to go. When we tell stories and we put them into a narrative, people remember the detail of the story. When we just tell them a linear plain story, they'll forget the important details. And that is why the work that Ramin has done. And I really have to commend you Ramin, the volume of process safety-related material that you have not only created, but also make freely available to the world by posting it on your LinkedIn, I think is absolutely admirable.

Ramin:  Yeah. Thank you for that, Trish. I myself, I'm a visual learner and I know a lot of the, especially among the operating staff in plans that there are generally also visual learners. Again, I don't want to generalize and sometimes very worthy procedures and instructions they try to avoid and have somebody explain it to them.

Traci:  And Trish, as you were talking about that, it reminded me of the column you wrote for us: “What are Your Shell Middens?” And so the visualization really sticks with you and Ramin, as I was going through your graphic novels, they were just so detailed and brought things to me who, I'm not an engineer, I'm a journalist. So, seeing that visually helped me better understand it. And so this is going to help generations coming through maybe better understand some process safety incidents. How long does it take you to create something like this?

Ramin:  Yeah, it takes quite a while because before engaging in the creative activity of putting together the story and sketching out the panels with the narrative, I first have to do the research because I don't want to put things down that are not supported by facts, especially if it isn't on an actual event like, let's say, Bhopal. So I spent about at least six months reading everything I could on Bhopal. There are three major books corresponding to the three theories that are explored for about how water got into the MIC storage tank. I read all three of those books, and I think they're included as references and the graphic novel. Yeah, so on average, I would say in the changes between three months to six months for when there is more research involved.

Investigating Bhopal, Three Theories of Tragedy

Traci:  I did pick that up in Butterflies of Bhopal. You walk readers through those three theories of how water got inside the tank and each time you take care to point out that the operators were on a tea break. Can you tell me about that detail you included?

Ramin:  Sure. But let's first though, I think it's important to kind of set back about this whole investigation reports. As Trish mentioned, that everyone agrees that what started the runaway reaction in that MIC storage tank was about one ton of water getting into that 40 tons of MIC in that storage tank. However, there's still no agreement about how that water entered. So there are two major investigations on this, two major reports out there. One is the CSIR Report, Council of Science and Industry Research in New Delhi. They had their own investigation report. And then there was also the Arthur D. Little investigation report. These two investigation reports lay out timelines of events, and these timelines start to diverge at the shift change. The shift change that the night shift comes on late in the date December 2nd, and then the different investigation report timelines re-converge after the midnight tea break.

So in the story that at midnight tea break is where the two different narratives re-converge and also the shift change where start to diverge becomes where I start and end the three different theories. So that's the significance of the tea break. Another point that I wanted the tea break to make it was that it provided a window into how little warning the operators had about the runaway reaction that was happening as they were taking their midnight tea break. See, it's important to recognize that they were essentially running that unit with one of their hands tied behind their back. They did not have all the instrumentation working in particular got MIC storage tank had instrumentation to warn of an onset of a runaway through temperature alarms, through temperature indicator and temperature alarm.

However, that safeguard system assumed that MIC storage tank was kept chilled at temperatures below 40 degrees F with the alarm being essentially close to ambient like 50 degrees F. Since they had disabled that refrigeration unit earlier. And we can give if you want the causes for that. But basically the plant, as Trish mentioned, was shutting down. So there was no economic justification to get a lot of these systems that weren't working to work again because they were going to shut it down. So they had actually removed the refrigerant from the refrigeration system. And so the tank, the MIC storage tank was in a permanent state of alarm because there were essentially ambient temperatures, which was above the alarm point.

So their only indication of what was going on, given that the temperature gauge was already pegged, they didn't know whether temperature was going to rise anymore because it was already maxed out and the alarm was acknowledged they were already in the alarm state was pressure. And the pressure only happens after there is enough of the MIC that has been vaporized, that is building up pressure and enough of reaction that is generating gas phase byproducts that it raises that pressure. So it's essentially, it's not a really real-time indication of a runaway reaction, but that's all they had to go by. And they had already seen signs of pressure rise in that MIC tank during that tea break, but they were kind of used to that pressure swinging between high and low due to a couple of reasons.

One was the fact that they themselves used the pressure transfer method to move the MIC out of the storage tank to the batch Sevin pesticide production reactors. And so they were used to pressurizing it from 2 PSI to up to close to 20 PSI to move the MIC out. And so when they saw this pressure moving, they didn't think much of it. And also the fact that there was, because there was no chiller, that MIC vapor pressure would go up and down depending on ambient temperature because it was no longer temperature controlled. So the point I'm trying to make is that during that tea break, they knew there were signs of pressure rising, but they didn't know it was dangerous just because of lack of that working instrumentation due to the fact that they were outside of the range for that temperature indication and alarm.

Traci:  It was a very effective literary device because it stopped me and it made me realize that, "Okay, these things were happening." So I applaud you on that. It was interesting and it was neat to see. And you had mentioned, Nylon Years, which looks back at the Flixborough disaster. One of the other graphic novels that you've done, and many folks say that Flixborough should have served as a lesson to prevent Bhopal, a number of factors that made Bhopal accident so disastrous. As you've been talking about with the amount of MIC on site, how it was stored, shortcomings in the safety system operation and the large number of people living in a town that had grown up adjacent to the plant. First, Trish, I want to get your take on some of those factors in the lessons learned. And then Ramin, I know that you have some insight on these commonalities as well, so I'm going to tap you next. But Trish, can you talk a little bit about those factors in the lessons learned?

Deadly Cost of Improvements

Trish:  Yeah. So both incidents certainly had a lot of focus area for us that we call inherently safer design principles. The first principle we talk about in that is elimination. And that comes down to Trevor Kletz's famous quote of, "What you don't have can't leak." In Flixborough, the amount of cyclohexane they had at that point as they were going through the reactions. So the sheer volume of product, it means that if you've got that much here, it can leak. In Bhopal, the methyl isocyanate was actually just an intermediate stock. It didn't need to be produced and stored. It could have actually been produced and consumed in the same continuous process. So it didn't even need to be stored, let alone storing so much of it as they actually did in Bhopal. Management of change occurs across both of them as well where we see the issue of...

In Flixborough, obviously they didn't do a management of change. It didn't exist. Basically management of change didn't exist when Flixborough occurred, when they changed out Reactor 5 and replaced it with a dogleg at that point. So there was a change that had occurred. There were a number of other changes. There's also organizational change that had occurred at Flixborough too that hadn't been managed. And in Bhopal we also saw over years, various parts of the plant had been changed from their original design. And Ramin actually mentioned the cooling system. It was now permanently in alarm because that actually removed the cooling system because it was using a lot of electricity and they decided they didn't really need to keep the MIC that cool anymore. They basically switched it off, but they still had this continual alarm, so they didn't have good data coming to them because they didn't trust the instrumentation because it was wrong. We see some of those that are parallel.

The other one was around, I guess the location of people to the plant. As you mentioned, in Flixborough, there were some almost 2000 buildings damaged when that explosion occurred. And I think it was 58 people were injured, not at the plant. 28 people were killed on the plant and there was some other injuries as well, but another 58 people were injured in the town of Flixborough when that explosion occurred. And obviously the town was close to the facility there, the facility had been built in the town where everybody lived. In Bhopal, the facility was actually built near a town, but that town grew and expanded and grew around the facility. It wasn't so much that Bhopal didn't learn the lessons from where you site a plant relative to people. The fact was that the Bhopal plant was actually built way before the Flixborough explosion happened anyway, but it had suffered what we call encroachment.

And we see that today still where we have plants that when they were built, they were built in the middle of nowhere, but now they have encroachment by people moving in and around. And I think from that perspective, we actually need to get a lot better at land use planning and let's perhaps not build high-density sensitive populations right beside chemical or manufacturing facilities that should they have an incident, have the potential to kill everybody in that particular area. And I think that's one of the big challenges that we see around the world with facilities that were there a long time ago, and now we have encroachment coming onto them because people have moved to those areas typically because land was cheap and so living there was cheaper and they could afford it. But we need to, I think, be better about how we actually provide suitable land for people to live in those instances.

Traci: Ramin, you want to offer your thoughts?

Ramin:  Yeah. I think what always fascinated me about both Flixborough and Bhopal was the fact that they deviated from inherently safe design practices and the fact that they were both supposed to be new and improved processes for making the product. They were not the first of a kind plans. They were already both in... Let's first talk about Flixborough. In Flixborough, caprolactam, which is the nylon intermediate, was already made by Nypro, which is that joint venture between the Dutch petrochemical company, DSM and the UK partner that Nypro already had a plant that made caprolactam by an older process, which was called a phenol hydrogenation to make then cyclohexanone that is then reacted to make caprolactam with hydroxy some acid and base treatment. But when the cyclohexane oxidation process started, a concept was it was going to be a more advanced process because it used a much lower cost feedstock cyclohexane compared to phenol.

But because the process, it was an oxidation process and had to operate under relatively low temperatures, it did not have a very high per pass conversion so that all the un-reacted cyclohexane had to be then recycled back around. So it had a much larger reactors and much larger volumes of cyclohexane, which was this very flammable hydrocarbon that had to be circulated. And so clearly, compared to the phenol hydrogenation, which was a reaction that 100% to conversion, there was no recycle and phenol was not flammable. This new process was inherently more unsafe because anywhere within that cyclohexane recycle loop, you could have had a loss in containment event like it happened when they had that dog-leg pipe failure. In the case of Bhopal also, the original process did not use MIC. The original process started with, again, they had that phosgene reacting with alpha-naphthol to make naphthyl chloroformate that then reacted with methylamine to make that carbaryl pesticide, that Sevin pesticide.

However, Union Carbide invented in the 60s, this process that had much higher yields where it required MIC as the intermediate product. However, unlike the older process where the intermediate was not hazardous, it was not a product that needed to be chilled and all that, and it was very, I guess you could say it was storage-friendly, intermediate. The new process introduced the MIC. So I think that is kind of interesting that we, especially my job is process development. So I'd like to always keep in mind that always the improvements that we make in yields and improvements we make in terms of introducing raw material costs, it sometimes comes at the cost of introducing, making the process inherently more unsafe, that's what ultimately storing that new intermediate is what caused the disaster in Bhopal.

Traci:  Certainly an interesting takeaway that by improving, you can introduce catastrophe. So things to think about, and you really have done your homework on this. And going back to Butterflies of Bhopal and the opening scenes of that, you introduce us to the Goddess of Death who adopted a new nickname, MIC, and then the title of the book and bringing in the Butterflies of Bhopal. Tell me how you created both, and I'm assuming that the butterflies at the toxic dump site are real, that those actually are there.

Chandi Protects, Chamunda Punishes

Ramin:  Yes. In fact, both of those references comes from articles that Fiona McLeod that you've had in your show before had in her articles. The reference to Chamunda, the terrifying statue of Chamunda as being the perfect symbol of the death and carnage after the MIC release came from Fiona's 2014 article Impressions of Bhopal during her first visit to Bhopal. And that was something she wrote in passing. And to me, after I researched Chamunda, I was fascinated by that image. What I found in my research was that in some Hindu traditions, she is considered to be a manifestation of the goddess that can take on a protective form as Chandi or a fierce form as Chamunda. I thought that was a good metaphor for pesticide plant that can either make a product that protects humanity from famine and disease, or if shown disrespect by not maintaining equipment and bypassing safety systems, it can wreak havoc.

So plus I thought that I wanted to take T J Larkin's advice about that illustrating a dramatic image, and I thought that image of Chamunda could immortalize the Bhopal's lesson kind of dramatizing the whole loss of containment of the MIC. The butterflies came from a different Fiona McLeod article, but she again observed that in her more recent visit in Bhopal, she again mentioned that there were these butterflies that were hovering over the toxic residue of the plant's evaporative pond. Here again, I use that to visually show where the toxic dump was in the graphic novel. And in terms of symbolism, again, butterflies signify rebirth in many cultures, and the image of the butterflies stuck over that toxic residue instead of being free to do what butterflies do, which is go where the flowers are. What's kind symbolic of the community, not finding peace until that plant's life is remedied and remediated, which kind of was I think one of the messages of one of Fiona's articles.

Traci:  I find it fascinating that you and Trish and Fiona have your chemical background or your mechanical engineering background, but you're so creative and so great storytellers on your own, and I so appreciate the thought that you put into all of that and explaining that for us. So thank you for that. Another question that I want to toss out here is that this incident led to important efforts to make the industry safer. Can you both talk about that.

Bhopal Lessons Written in Blood

Trish, you can go first and then we'll hear from you Ramin.

Trish:  Yes. Certainly when this incident happened, it completely shocked the world that something of this magnitude could happen. And interestingly, it was only a couple of weeks before this incident that we'd actually seen the worst ever process safety incident, which was Mexico City LPG BLEVE, which killed over 500 people. And then a couple of weeks later, Bhopal happened, and it was by far the worst by orders of magnitude more. It caused a lot of different changes around the world. It really did lead to, certainly in the US area, it led to the development of the OSHA 1910 PSM standard. He'd led to the creation of the American Institute of Chemical Engineering Center for Chemical Process Safety, because industry said, "We can never let this happen again. We need to do something." So they formed a collective group, and we now have the CCPS going strong for decades now because of Bhopal.

I believe it actually also originally might've led to what later became established as the Chemical Safety Board in the U.S. as well. The first legislation that was passed under the EPA acts to form the CSB started way back as a result of Bhopal, even though they didn't form for several years after that. We've seen a lot of changes in the U.S. area. From the rest of the world perspective, so over in the UK and Europe, they'd already started to have some legislative change occur because of Flixborough that had happened 10 years earlier. But I think Bhopal really started to ramp up some of those changes. So in Europe, they talk about Seveso protocol. So Seveso was a town in Italy that had a dioxin chemical release occur in the 1970s just after Flixborough had occurred. And that really drove a lot of the changes.

I think then when Bhopal occurred, the Seveso directive continued to be revised and updated, and it still exists today and a lot of other countries have now taken on what came out of the Seveso directive. So in Australia where I live in New Zealand, our laws are based originally on the Seveso directive and where that came from. So from these tragedies, we do take on board and learn and implement different laws. The old adage that the safety laws are actually written in blood is very, very true. Sadly, when we create a new safety law, it's because we've had a series of fatalities or tragic incidents that have led to us creating a rule so it doesn't happen again.

We do need to get better at learning though, because whilst we share information and whilst we talk about these incidents, and I think it's still important to talk about incidents that are 40, 50 years old because some people have never heard of them. They weren't born when these things happened, and some people have forgotten the stories. And I think we need to continue to retell the stories so that we can continue to remind people and hopefully create some of that learning from these incidents. So we never see anything truly as horrific as we saw in Bhopal.

Traci:  Ramin, your thoughts?

Ramin:  Clearly, I agree with everything that Trish said about its impact in regulations and the like. And yes, CSP in its website actually does consider its origin to be Bhopal incident, even though it didn't really establish fully until several years after that. But I would like to, I guess I'll talk a little bit about what areas that I see that tied to the learnings from the Bhopal tragedy, but haven't been fully adopted into our consciousness. And one of this I think is about decommissioning a plant. So here Bhopal was a plant was undergoing decommissioning. When this happened, there were shutting down, in fact, the continuous units had shut down that were made. The MIC, they had stocked up on MIC, in fact, that was another cause for this. The severity of the accident is because the storage tanks that were supposed to be only filled to, I think 50 to 60% max were now filled above 70% capacity.

And we talked about how neither the caustic scrubber nor the flare were in service in the case of the flare, the reason was that there was a corrosion in the flare stack, and because the plant was shutting down, they did not fix it. They figured no need to put more money in the plant that they're shutting down. So under decommissioning strategy was to shut down the plant in parts, and somehow they figured the batch units that took the MIC and converted it to the finished product. That one with the alpha-naphthol reaction that one could operate in its own little bubble with all the other parts of the plant shut down, including the flare stack.

And I think what I would like to see is just guidelines that the industry adopts in terms of how during decommissioning, nothing that is critical to safety has to be decommissioned until there's no chemicals being processed. Timeline essentially, they had to shut everything down by end of the year in 1984. And I think that itself also introduced some limitations that they felt they had to... They couldn't order anything that could help them operate more safely because they knew how they had to just convert that MIC and shut down. I know this is not guidelines that have translated into industry practice, but it would be nice if we see some learnings from Bhopal into how a plan should be decommissioned.

Traci: Trish, do you have anything that you want to add on this topic?

Trish:  So my final thoughts on this one, Traci, are there's so much that we can still learn from incidents that happened in the past. We need to continue to revisit them and tell the stories about them. And again, I'd just like to thank Ramin for his amazing work that he does in making the learnings from these incidents far more accessible. And I do remember one of the first times I met Ramin, he came up to me at a conference and he'd actually done a drawing for me, and it was my poem that I'd written about leadership, and he'd written that out beautifully and he'd actually sketched out my face on that page as well. And that picture is still framed on my wall in my office, and I use it to remind me that there are different ways that we need to keep communicating and storytelling is one of them. So thank you, Ramin, for all you do in this space. I think it's absolutely amazing and I'm and privileged to know you.

Ramin:  Thank you, Trish, and very much the same. Before you joined, I was just telling Traci that you are so knowledgeable. I was binge listening to the old editions of this podcast, and I learned a lot by just listening to those old podcasts with you on. And yeah, no, this is a great show. Thank you guys for doing this.

Traci:  I agree, and it is my privilege and I am so lucky to have Trish and to have you on here to help us continue to talk about these stories and talk about Bhopal 40 years later. So thank you again for all of the thoughts that you gave us today.

Unfortunate events happen all over the world, and we will be here to discuss and learn from them. Subscribe to this free podcast so you can stay on top of best practices. You can also visit us at chemicalprocessing.com for more tools and resources aimed at helping you run efficient and safe facilities. Be sure to go on to Ramin's LinkedIn page so you can access some of his graphic novels there. I ordered the Nylon Years. It's an actual hardback copy. You can pop onto Amazon or other places to get that to great work. And it's just neat to see an interesting way to tell the story of process safety. On behalf of Trish and Ramin, I'm Traci, and this is Process Safety with Trish and Traci. Thanks again, you two.

Trish:  Stay safe.

Ramin: Thank you.