Chapter 3:

Case Studies
Presented by:
Caoile, Phoebe Perlado, Erickah
Santiago, Meryl Sumapig, Ameel
5IE-B
 Case Study 1: The Disaster at Bhopal
● MIC storage tank leakage (10,000
gallons)
● Methyl Isocyanate- a highly toxic
chemical used in the
manufacture of pesticides
● Accidental pouring of water in
the tank
● Mixing of water with MIC
increased the temperature of the
liquid to an estimated 400°F December 2, 1984 - Union Carbide
chemical plant at Bhopal, India
 Case Study 1: The Disaster at Bhopal
● Increased temperature led to
build-up of high internal
pressure; MIC vaporized
● The tank vented releasing
toxic gases into the
atmosphere.
● Water curtain to cool the gas
was not high enough.
● The gases were blown by
northwesterly winds over
Bhopal.
 BHOPAL DISASTER TIMELINE SUMMARY

INSIDE THE PLANT OUTSIDE THE PLANT

9:00 P.M Water cleaning of pipes 10:30 P.M First sensations due to the gases are felt—suffocation,
starts. cough, burning eyes and vomiting.
10:00 P.M Water enters tank 610, 1:00 A.M Police are alerted. Residents of the area evacuate. Union
reaction starts. Carbide director denies any leak.
10:30 P.M Gases are emitted from the 2:00 A.M The first people reached Hamidia Hospital. Symptoms
vent gas scrubber tower. include visual impairment and blindness, respiratory
The large siren sounds and difficulties, frothing at the mouth, and vomiting.
12:30 A.M is turned off. 2:10 A.M The alarm is heard outside the plant.
The siren is heard within 4:00 A.M The gases are brought under control.
12:50 A.M the plant area. The 7:00 A.M A police loudspeaker broadcasts: "Everything is normal".
workers escape.
 Case Study 1: The Disaster at Bhopal
Factors that Lead to the Magnitude of Gas Leak

● The Flare tower and several vent scrubbers had been out for 5 months
● Failure of safety systems
● Some of the safety systems were under maintenance and were off-line
● Lack of skilled operators. No training was given by the company
● Negligence of the management
● Plant is situated near a densely populated area
● Lack of Safety Management, Insufficient maintenance, and Inadequate
Emergency Action Plans
Case Study 1: The Disaster at Bhopal
● 28 leaks of MIC over 5 years
● “a real potential serious
incident exits” -- memo
from internal Union
Carbide 3 months before
the Bhopal incident
● Indian Government - lack
of safety standards due to
the costs

Union Carbide Plant in West Virgina

 Case Study 1: The Disaster at Bhopal
Aftermath of the Tragedy

● Union Carbide will compensate $470 million ($500 per dead)

● 20,000 were killed
● 10,000 will suffer from permanent damage
● 550,000 were severely affected
● Job trainings and relocation programs for the victims of the accident were
set up by the company
CASE STUDY 1: THE DISASTER AT BHOPAL

3.6 Ethical Theories on Bhopal Tragedy

❖ UTILITARIANISM
➢ The emphasis is NOT on maximizing
the well-being of the individual, but
rather on maximizing the well-being of
society as a whole.
➢ Violations:
■ “Science helps build a new
India”-UCIL advertisment (the
benefits of producing pesticides to
agriculture vs. the threat it poses on
environmental health)
CASE STUDY 1: THE DISASTER AT BHOPAL ■ In 1975, two months before UCIL
3.6 Ethical Theories on received a permit to build an MIC
Bhopal Tragedy production unit, the city of Bhopal
had enacted a development plan
requiring dangerous industries to
relocate in an industrial zone 15
miles away, converting the site to
housing & light commercial use.
■ For reasons unclear, efforts of
M.N Buch, the Bhopal city
administrator, failed & he was
soon transferred to forestry
duties elsewhere.
CASE STUDY 1: THE DISASTER AT BHOPAL

3.6 Ethical Theories on the Bhopal Tragedy

❖ DUTY ETHICS & RIGHTS ETHICS
➢ In duty ethics, people have duties, an important one of which is to
protect the rights of others. In rights ethics, people have fundamental
rights that others have duties to protect.
➢ Violations:
■ Reports issued months before the incident by UCC engineers
warned of the possibility of an accident almost identical to that
which occurred in Bhopal. The reports never reached UCC's
senior management.
CASE STUDY 1: THE DISASTER AT BHOPAL

3.6 Ethical Theories on the Bhopal Tragedy

❖ DUTY ETHICS & RIGHTS ETHICS
➢ Violations:
■ In November 1984, most of the safety systems were not
functioning. Many valves and lines were in poor condition. Tank
610 contained 42 tons of MIC, much more than safety rules
allowed.
■ Though the audible external alarm was activated to warn the
residents of Bhopal, it was quickly silenced to avoid causing panic
among the residents. Thus, many continued to sleep, unaware of
the unfolding drama, and those that had woken assumed any
problem had been sorted out.
 Case Study 1: The Disaster at Bhopal
AMERICAN INSTITUTE OF CHEMICAL ENGINEERS *(AICHE) Code of Ethics

• Being honest and impartial and serving with fidelity their employers, their clients, and the public;

• Striving to increase the competence and prestige of the engineering profession;

• Using their knowledge and skill for the enhancement of human welfare. To achieve these goals, members shall:

• Hold paramount the safety, health, and welfare of the public and protect the environment in performance of their
professional duties.

• Formally advise their employers or clients (and consider further disclosure, if warranted) if they perceive that a
consequence of their duties will adversely affect the present or future health or safety of their colleagues or the public.

• Accept responsibility for their actions, seek and heed critical review of their work, and offer objective criticism of the work
of others.

• Issue statements or present information only in an objective and truthful manner.

CASE STUDY 1: THE DISASTER AT BHOPAL

3.7 Responsibilities of Engineers

3.7 What does the code say about the responsibilities of the engineers who
designed the plant and the engineers responsible for making maintenance
decisions?

The code states that Engineers in charge should let their clients know all about
the possibilities of risks that might occur and should have back-up plans. Repairs
of safety systems should not be done by bulk but simultaneously. Engineers
should not let incidents like this ever happen again. Safety of the human race
should be the first priority. When accidents happen, engineers take full
responsibility for their failure.
CASE STUDY 1: THE DISASTER AT BHOPAL

3.8 Responsibility of Union Carbide to its subsidiaries

Although Carbide employees from the U.S managed the plant in its early years,
in 1982, the experience of colonial rule in India created a strong political need
for leaders to put on shows of strength with foreign investors.

This is what had led to the passage of law requiring foreign investors to use
Indian firms & workers in certain ways & to put pressure on Union Carbide to
turn the plant completely over to its Indian subsidiary.

Thus, the Bhopal plant was run by UCIL with near total independence. Despite
this, shortly after the gas leak Chairman Warren M. Anderson said that
Carbide accepted “moral responsibility” for the tragedy.
CASE STUDY 1: THE DISASTER AT BHOPAL

3.9 Union Carbide’s duty to India

3.9 What duty did Union Carbide have to inform local officials in India of the
potential dangers of manufacturing and storing MIC in India?

It is a standard from the Western countries that business owners especially the owners of
manufacturing of chemical substances should inform the local officials about what they are
producing and what might be the risks accompanied by the production. Analysis of the
Bhopal accident shows that organizational or corporate level failures are the most critical
ones that need attention if accidents are to be avoided. If the government then had been
properly informed, the disaster could have been lessened. For example, the government
shouldn’t have granted them permission to build a plant that is near a populated area. This
is a duty towards the welfare of everyone and the environment.
CASE STUDY 1: THE DISASTER AT BHOPAL
3.10 Ethical implications of Carbide’s reports on India’s inadequate workforce
● Workers were forced to use English manuals, despite the fact that only a few had a
grasp of the language.
● By 1984, only six of the original twelve operators were still working with MIC and
the number of supervisory personnel was also cut in half. No maintenance
supervisor was placed on the night shift and instrument readings were taken every
two hours, rather than the previous and required one-hour readings.
● The company cites an investigation conducted by the engineering consulting firm
Arthur D. Little, which concluded that a single employee secretly and deliberately
introduced a large amount of water into the MIC tank by removing a meter and
connecting a water hose directly to the tank through the metering port.
● Carbide claims such a large amount of water could not have found its way into the
tank by accident, and safety systems were not designed to deal with intentional
sabotage.
CASE STUDY 1: THE DISASTER AT BHOPAL

3.11 Responsibility of the Bhopal Government

3.11What responsibility should the national and local government in Bhopal
have for ensuring that the plant is operated safely?

The local and government in Bhopal should have monitored the operations and
they should have implemented such emergency actions especially that the
location of the plant was near to the city. The government should have
coordinated with the Americans to avoid safety lapses on the decision-makings
of such maintenance.
CASE STUDY 1: THE DISASTER AT BHOPAL
3.12 Relative Importance of keeping safety systems operating to maintaining
operations
● It is useless to regulate plant operations if safety factors are bypassed. In
the case of Union Carbide, the Indian government had filed a suit against
them stating that the company had exercised policy control over the
establishment & design of the Bhopal plant. The plant was defective in
design as its safety standards were lower than similar plants in the United
States.
● Cost-cutting was also a problem for Carbide. In their attempt to decrease
company expenses through employee attrition, they led themselves to
suffer a larger cost. Less people in maintenance meant safety systems are
not monitored according to standards.
CASE STUDY 1: THE DISASTER AT BHOPAL

3.13 Question on ethics

3.13 In the absence of environmental or safety laws in the locality where it
operates, what responsibility does a U.S. corporation have when operating
overseas? Does the answer change if the locality does have laws, but they are
less strict than ours? What about the ethics of a U.S. corporation selling
products overseas that are banned in the United States, such as DDT?

No matter where a corporation goes, regardless of the nationality, they have the
responsibility to ensure the safety of the environment and of the people. It won’t
change as it is a universal law to protect the welfare of those that are involved
especially the ones that are directly affected. Ethical standards not only pertain
to the well-being of human beings, but also to the environment. The corporation
should be aware of the effects of DDT on the environment and wildlife, and the
need to make it public.
 Case Study 2: The Aberdeen Three
● One of the classic cases
used in Engineering Ethics
● Illustrates the importance
of:
○ Environmental
protection
○ Safety of workers
exposed to hazardous
and toxic chemicals
Case Study 2: The Aberdeen Three
Aberdeen Proving ground:

● U.S. Army weapons

development and test center
● Military base located in
Maryland
● No access by civilian non
employees
 Case Study 2: The Aberdeen Three
● Involves three civilian managers at the
Pilot Plant:
○ Carl Gepp - Manager of Pilot Plant
○ William Dee- Headed Chemical
Weapons Development Team
○ Robert Lentz- Incharge of developing
manufacturing processes for the
chemical weapons

Between 1983-1986, Inspections at the Plant

indicated there were serious safety hazards
Case Study 2: The Aberdeen Three
Safety hazards include:

● Carcinogenic and flammable

substances left in open containers
● Chemicals that can be lethal when
mixed are stored on the same room
● Barrels of toxic chemicals were
leaking
● Unlabeled containers of Chemicals
● Leaked 200 gallons of sulfuric acid
in the local river
 Case Study 2: The Aberdeen Three
June 1988 - Violation of RCRA (Resource Conservation and Recovery Act- 1976) by
the three managers

● Intended to provide incentives for the recovery of important resources from

wastes, conservation of resources, and control of disposal of hazardous
wastes
● Banned dumping of solid hazardous wastes - criminal penalties for violation

Three managers weren’t aware that the plant’s storage practices were illegal and
thought they did things according to accepted practice at the Pilot Plant

The Army could not help defray the costs of the manager’s defense, all incurred
great costs defending themselves.
 Case Study 2: The Aberdeen Three
At year 1989:

● Three engineer/managers were convicted of

illegal storing, treating, and disposing of
hazardous wastes
● No indications that they were the ones who
actually handled chemicals in an unsafe
manner but they were responsible for the
storage and maintenance of safety equipment.
● Potential penalty: Fine of $750,000 & 15 years
imprisonment
● Penalty: 3 years probation and 1000 hours of
community service
 Case Study Questions: The Aberdeen Three
3.14 What does utilitarianism tell us about the behavior of the Aberdeen
Three?What do duty and rights ethics tell us? In analyzing this, start by
determining who is harmed or potentially harmed by these activities and
who benefits or potentially benefits from them.

Utilitarianism is an effort to provide an answer to the practical question

“What ought a man to do?” Its answer is that he ought to act so as to
produce the best consequences possible.

Rule-Utilitarianism Looking at this case from a rule-utilitarianism point of

view, many codes of ethics were breached.
 Case Study Questions: The Aberdeen Three
3.14
For example, the following codes that are taken from the American Institute of
Chemical Engineers (AIChE) were clearly violated:

1. “Chemical engineers should hold paramount the safety, health and welfare
of the public and protect the environment in performance of their professional
duties.” - The three chemical engineers which are professionals should have
had the knowledge of the hazardous chemical stored in the plant. They should
be careful and alert with the chemical and take all necessary safety steps to
protect the workers in the plant and be concern with the condition of the plant
from time to time.
 Case Study Questions: The Aberdeen Three
3.14
2. “Formally advise their employers/clients if they perceive that a
consequence of their duties will adversely affect the present/future
health/safety of their colleagues or the public.” The managers of the
pilot plant should have reported to their superior about the
conditions of the plant so that actions can be taken to cure it before
it is too late. Carl breaks the law and by not reporting, he commits a
lie by omitting it in the report.
 Case Study Questions: The Aberdeen Three
3.14
3. Accept responsibility for their actions, seek and heed critical
review of their work/offer objective criticism of the work of others.
They should not take environmental matters lightly and
environment care as their most vital responsibilities. They should
have taken into consideration the safety of the plant and the
condition of the plant. When the chemicals spilled, actions should
have been taken. They should not store the reactive chemicals
together with the knowledge they have learned.
 Case Study Questions: The Aberdeen Three
3.15 Can the actions of these engineer/managers be classified as
engineering decisions,management decisions, or both? Ethically, does it
matter whether these decisions were engineering or management
decisions?

Both. As both engineer and manager, it is their responsibility

in knowing the rules and acts implemented to avoid such
penalties.
 Case Study Questions: The Aberdeen Three
3.16 Do you think that the Aberdeen Three knew about RCRA? If not,
should they have? Does it really matter if they knew about RCRA or not?

No, the three managers have no idea about the RCRA. Yes, as an engineer, it is
their responsibility to be aware of this act since RCRA was passed by the Congress.

The Resource Conservation and Recovery Act(RCRA), enacted in 1976, is

the principal federal law in the United States governing the disposal of solid waste
and hazardous waste.
 Case Study Questions: The Aberdeen Three

3.17 Do you think that the Aberdeen Three were knowledgeable about
the effects of these chemicals and proper storage methods? Should they
have been?

Throughout the case, the three engineers maintained that they had no knowledge
of RCRA. However, all containers of hazardous chemical have labels which state
that the chemicals must be disposed of according to RCRA requirements. One
possible answer is that since they did not hold their responsibilities to the public as
engineers as high on their list of priorities, they did not bother to research existing
laws and regulations that were related to public safety. Whether or not they really
had no knowledge of the RCRA, as defendants they cannot escape liability by
claiming ignorance of the law.
 Case Study Questions: The Aberdeen Three
3.18 Were the actions of the Aberdeen Three malicious?

Yes, because they were found guilty according to the US Justice Department.

The three managers still claimed that they were not aware that the plant’s storage
practices were illegal and that they did things according to accepted practices at
the Pilot Plant. This actions tarnishes the reliability of the three manager. Their
irresponsible action had threatened the lives in the river and indirectly affecting
the life of the residents around Aberdeen. On the other hand, they put the workers
in a risk that exposed to hazardous and toxic chemicals which may cause cancers
or died. The three were ultimately responsible for how the chemicals were stored
and for the maintenance of the safety equipment.
 Case Study Questions: The Aberdeen Three
3.19 In the course of this case, it came out that cleaning up the chemical
storage at Aberdeen would have been paid for out of separate Army funds
and would not have come from the budgets of the three managers. What
bearing does this information have on the case?

The U.S. Army should not develop chemical weapons which definitely will harm
the health of the public.

The three engineers claimed themselves to be part of the Army, and certain leeway
could be provided exclusively to them. Their action is immoral because everyone is
equal before the law. They are still engineers, and must follow the professional
ethics as others do.
 Case Study Questions: The Aberdeen Three
3.20 What should the Aberdeen Three have done differently? Should the
lower level workers at the plant have done anything to solve this problem?

The three engineers did not take the responsibilities to clean up the chemicals that
dripped down from the leaky pipes. Moreover, they ordered the workers who had
no hazardous materials training to handle and dispose the hazardous chemicals
without inform them how to deal the materials properly. As a conclusion, these
engineers are placing the safety of workers as the lowest priority. Hence, the
workers did the correct way to protect themselves which is to the press and
exposed what was going on at the Pilot Plant.
 Case Study Questions: The Aberdeen Three
3.21 The bosses of the Aberdeen Three claimed to have no idea about the
conditions at the Pilot Plant. Should they have done anything differently?
Should they have been prosecuted as well?

The bosses of the Aberdeen Three should held seminars or trainings regarding this
matter so that everyone is aware about the rules and regulation.. I think that they
should also be penalized as well.
 Case Study Questions: The Aberdeen Three
3.22 Apply the code of ethics of one of the professional societies to this
situation. Were the managers guilty of ethical violations according to the
code?

Ethical leaders are advocates for integrity. It also requires more than
obeying the law.

Virtue Ethics say that good character is central to morality. Yes, they were
proven guilty for being dishonest, unreliable, irresponsible and unfair
managers.