Case Studies

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The Columbia Accident: When Uncertainty Becomes the Decision

The Space Shuttle Columbia disintegrated during re-entry on 1 February 2003, killing all seven crew members. The proximate cause was a breach in the leading edge of the left wing, created when a piece of foam insulation broke off the external tank 81.9 seconds after launch and struck the reinforced carbon-carbon panels at high velocity. […]

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Uber Autonomous Crash: Seeing vs Understanding

This case study sits at the boundary of aviation and autonomous systems — included here because the failure modes it demonstrates are directly relevant to autonomous aviation, and because the safety architecture questions it raises are central to the certification of autonomous flight systems. On 18 March 2018, an Uber self-driving Volvo XC90 test vehicle

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Swissair Flight 111 — The In-Flight Fire That Couldn’t Be Stopped

Swissair 111 perished because an in-flight fire started in the entertainment system wiring above the cockpit ceiling and spread through the aircraft faster than any checklist could address it. The wiring used insulation material that had passed certification tests — tested individually, in isolation, at standard conditions. Installed in a dense bundle in an enclosed

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Japan Airlines Flight 123: Structural Fatigue and Systemic Maintenance Drift

Japan Airlines Flight 123 is the deadliest single-aircraft accident in aviation history. Five hundred and twenty people died on 12 August 1985 when the aft pressure bulkhead of a Boeing 747 — improperly repaired seven years earlier after a routine tailstrike — ruptured explosively at 23,900 feet, destroying the vertical fin and severing all four

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Tenerife Airport Disaster — When a System Has No More Margins Left

The Tenerife disaster is not the story of one mistake. It is the story of a system that had been stripped of every redundancy, every barrier, and every margin — until nothing remained between 583 people and catastrophe. On 27 March 1977, a bomb at Las Palmas airport forced dozens of aircraft to divert to

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Lion Air Flight 610 — MCAS and the Architecture of a Single Point of Failure

Lion Air Flight 610 is the accident that exposed a fundamental systems engineering failure in one of the world’s most commercially critical aircraft programs. The Boeing 737 MAX MCAS — Manoeuvring Characteristics Augmentation System — was a flight control system installed to address a handling characteristic of the re-engined 737, designed to activate when the

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Air France Flight 447 — When the Automation Stopped and the Crew Couldn’t Take Over

Air France 447 is the defining 21st-century case study in automation dependency and the degradation of manual flying proficiency. When the aircraft’s pitot tubes iced over simultaneously and the airspeed indications became unreliable, the autopilot and autothrust disconnected — exactly as designed. The crew was returned control of a perfectly serviceable aircraft at cruise altitude