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.
Three Mile Island: how a misleading indicator caused a partial meltdown
When a control panel indicator shows what was
Virgin Galactic: how a missing interlock turned human error fatal
I have sat in enough 8D review rooms to know the pattern. The room goes quiet. The timeline goes on the wall. The discussion drifts toward "operator error." Someone reaches for stricter procedures, a…
Southwest 1380: how a fatigue fracture defeated engine containment
Borescope inspections caught visible wear for years—until they missed the micro-fatigue growing underneath. How a latent defect
DC-10 cargo door: how a false-lock design killed 346 people
The DC-10's cargo door design relied on a visual check that confirmed the lock cycled—not that it actually engaged—leading to two crashes and 346 deaths.
Apollo 13: how a dropped tank and a voltage mismatch caused a deep-space failure
Here is an uncomfortable observation: catastrophic failures rarely come from a single dramatic event. They come from a chain of small decisions, each defensible in isolation, that collectively strip…
Heartbleed: how unvalidated infrastructure became a global failure
Heartbleed exposed how the internet's most critical security infrastructure ran on unaudited, underfunded code — and why nobody asked the questions that matter.
Knight Capital: how a dead code flag bankrupted a firm in 45 minutes
When a dead code flag reached one old server out of eight, it woke an algorithm that bought high and sold low, bankrupting Knight Capital in 45 minutes.
BP Texas City: how cost cuts dismantled the process safety grid
BP's Texas City refinery disaster killed 15 and injured 180 after years of cost cuts eroded safety systems, leaving operators blind to warnings that had already been reported.
Union Carbide Bhopal: when degraded safety layers guarantee catastrophe
An auditor's perspective on how Union Carbide normalized the absence of safety systems at Bhopal, disabling every engineered barrier until catastrophe became inevitable.
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.