The Case File Library
Publicly documented quality failures, dissected for lessons — case file by case file. Recalls, groundings, outbreaks: what actually failed, and which discipline would have caught it.
Concorde AF4590: how catalogued precursors became a fatal cascade
Here is an uncomfortable observation for anyone who owns occurrence data: on 25 July 2000, Concorde's tyre-burst file was not thin. The type had logged bursts for two decades, including a 1979 event…
Patriot at Dhahran: how truncated arithmetic became a 687-metre miss
Patriot at Dhahran: how truncated arithmetic became a 687-metre miss Twenty-eight soldiers died because a computer could not write one-tenth of a second in binary. Not slowly. Not occasionally. The…
Hubble: how ignored test data blurred the sharpest eye in orbit
Here is an uncomfortable observation for anyone who signs test reports for a living: Hubble's mirror was flawless. Polished to a precision the optical world had rarely achieved, certified by every…
Melamine 2008: how a passing protein test poisoned 300,000 infants
Melamine 2008: how a passing protein test poisoned 300,000 infants The situation China's dairy chain in 2008 was a three-tier machine: millions of smallholders with a couple of cows each, thousands…
Thalidomide: how an unproven sedative rewrote drug regulation
Here is an uncomfortable observation from two decades of chasing defects: most failures I have worked were execution failures. Sound design, fumbled somewhere downstream. Thalidomide was the…
Piper Alpha: how a permit-to-work failure killed 167 men
The paperwork was in order. That detail should keep every quality manager awake. Piper Alpha did not burn because someone skipped the permit system. It burned because the system produced a correct…
Exxon Valdez: how three tolerated deviations spilled 11 million gallons
Here is an uncomfortable observation from two decades of closing 8Ds: a root-cause analysis that ends at "operator error" has not ended. It has stopped. Exxon Valdez is the proof. A tired third mate,…
Chernobyl: how a delayed safety test met an unforgiving design
On the RBMK, the emergency shutdown button briefly made the reactor run hotter. A look at how a postponed turbine test met a design that amplified every mistake.
St. Jude Riata: how a silent wear mechanism defeated every monitoring system
Here is an uncomfortable observation: every monitoring system attached to the Riata lead worked exactly as designed, and roughly 128,000 patients were still carrying cables wearing through their own…
Uber Tempe: how suppressed braking and a phone killed Elaine Herzberg
The situation Uber's Advanced Technologies Group was testing on public roads in Arizona because Arizona asked the fewest questions. California's regulator had all but shown them the exit; Phoenix…
Jeep Grand Cherokee: how a packaging decision outran crashworthiness
Here is an uncomfortable observation from two decades of gateway reviews: the fuel tank never wins a packaging argument. It has no advocate in the studio, no line on the option sheet, no seat at the…
Flint: how a skipped corrosion inhibitor poisoned a city
Nobody in Flint shipped a bad part: a water-source swap skipped ~$100/day