Incident Reviews
In-depth reviews of real-world incidents — what went wrong, why, and what the systemic fix looks like. Drawn from manufacturing, quality, safety, and operations.
- 7 min read
Ponte do Esqueleto: a 3-legged 5-Whys review of the Brazil rope-jump fatality
Most coverage stopped at the missing rope. A 3-legged 5-Whys shows the jurisdiction gap that made the fatality possible.
- 9 min read
"Prove it will fail": the sentence that launched Challenger
The engineers had the data and the right answer the night before Challenger launched. A single flip in the burden of proof was enough to overrule them. How a go/no-go hold point quietly inverts under pressure — and how to catch it in your own organization.
- 9 min read
Five whys behind the CrowdStrike outage: where the validator gap actually lived
A blameless 5-Whys incident review of the 2024-07-19 CrowdStrike Falcon outage using only public sources. The validator bug was the trigger; the architecture made it a disaster.