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Cases where bad documentation caused accidents or worse
Subject:Cases where bad documentation caused accidents or worse From:HALL Bill <bill -dot- hall -at- tenix -dot- com> To:"TECHWR-L" <techwr-l -at- lists -dot- raycomm -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.
Please reply directly as well as to the list, as I am on digest mode and I
need some pointers today, if possible.
Many thanks.
Bill Hall
Documentation Systems Analyst
Strategy and Development Group
Tenix Defence
Nelson House, Nelson Place
Williamstown, Vic. 3016
Australia
Tel: +61 3 9244 4820
+61 3 9244 4000 (Switch)
URL: http://www.tenix.com
Mailto:bill -dot- hall -at- tenix -dot- com
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