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.
Jack in the Box: how a temperature spec cost four children their lives
In aerospace, when I rate a failure mode as Severity 10 on a PFMEA, the next question is not "can we work around this." The question is "what engineered control eliminates the failure mode." If a…
IKEA Malm: how ignored misuse caused a 17-million-unit recall
Hierarchy of controls. Elimination, substitution, engineering controls, administrative controls, and at the very bottom — the warning label. A leaflet stuffed in a flat-pack box is an administrative…
Sony: how particle contamination ignited a 9-million-unit battery recall
A microscopic metal particle caused Sony's 2006 recall of 9 million batteries. A case study showing defect cost is driven by system scale, not particle size.
Theranos: how bypassing APQP and validation built a $9bn fraud
A quality professional examines how Theranos scaled process bypass and ignored validation to a $9bn valuation—putting real patients at risk.
De Havilland Comet: how a window shape dictated aerospace fatigue testing
The gap between "strong enough on paper" and "strong enough after the three-thousandth pressurisation cycle" is the gap that killed fifty-six people. I think about this every time a junior engineer…
Ariane 5: how unvalidated software reuse doomed a maiden flight in 40 seconds
Ariane 5's maiden flight self-destructed in 40 seconds due to inherited Ariane 4 software that couldn't handle higher velocities—a $500M lesson in unvalidated code reuse.
Mars Climate Orbiter: how a missing interface requirement cost $327m
Two good teams, two solid systems, one assumption nobody wrote down — the interface failure pattern behind the $327M Mars Climate Orbiter loss.
Ford Pinto: when a cost-benefit calculation overrules PFMEA
I have been in the room where the spreadsheet says ship and the PFMEA says stop. The Pinto is what happens when the spreadsheet wins – when a cost-benefit calculation is allowed to override the…
Guidant: how a known short-circuit became the first device-maker crime
Guidant fixed a deadly defibrillator flaw on the production line but stayed silent about flawed units already implanted—becoming the first device maker criminally convicted.
Alaska 1282: How undocumented rework led to an in-flight blowout
Four missing bolts and zero production records: how undocumented rework on a 737 MAX 9 door plug led to a sudden in-flight blowout at 16,000 feet.
Maggi 2015: when a legal defense failed quality containment
When a contamination crisis hit Maggi noodles in India, legal defense trumped operational containment—and ~38,000 tonnes of product were destroyed in a recall that erased 80% market share.
DePuy ASR: how post-market surveillance failure became a $4B recall
Here is an uncomfortable observation from someone who has spent two decades chasing defects across automotive and aerospace: most quality catastrophes don't fail because no one saw the signal. They…