The Case File Library
One publicly documented quality failure, dissected for lessons — a new case file every day. Recalls, groundings, outbreaks: what actually failed, and which discipline would have caught it.
Tylenol: how a $100M recall against advice set the crisis gold standard
When cyanide-laced Tylenol killed seven in 1982, J&J pulled 31M bottles nationwide against FBI and FDA advice—a $100M bet that rewrote crisis response and saved the brand.
Philips Respironics: how known foam risk became a 5.5M-device recall
One of the largest medical-device recalls on record: 5.5M Philips CPAP and ventilator units pulled after foam degradation risks went unaddressed—costing billions.
Samsung Note 7: how schedule pressure defeated dual-sourcing strategy
Samsung's Note 7 crisis shows how launch pressure undermines even dual-sourcing: two suppliers, two different failure modes, one $5.3 billion root cause.
Therac-25: what removing a hardware interlock costs in human lives
When AECL replaced physical safety interlocks with software checks in the Therac-25, three patients died from radiation overdoses—and the risk register was never updated.
Challenger: how a known seal defect became an acceptable flight risk
How NASA's normalization of a known O-ring defect turned a preventable failure into the Challenger disaster.
Volkswagen dieselgate: how software deception became a €30B quality failure
Volkswagen shipped defeat-device software in roughly 11 million diesel vehicles — compliant on the test stand, up to 40x over NOx limits on the road. The €30B lesson: a quality system whose gates can be deceived eventually will be.
Toyota unintended acceleration: when growth outran the andon cord
Toyota's 9-million-vehicle recall crisis exposed what happens when quality infrastructure scales slower than production volume, silencing critical field signals.
737 MAX MCAS: how delegated authority certified a single-point failure
How delegated authority allowed Boeing to self-certify a single-sensor flight control system—and what happens when quiet engineering compromises scale into tragedy.
GM ignition switch: how a silent redesign bypassed quality and cost 124 lives
A silent 2006 redesign of GM's ignition switch kept the same part number, leaving engineering records pointing at a nonexistent part and contributing to 124 deaths and a $900M settlement.
Takata: how suppressed test data became the largest recall in history
The Takata airbag recall exposed a hard truth: most quality catastrophes stem from known risks that governance systems failed to halt.