The (Unofficial) ITWorx Technical Architecture Blog

Catastrophic Development: Reflections on the Union Carbide Industrial Disaster in Bhopal

Posted by archworx on April 2, 2007



This year marks the 22nd anniversary of the world’s most catastrophic industrial disaster at the Union Carbide plant in the Indian city of Bhopal. On the morning of December the 3rd, 1984, 40 tonnes of Toxic heavier-than-air Methyl-Isocyanate (MIC) gas were accidentally released to spread across the surrounding roads and streets in Bhopal in the Indian state of Madhya Pradesh.

Thousands of people’s lives were abruptly terminated. The entire city’s transportation system was brought to a standstill, worsening the situation further, as many people were trampled while trying to flee.

People woke up to find their bodies burning, their family suffocating, and ran out to the streets to escape, only to find that those before them who had been blinded by the gasses and were aimlessly rushing in unknown directions eventually collapsed to the asphyxiation of the mortifying gasses and died, lining the streets in piles.

The effect of the gasses rolling out of the holding tank eventually injured from 150,000 to more than half a million people, and the death toll reached 15,000 people. Many sources confirm that contamination is still present in the region.

The damage from the gasses ranged from respiratory diseases, blindness and skin diseases, to reproductive problems.


  • “There were thousands of bodies. There were bodies everywhere. And people were dying all round.”
    • Mohammad Owais, a volunteer at Hamidia Hospital, Bhopal, India



The Causes of the World’s Greatest Industrial Disaster

In the investigations that followed this disaster, the catastrophe was attributed to many factors, tragically, all of which did not have to happen, and were completely preventable. These included:

  • Lack of preparation for this sort of problem. No action plans were available for emergencies, and no contingency plans available to mitigate risks.
  • Reports issued months before the disaster predicting something of this magnitude would happen, and they were summarily ignored and never presented to senior management.
  • An Audible External alarm that was sounded to warn residents in the early morning hours, was quickly silenced – to avoid causing panic to residents.
  • The gas burning exhaust tower that allows gases to burn off before escaping into the air was inoperational, waiting to be serviced.
  • Doctors and Hospitals were not informed of the risks of MIC inhalation, and of its treatment methods – so they simply administered cough medicine and eyedrops to their patients.


  • “We have to travel at least two kilometres to get clean water… My health is so bad that it prevents me from carrying the water I need from there.”
    • Hasina Bi of Atal Ayub Nagar, a neighbourhood in Bhopal near the plant

How is this related to what I do?

You might think that this is very remote from your daily line of work. This is a problem in a different industry, a chemical plant, so far away from me, in an Indian city whose name I can’t pronounce, by a company I’ve never heard of before.

That’s the problem. The entire statement above is false. The difference in industry is immaterial, Union Carbide’s now infamous name has become immortalized down the industrial hall of shame. There are people who rally against Union Carbide, and its new owner Dow Chemical every year on this anniversary, all over the world. India in this case represents exactly what Egypt does in terms of attractive labour-cost and more fundamentally, lack of attention to audits, risk awareness, reviews and safety measures.


  • One reason, according to the Canadian Law Professor Jamie Cassels, who has written a book on Bhopal, is “the unwillingness of the industrialised countries to forego the competitive advantages offered by the less developed world.”

Unlike a Natural Disaster (like an earthquake, volcano, tsunami or the like), Industrial Disasters are caused by mankind. The fateful truth is that more often than not, they are caused by varying degrees of negligence and ignorance.

Let’s look at some of the root causes of this calamity listed above, and examine them with an eye critical of behavioural traits in our human culture. In our society there is a tendency to ignore “safety nets”, measures taken to ensure completely smooth delivery are often thought of as being a luxury – if you can just barely get it through the deadline, then you’re a genius. Remember what happened a few weeks ago when the fire alarm sounded 10 times in the company? How did we react? Do we know why it did that?

There is an obvious trade-off between risks-assumed versus quality-expected in every human endeavour. If you are driving a donkey-cart on a side road, some may say its okay not to have to tightly pack your payload on to the donkey cart. What’s the worst thing that could happen if you drop something? You go back and get it!

If you are on the ring road, and the car in front of you all of a sudden drops a traveling suit case in the middle of your lane, you probably won’t live long enough to explain to the other car’s driver how dangerous it is to travel without securing your payload first.

The reality is, if the project fails, the client will never appreciate the shortcuts you took to save them the extra mile at their expense when in reality the client’s safety is being jeopardized. Sometimes people think that developing software in a Professional Services firm such as ITWorx is a relatively safe enterprise – and that no bug (or fault) can hurt anyone. On the contrary, we are conditioned to think that avoiding “extra” safety procedures pays off.

Here’s what you could typically hear the root causes to the disaster being dismissed:

  • Lack of preparation for this sort of problem: “Yaa Raagel, this thing happened only once in India, Kabar Dimaghak!”
  • Reports issued months before the disaster predicting something of this magnitude would happen: “Maho this is the way we’ve always done business, would you just shut up and go on with your work?”
  • An Audible External alarm that was sounded to warn residents in the early morning hours, was quickly silenced – to avoid causing panic to residents: “Why make such a big fuss about something? How bad could it be anyway? What does an early warning mean by the way?”
  • The gas burning exhaust tower that allows gases to burn off before escaping into the air was inoperational, waiting to be serviced: “It’s okay, maho nothing usually happens anyway – we rarely use it!”
  • Doctors and Hospitals were not informed of the risks of MIC inhalation: “Da Kalam? You want me to go around scaring the Doctors about something they don’t need to know about? Even if I tell them, they won’t understand. Just shut up.”

Software faults can actually be fatal. Software Bugs can kill you, they can squander all your money – wasting millions and millions of it – they can put you at great disadvantages in the institutions that rely on systems full of them, they can waster your time, or merely inconvenience you.

The point is, the larger the project you are undertaking, the higher the risks. Sometimes taking shortcuts is not an option.

Big Boxout: Am I a Catastrophic Developer?

  • This section asks several thought provoking questions about the way we conduct business in the computer science arena and how that will influence our delivery standards. Take a moment to think of each of these questions carefully.
    • Do you manage transparently?
      • Do you keep “sensitive”, “important”, “privileged” or “interesting” information to yourself first before sharing it? Do you often conceal this information unwillingly due to time constraints? Do you make an active effort to pro-actively share such important information periodically with your team? Do you hold yourself accountable on how transparent you are? Do you teach your team what you know, or do you just do the important parts yourself, because it takes less time?

        Do you manage from an ivory tower not really knowing what your team is doing because you’re too senior?

      Do you Version your deliverables?

      • If I asked you which version of your software was installed at the client’s location, would you be able to give me an exact number? Would you be able to reproduce that numbered version from your source repository to match the version at the client’s byte for byte? Would you be able to guarantee that for every version “number” there would be one and only one actual version associated with it? Can you tell the difference between each minor feature adjustment or bug-fix? Are your release documents updated to reflect changes?

      Do you conduct full traceability on all dimensions of your project?

      • Do you think they are a waste of time? Do you know that they are the only way to scientifically prove the completeness of your deliverable? Do you know that without traceability you have no way to securely guarantee scope completion?

      Do you Unit Test your work?

      • Do you use a good unit-testing check-list? Do you know that ITWorx has a recommended unit-testing check-list? Do you know that the developer is the one who is supposed to run these tests before submitting their work for testing? Do you just deploy your code to the testing server the minute you think its finished and leave it those testers to find out if it works or not – because that’s what they’re job is anyway?

      Do you conduct proper, full audits?

      • Do you intentionally mislead auditors or give them half-truths? Do you conduct Mechanical-Audits? Just asking questions without searching for hidden truths? Do you understand why the auditor visits you? Or do you hate their guts? If the auditor asks you a seemingly useless question do you pray that they disappear or do you raise your concern with them?

      Do you communicate properly within your team?

      • Do you pause after you make changes and ask yourself “which stakeholders does this change impact?” and then notify them? Or do you often wait until one day a group of team mates starts screaming and yelling about fundamental changes that have been done behind their back?

      Do you give your Risk Management plan due dilligence? Do you keep it updated?

      • Is your risk management plan just composed of “Volcanos cannot be mitigated”? Do you periodically re-visit your Risk Management Plan to make sure that nothing new has surfaced? To make sure that you are increasingly ready for risks coming up on your radar?

      Do you re-invent or re-use the wheel?

      • Do you jump into developing first without looking to see if what you need has already been done? Do you seek to learn from the experiences of your pre-decessors? Do you ask yourself what others have done before you? Or do you prefer implementing from scratch? Every single time? Do you broadcast good ideas that you discover? Do you institutionalize reform and change? Do you contribute to re-use repositories?

        Do you keep the improvements to yourself, and end up being the only one to benefit from your lessons-learned?

      Do you review your work?

      • Do you peer-review your designs? Do you check that your packages actually install? Are spelling mistakes important to you?

      Have you considered emergency procedures?

      • Do you have plans to support your clients with high severity issues? Do you not think about this because it is not mandated explicitly by anyone?

Boxout: We’re Doomed – I can’t do anything about these problems!

  • If you’ve read some of the questions in the “Am I a Catastrophic Developer” panel, you probably guessed what the right answer we are hinting at was. How can I avoid disastrous development given cost-constraints?
    • Here is a simple recipe to managing risks in a way that safe-guards you against catastrophic development:
    1. Take a minute to think of this – and make your own decision. Ask yourself: “Do I want to be part of a project that will produce a potentially catastrophic development?”. Set your own standards.
    2. When you make your decision – make a point of taking time out every day – give yourself a minute to think of any major risks you may have glossed over today. Is there any one that your work today may impact negatively, either today or in the future?
    3. Make sure you are always current – new risks and new solutions are identified every day in our dynamic industry. It is your prerogative to make sure you are always current with technology.
    4. Learn how to make balanced decisions to deliver efficient risk management, and if you don’t know how to handle a specific situation, don’t just leave it – share the risk transparently with those responsible in your team and take educated decisions, even if you need to consult the client. Your experience will only grow by observing and asking mentors to give you their experience too.
    5. Finally if you are asked to blindly work on Impossible Situations where catastrophes are imminent without transparently communicating links to all stakeholders (including the end client), then make your own judgment call – are you going to be a part of the catastrophe, or the mitigation?


The Obligation to Fight Catastrophic Development is everyone’s responsibility. If you don’t, you bear on your shoulders the responsibility of potentially bringing harm on to others, perhaps very grave harm. The irony is that you can be a very hard worker, and yet by ignoring certain precautions, you can still be a catastrophic developer. One can only hope that we are always alert and aware of this fact. Our only defense against this is to continue to seek to be armed with knowledge, alertness and integrity.

Boxout: References

For further information, please browse these links out. Please note that the content in these pages can be deeply disturbing.

Bhopal Disaster:

Software Related Disasters:

This post was originally published in ITWorx Insite (April 2007).


28 Responses to “Catastrophic Development: Reflections on the Union Carbide Industrial Disaster in Bhopal”

  1. science said

    it was a very bad approach by you.
    it was never expected that you could do such pathetic
    please,never try it again………….

  2. It is a great article. What exactly do you mean by bad approach?

  3. aluminum french press…

    […]Catastrophic Development: Reflections on the Union Carbide Industrial Disaster in Bhopal « TechnicalArchitectureWorx[…]…

  4. Searching I noticed your blog book-marked as:
    Catastrophic Development: Reflections on the Union Carbide Industrial Disaster in Bhopal TechnicalArchitectureWorx.
    I’m assuming you book marked it yourself and wanted to ask if social book-marking gets you a large amount of targeted traffic? I’ve been thinking of doing some book-marking
    for a few of my sites but wasn’t certain if it would produce any positive results. Thanks.

  5. Greetings from Colorado! I’m bored at work so I decided to check out your blog on my iphone during lunch break. I love the information you provide here and can’t wait to take a
    look when I get home. I’m shocked at how fast your blog loaded on my cell phone .. I’m not
    even using WIFI, just 3G .. Anyways, wonderful blog!

  6. Muriel said

    Hola! I just discovered your web page: Catastrophic
    Development: Reflections on the Union Carbide
    Industrial Disaster in Bhopal TechnicalArchitectureWorx when I was browsing It looks as though someone enjoyed your blog so
    much they decided to bookmark it. I’ll certainly be returning here more often.

  7. Brianna said

    Hi! I just wanted to ask if you ever have any problems with hackers?

    My last blog (wordpress) was hacked and I ended up losing
    several weeks of hard work due to no back up. Do you have any solutions to stop

  8. Hey there your website url: http://archworx. seems
    to be redirecting to a completely different web-site when I click the home
    page link. You may want to have this looked at.

  9. Because the admin of this web site is working, no uncertainty very quickly it will be well-known, due to
    its quality contents.

  10. I am regular visitor, how are you everybody? This post posted at this web page is in fact pleasant.

  11. If you are going for finest contents like I do, simply pay a
    visit this website daily since it provides feature contents, thanks

  12. First of all I would like to say awesome blog! I had a quick question that I’d like to ask if you don’t mind.
    I was curious to find out how you center yourself and clear your head
    prior to writing. I’ve had difficulty clearing my mind in getting my thoughts out there. I truly do enjoy writing but it just seems like the first 10 to 15 minutes tend to be wasted just trying to figure out how to begin. Any suggestions or hints? Thanks!

  13. It’s amazing to go to see this web site and reading the views of all friends regarding this piece of writing, while I am also keen of getting knowledge.

  14. Howdy! This is my first visit to your blog! We are a collection of volunteers and
    starting a new initiative in a community in the same niche.
    Your blog provided us useful information to work
    on. You have done a extraordinary job!

  15. Incredible quest there. What happened after?
    Good luck!

  16. Can I just say what a relief to discover somebody who really knows what they’re talking about on the internet. You actually know how to bring an issue to light and make it important. A lot more people really need to read this and understand this side of your story. It’s surprising you aren’t more popular because you surely possess the gift.

  17. Wow, this piece of writing is nice, my younger sister is
    analyzing these things, so I am going to tell her.

  18. I think this is one of the most important information for me.
    And i’m glad reading your article. But should remark on some general
    things, The site style is great, the articles is really nice
    : D. Good job, cheers

  19. Pretty section of content. I just stumbled upon your website and
    in accession capital to assert that I get in fact enjoyed account your blog
    posts. Anyway I’ll be subscribing to your augment and
    even I achievement you access consistently quickly.

  20. When some one searches for his vital thing, therefore he/she needs to be available
    that in detail, so that thing is maintained over here.

  21. Greetings I am so grateful I found your blog page, I really found you by accident, while I was browsing on Google for something else, Nonetheless I am here now and would just like to say thank you for
    a fantastic post and a all round interesting blog (I also love the theme/design), I don’t have time to read it all at the moment but I have saved it and
    also added in your RSS feeds, so when I have time I will be back to
    read much more, Please do keep up the superb

  22. Thank you, I’ve just been searching for info about this topic for a long time and
    yours is the best I’ve found out so far. But, what about the conclusion?
    Are you positive about the supply?

  23. It is not my first time to pay a quick visit this website, i am
    browsing this web site dailly and take good facts from here every day.

  24. Faustino said

    Hey There. I found your blog using msn. This is an extremely well
    written article. I will be sure to bookmark it and return
    to read more of your useful info. Thanks
    for the post. I will definitely return.

  25. Feng Shui tea (9): This tea is a combination of traditional oriental herbs designed to help reduce
    the body’s susceptibility to electromagnetic stresses. If
    you experience problems with your eyes or vision that are not solved by the usual means,
    this is an excellent visual therapy to turn to. Apart from being
    used in jewelry making quartz beads are used in making watches, radios, and in numerous mechanical devices as oscillators.

  26. azurite said

    Unlike other gems, which are usually varieties of a single mineral,
    jade has complex mineralogical attributes. Let’s talk about
    several these gemstones as are used by the psychic to improve their psychic ability.
    These gemstones are perfect to open one’s consciousness and not to mention, enrich one’s creativity.

  27. In the modern age bifocals presents co many types such as a
    material called non crystalline. They were widely
    used in World War I for attacking enemy surface
    vessels or other submarines, blockade running and reconnaissance.
    Their tactics were to operate primarily on the surface using their regular engines, then submerging to attack, using battery power.

  28. you are definitely a very good webmaster. The web site loading speed is incredible. It seems that you are doing any unique trick. Moreover, The contents are masterwork. you’ve completed a great job on this topic!

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )


Connecting to %s

%d bloggers like this: