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Old 19th Dec 2010, 10:48
  #446 (permalink)  
Mike7777777
 
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In overview, from the information within the public domain, the underlying issues behind the Concorde crash are familiar to those who design complex systems and investigate catastrophic failures of complex systems.

1) O&M (or equivalent) documentation states "x"
2) Operatives/users (including maintenance staff) do not comply with "x" for various reasons (cost, time, convenience, "we've always done it like this", "don't see why we need to do that" etc)
3) The complex system generally continues to perform without catastrophic failure for a time period, this can be perceived by operatives/users as validation for non-compliance to "x"
4) Catastrophic failure occurs
5) Subsequent investigation identifies that non-compliance to "x" was a primary factor leading to catastrophic failure
6) Responsibility and liability ("blame") is allocated
7) Reduction in risk occurs .. until the next catastrophic failure

Prime examples are Chernobyl, Piper Alpha, Deep Water Horizon (probably ..)
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