Case studies: long runs of success, then failure

The cases #

1. The 1995 top landing Hang gliding · July 1995

   Some 1,500 landings on the hilltop over fifteen years, each a success, then a hard crash after a flawless approach. The case where Murphy’s Corollary was first recognized.

2. The 2015 certification launch Hang gliding · February 3, 2015

   A deadline, pilots depending on him, and a wind that wasn’t going to improve. Mike went, seven weeks before he first presented the paper.

   From the 2018 Gulfstream talk; not in the paper.

3. Apollo 1 Spaceflight · 1967

   NASA had a history of success with a pressurized pure-oxygen environment in manned capsules, and even previous fires in such environments. The Senate committee concluded that NASA’s long history of successes with pure oxygen “led to overconfidence and complacency.”

4. Challenger Spaceflight · 1986

   Shuttles flew successfully with O-ring erosion and hot-gas blow-by in the booster joints. Influenced by repeated successes, NASA and Thiokol expanded both the blow-by they accepted and the low temperatures they would launch in. Feynman called it “a kind of Russian roulette.”

5. Columbia Spaceflight · 2003

   Shuttles re-entered and landed with heat-shield tiles damaged by foam shed from the external tank. “With each successful landing,” the board wrote, “it appears that NASA engineers and managers increasingly regarded the foam-shedding as inevitable, and as either unlikely to jeopardize safety or simply an acceptable risk.”

6. The F-86 aileron bolt Aircraft production · from Yeager’s autobiography

   A series of crashes traced to a bolt on the aileron cylinder installed upside down, reportedly by one worker who felt he knew better. Murphy’s Law itself: if it can be done wrong, eventually it will be. Design it out.

Cases by factor #

For trainers looking for a case that shows a particular factor. ● strongly present, ○ also present.