Examples of Data Safety Accidents
An infant boy died after a series of medical errors: incorrect information was entered into an electronic intravenous order; automatic alerts had been turned off; and a bag was mislabelled.
Anti-collision radar thresholds were apparently set incorrectly; there were also sizeable discrepancies between positions plotted on a chart and those displayed on the radar. The vessel grounded at more than 16 knots; no pollution occurred.
Following a signalling system design error, a passenger train had to unexpectedly apply its brakes; it stopped just 5 m short of a goods train.
A software misconfiguration led to 206 patients receiving radiation doses approximately 8 times higher than intended; the error persisted for 18 months.
An unapproved electronic chart system was apparently being used as the primary means of navigation for the passenger ferry The Pride of Canterbury. Due to user settings a charted wreck would not have been displayed on this system. The vessel grounded on the wreck, causing severe damage to her port propeller system.
Inaccurate (out of date) aerodrome charts led to take-off being attempted from the wrong runway. Aircraft overran the runway; 49 fatalities.
Contradictory advice from Traffic Collision Avoidance System (TCAS) and an air traffic controller led to a mid-air collision between two TCAS-equipped aircraft. 71 fatalities.
Movement of an artillery site led to errors in targeting. Artillery shells were fired more than a mile off target: 2 soldiers killed; 13 injured.
A software update led to miscalculation of the time an inmate was due to serve in prison. Although the results of the calculation could easily be checked, the problem persisted for 13 years and over 2,000 offenders were released early.
A mismatch in the units used by two software teams led to errors in the Flight Management System and, ultimately, the loss of a multi-million dollar space mission.
Controlled flight into terrain; the ground-based minimum safe altitude warning designed to alert air traffic controllers had been inhibited. 228 fatalities; 26 serious injuries.
Whilst drilling a test well, a rig crew inadvertently caused a flood in a nearby salt mine. The previously freshwater lake became a salt water lake and the flow of a river was reversed.
Speed restriction data failed to be passed to trains, placing pedestrians on level crossings at risk.
Inaccurate navigation data, relating to runway location, led to touchdown with left main gear off the paved surface. Aircraft written off.
Default settings meant that children were incorrectly recorded as adults, resulting in incorrect aircraft weight and balance. Take-off safety speed was exceeded by about 25 knots.
The Navigator Scorpio was sailing with out of date charts, the planned route was not checked and positional fixes were not taken as often as required. The vessel was grounded, but refloated on the rising tide, with no damage. After the event, false information was added to the navigation chart.
The ground control station was mis-configured following a change from MQ-1 to MQ-9 operations. The misconfiguration was not spotted. It caused any throttle position aft of full forward to command negative thrust. The aircraft decelerated below stall speed and impacted ground in unpopulated area.
Whilst attempting an automatic landing the Unmanned Air System (UAS) self-aborted. This abort was due to an incorrect set-up parameter that had been loaded by the crew. The crew elected to intervene rather than let the UAS self-recover. The air vehicle hit a new, unoccupied hangar; it was ultimately deemed ?non-repairable?.
At the time of writing, the investigation is continuing; possible controlled flight into terrain; possible issues with terrain / obstacle databases. Four fatalities.
High rates led to the saturation of the Inertial Measurement Unit (IMU); the lander prematurely believed it was on the ground and released its parachute; the lander was lost. The high rates should have been expected, but were not due to modelling deficiencies.
Incorrect data was disclosed during an investigation into indecent images. A welfare check was delayed on a child believed to be in crisis.
A software update apparently wiped the engine torque control parameters. Aircraft crash; four fatalities.
A Royal Navy submarine snagged the fishing gear of the trawler Karen. The trawler was dragged backwards at about 7 knots and suffered structural damage.
Two independent and inadvertent data entry errors meant weight used when calculating take-off performance was 10 tonnes less than actual weight. Tail strike.
A man suffering from Ebola was mistakenly sent home from a Dallas hospital. He later returned to hospital, was diagnosed but died; two nurses contracted Ebola but survived.
Incorrect data input to the Flight Management System, ‘E’ rather than ‘W’, meant loss of instruments. Aircraft had to return to Heathrow.
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DSIWG meeting #73 Links https://www.theregister.com/2022/12/14/microsoft_drivers_ransomware_attacks
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