Human negligence and lapses in warning systems led to the styrene vapour leak at LG Polymers’ plant in Visakhapatnam in May, said a high-power committee investigating the incident. At least 11 people were killed and over 200 hospitalised after the gas leak on May 7.

The committee, formed by the Andhra Pradesh government, submitted its 4,000-page report to Chief Minister YS Jagan Reddy on Monday, according to The Indian Express. The committee included Neerabh Kumar Prasad, the special chief secretary (Environment, Forests, Science and Technology), his counterpart in industry and commerce department Karikal Valaven, Visakhapatnam Collector V Vinay Chand and Police Commissioner RK Meena.

The committee has recommended filing cases against all directors and managers of the company, shutting it down or shifting it out, or converting it into a non-polluting unit. “The company cannot be allowed to function in its existing form at RR Venkatapuram,” the report read. “It should be shifted out or it should turn into a non-polluting unit.” Some of the main causes of the accident are poor design of the tank, inadequate refrigeration and faulty cooling system, absence of circulation and mixing systems and poor safety protocol and total breakdown of the emergency response, said the report.

“There were no proper preventive mechanisms to avert such incidents and the warning siren facility was also not in order,” the Andhra Pradesh government said, according to Reuters. “The Committee in its report mentioned 36 [times] about how the alarm system did not function and the siren did not [sound].”

Committee chairperson Prasad said they have identified and fixed the negligence of each and every person responsible. “It includes the Korean directors and managers,” he told The Indian Express. We have also recommended that either the company turn into a white and green unit or it be shifted out. The company, as it exists now, cannot be allowed to function.”

Prasad said the tank gave initial signs of polymerisation on April 24. “Had the plant management taken it as a warning sign and corrective action taken, the accident could have been averted,” he told The Hindu.

After the report was submitted, Chief Minister Reddy on Monday directed authorities of various departments to initiate legal action against those responsible for the gas leak. He also ordered that the entire report be placed in public domain for people to access.