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The following list of case studies is categorised into the
domains
to which they relate.
-
Transportation
accidents
(not including the
traffic control
incidents
below)
include those from
space
(the
Apollo 13 explosion,
Ariane 5 launch failure,
Aurora 7 splashdown,
Challenger launch explosion,
and
Mars Climate Orbiter loss),
rail
(crashes at
Granville,
Moorgate
and
Gare de Lyon,
the
fire
in the
Channel Tunnel,
and the
Armi Tunnel stall),
aviation
(crashes
on takeoff from
Chicago
and into
Mt Osutaka,
the controlled descent into terrain (the Florida Everglades) by a
Valujet
and a
Lockheed Tristar,
overrunning the runway at
Warsaw,
and suffering a stray
golf ball at Livermore),
maritime
(the
Westralia fire)
and
automotive
(the
Ford Pinto fires)
industries.
-
Traffic control
failures led to
train
collisions 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
the release of methyl isocyanate in
Bhopal,
the cyclohexane explosion in
Flixborough,
the explosion in the sewers in
Guadalajara,
the gas plant explosion in
Longford,
the LPG terminal explosion in
Mexico City,
the Phillips 66 ployethylene explosion in
Pasadena,
and
the
Piper Alpha oil platform inferno.
-
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.
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Why?
A
greater understanding
of the errors of the past can help your organisation to avoid repeating them.
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