Root Cause Analysis

From: Pinizzotto,Russell (
Date: Fri Feb 07 2003 - 16:43:39 EST

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    Dale et al:
    I agree with Dale that these types of things very often uncover fundamental
    design flaws.  That's why it takes so long to get something back into
    service after it's figured out.
    Another interesting example is the hotel bridge that collapsed during a
    party in Kansas City.  As it turns out, the bridge design depended on ONE
    bolt.  When it failed, the cascading stresses caused the others to exceed
    their design margins and fail also and the entire structure fell several
    stories.  Those bridges aren't made that way anymore.
    I was thinking about the Turkish airline crash in Paris.  I was in graduate
    school at the time and we actually analyzed the pin I was talking about.  It
    had microscopic markings that indicated that it had been moved inwards
    repeatedly to make the baggage door easier to close.  Unfortunately, the
    baggage handler who closed that door was also on the plane.
    Best Regards,
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