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Re: Cases where bad documentation caused accidents or worse
Subject:Re: Cases where bad documentation caused accidents or worse From:Sandy Harris <pashley -at- storm -dot- ca> To:"TECHWR-L" <techwr-l -at- lists -dot- raycomm -dot- com> Date:Thu, 18 Apr 2002 21:27:27 -0400
HALL Bill wrote:
>
> ... 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. ...
Check the archives a month or so back for a thread I started,
about an incident in which a B-52 bombed a US battalion HQ
due to a soldier not realising that after a battery change
his handheld GPS/rangefinder unit showed his own position,
not the Taliban target.
I used to subscribe to "Defense Computing" magazine, one of
those ones you get free if you answer the questions on the
form right. Remember the incident ten years or so back when
a US ship shot down an Iranian airliner in the Gulf, killing
a whole lot of civilians? The magazine claimed that was at
least partially a training/documentation/communication error.
The display of the aircraft's position was not realtime. The
spec hadn't asked for that; it would have cost too much. The
captain didn't know that. He gave some radio warnings, and
when they didn't turn away, he fired. They had turned before
he fired, but it wasn't visible on his screen and no-one had
told him the display wasn't realtime.
A year or so later, another US ship made the opposite error
and didn't fire soon enough to defend itself from what
turned out to actually be hostile aircraft. I wonder if that
captain was constrained by some procedure put in place after
the first incident.
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