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Re: Cases where bad documentation caused accidents or worse
Subject:Re: Cases where bad documentation caused accidents or worse From:"Dick Margulis " <margulis -at- mail -dot- fiam -dot- net> To:"TECHWR-L" <techwr-l -at- lists -dot- raycomm -dot- com> Date:Thu, 18 Apr 2002 21:05:03 -0400
Envisioning Information, Edward Tufte's third book, gives the case history of the Challenger disaster, with reproductions of original charts and diagrams and a thorough exegesis of how poor information design contributed directly to the decision to launch.
---------- Original Message ----------------------------------
From: HALL Bill <bill -dot- hall -at- tenix -dot- com>
Reply-To: HALL Bill <bill -dot- hall -at- tenix -dot- com>
Date: Fri, 19 Apr 2002 09:46:07 +1000 (EST)
>
>Someone in the last couple of days cited an accident investigation of an
>airline crash in Puerto Rico where a bolt was incorrectly installed in an
>engine due to bad documentation.
>
>I have been unable to track down the post, and it has suddenly become
>relevant to come up with a list of cases where documentation failures were
>the direct cause of accidents or major losses. These would also represent
>cases from which we can learn valuable lessons about our trade.
>
>There are some Australian cases where the lack of documentation or the
>failure to follow procedures that were documented caused major disasters
>(e.g., respectively the Longford Gas Plant disaster, and the fire onboard
>HMAS Westralia), but it would be helpful if people could list other cases
>where documentation failures had obvious consequences.
>
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