Case Studies

A collection of case studies and incident investigations related to safety-critical and other high-integrity systems.

The following list of case studies is categorised into the domains to which they relate. For those seeking Australian case studies, they include the Longford Esso gas plant explosion, the Westralia fire, the Granville train crash, the Canberra Hospital demolition, the Robert Sergi Bridge collapse, and the Kianga No. 1, Moura No. 2, and Moura No. 4 mine explosions.

Transportation incidents (not including the traffic control incidents below) include those from space (the Apollo 13, Ariane 5, Aurora 7, Challenger, and Mars Climate Orbiter spacecraft), rail (incidents at Granville, Moorgate, Gare de Lyon, and in the Channel and Armi tunnels) aviation (on takeoff from Chicago, into Mt Osutaka, above the Florida Everglades, and on landing at Warsaw and Livermore), maritime (the Westralia fire) and automotive (the Ford Pinto fires) industries.
Traffic control failures led to train crashes at Clapham Junction, Norwich Yarmouth and Staplehurst, and (at a slightly higher level of traffic control) the London Ambulance dispatch failure.
Process industry mishaps include those at Bhopal, Flixborough, Guadalajara, Longford, Mexico City and Pasadena, and on Piper Alpha.
The defence industry was involved in the Patriot Missile mistiming and the Westralia fire.
Medical treatment was incorrectly applied in the Therac-25 mistreatment, and was unable to be given in a timely fashion in the London Ambulance dispatch failure.
Power generation, and more specifically the nuclear industry, was involved in the Three Mile Island release, and power distribution in the musical blackout.
The Canberra Hospital demolition and the Robert Sergi Bridge collapse are examples of mishaps in the building industry.
The mining industry was involved in the Kianga No. 1, Moura No. 2 and Moura No. 4 mine explosions.

Why?

A greater understanding of the errors of the past can help your organisation to avoid repeating them.

Aside:

Incident investigation has the benefit of hindsight, and it is often easier to find flaws in failure than gems in success.

More?

You can learn about some means of avoiding similar outcomes through training courses offered by Savive.