Unsafe Actions:
1. The leak was not attended as soon as it was reported. Initial time passed in tea break.
2. The
first information of five-fold pressure rise was dismissed in the belief that
the pressure gauge could be faulty.
3. A
newly recruited supervisor had asked a novice operator to clean a pipe and the
blind disc was not inserted while doing so.
4. The
public siren was put on around 1 am. nearly an hour after the gas leakage and that too for a
few minutes.
5. The
correct antidotes and medical treatments were not suggested to surrounding
doctors. On the contrary confusion of MIC or Phosgene or Hydrogen cyanide was confounded.
Unsafe
Reactions:
Above unsafe conditions and actions lead to the
violent unsafe reaction. Different hypothesis have been expounded by Carbide's
scientists, Indian experts and Dr. S. Varadrajan, who lead the investigations
on behalf of the Government. According
to him small quantity of water reacted with Phosgene in the tank, mixed with
MIC as animpurity to make it unstable. The Phosgene water reaction (hydrolysis)
produced heat, CO2, and HCI.
The heat and HCI acted as the accelerators of the polymerisation,
additions and degradation of MIC leading to a runaway reaction. According to
others, the increased temperature of MIC (it vaporises above 38°C) generated
heat, pressure and side-reactions, higher than normal amount of Chloroform in
the stored MIC and an iron catalyst lead to the violet reaction. Because of the colder night of December, the
escaped MIC settled down and travelled downward covering the sleeping
surroundings with the blanket of death and damages.
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