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01 · Boeing 737 MAX / MCAS (2018–2019) — component-vs-system, automation-over-trust — a single sensor with no cross-check, certified as a Speed Trim add-on.
SPEC MET — OUTCOME MISSED
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02 · Mars Climate Orbiter (1999) — interface-nonconformance — a correct interface spec, simply not followed.
SPEC MET — OUTCOME MISSED
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03 · Ariane 5 Flight 501 (1996) — component-vs-system, under-specification — code correct for Ariane 4, fatal 40 seconds into Ariane 5.
SPEC MET — OUTCOME MISSED
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04 · Space Shuttle Columbia (2003) — normalization-of-deviance — foam strikes reclassified from near-misses to routine maintenance.
SPEC MET — OUTCOME MISSED
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05 · Space Shuttle Challenger (1986) — normalization-of-deviance — a Criticality-1 waiver signed, then re-signed, for every flight after.
SPEC MET — OUTCOME MISSED
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06 · Post Office Horizon (1999–2015 and after) — model-as-truth, automation-over-trust — a legal presumption of reliability that put the burden of proof on the accused.
SPEC MET — OUTCOME MISSED
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07 · Nimrod XV230 (2006) — wrong-metric, under-specification — a signed £400k Safety Case that missed the exact hazard that killed the crew.
SPEC MET — OUTCOME MISSED
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08 · Genesis (2004) — component-vs-system, under-specification — three review gates, one inverted switch, none caught it.
SPEC MET — OUTCOME MISSED
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09 · Schiaparelli (2016) — literal-rule-harm, under-specification — a saturated sensor told the computer it was already on the ground.
SPEC MET — OUTCOME MISSED
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10 · Mars Polar Lander (1999) — under-specification — no requirement existed to clear a spurious touchdown signal.
SPEC MET — OUTCOME MISSED
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11 · Starliner OFT-1 (2019) — component-vs-system — every component passed; nothing tested the mission as a whole.
SPEC MET — OUTCOME MISSED
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12 · OceanGate Titan (2023) — INVERSE — inverse-no-spec — certification refused, judgment unconstrained by any external structure.
NO SPEC — OUTCOME MISSED
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13 · Therac-25 (1985–1987) — under-specification, automation-over-trust — hardware interlocks removed on trust in software with a race condition.
SPEC MET — OUTCOME MISSED
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14 · Mid Staffordshire NHS Foundation Trust (2005–2009) — goodhart, wrong-metric — targets and finances met while mortality signals were explained away.
SPEC MET — OUTCOME MISSED
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15 · Bristol Royal Infirmary (1988–1995) — INVERSE — inverse-no-spec — no outcome-monitoring system existed at all.
NO SPEC — OUTCOME MISSED
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16 · NHS A&E Four-Hour Target (2000s) — goodhart, spec-gaming — ambulances queued outside to stop the clock.
SPEC MET — OUTCOME MISSED
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17 · WHO Surgical Safety Checklist, Ontario (2008–2010) — wrong-metric — high compliance, no significant change in mortality or complications.
SPEC MET — OUTCOME MISSED
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18 · Knight Capital (2012) — under-specification, component-vs-system — a compliance review that never asked whether the trading system itself could malfunction.
SPEC MET — OUTCOME MISSED
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19 · 2008 Financial Crisis — AAA Mortgage Securities — goodhart, model-as-truth — 83% of 2006's triple-A securities eventually downgraded.
SPEC MET — OUTCOME MISSED
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20 · JPMorgan "London Whale" (2012) — goodhart, spec-gaming — a new VaR model brought the number back within limits; the exposure kept growing.
SPEC MET — OUTCOME MISSED
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21 · 2010 Flash Crash — literal-rule-harm, under-specification — a sell algorithm executed its 9%-of-volume target exactly, without regard to price or time.
SPEC MET — OUTCOME MISSED
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22 · Long-Term Capital Management (1998) — model-as-truth — spread relationships treated as stable until Russia's default confounded them all at once.
SPEC MET — OUTCOME MISSED
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23 · Ofqual 2020 A-Level Grading — wrong-metric — a school-level statistical brief met; 39.1% of grades downgraded individually.
SPEC MET — OUTCOME MISSED
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24 · Robodebt (2015–2019) — automation-over-trust, wrong-metric — an income-averaging rule run after being told internally it did not accord with legislation.
SPEC MET — OUTCOME MISSED
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25 · SyRI (2020) — under-specification — a fraud-risk score no one outside the system could actually see.
SPEC MET — OUTCOME MISSED
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26 · Dutch Childcare Benefits Scandal — Toeslagenaffaire (2013–2019) — literal-rule-harm — an all-or-nothing clawback rule with no proportionality and no override.
SPEC MET — OUTCOME MISSED
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27 · FBI Virtual Case File (2000–2005) — under-specification — scope grew 80% against an intent that was never re-baselined.
SPEC MET — OUTCOME MISSED
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28 · Denver International Airport Baggage System (1994–1995) — under-specification — a spec too complex for anyone to hold in judgment while writing it.
SPEC MET — OUTCOME MISSED
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29 · London Ambulance Service CAD (1992) — automation-over-trust — dispatcher judgment removed, nothing put back in its place.
SPEC MET — OUTCOME MISSED
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30 · Healthcare.gov Launch (2013) — wrong-metric — a completed readiness checklist standing in for tested performance under real load.
SPEC MET — OUTCOME MISSED
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31 · Zillow Offers (2021) — goodhart — a predicted price that became the buy signal it was meant only to inform.
SPEC MET — OUTCOME MISSED
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32 · Amazon Recruiting Tool (reported 2018) — goodhart, model-as-truth — a decade of hiring data treated as intent nobody had actually authored.
SPEC MET — OUTCOME MISSED
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33 · Facebook Meaningful Social Interactions (2018) — goodhart — a single engagement score that rewarded the content it should have suppressed.
SPEC MET — OUTCOME MISSED
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34 · Tesla Autopilot Recall (2023) — under-specification, automation-over-trust — a Level 2 spec with no boundary for foreseeable driver misuse.
SPEC MET — OUTCOME MISSED
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35 · Microsoft Tay (2016) — under-specification — a learning objective with no boundary, trained on the same stream it was deployed into.
SPEC MET — OUTCOME MISSED
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36 · Grenfell Tower (2017 fire; 2024 Phase 2 report) — spec-gaming — guidance mistaken for the safety outcome it was meant to protect, on top of manipulated test data.
SPEC MET — OUTCOME MISSED
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37 · Deepwater Horizon (2010) — wrong-metric — an exemplary personal-injury record in the same year process safety failed.
SPEC MET — OUTCOME MISSED
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38 · BP Texas City Refinery Explosion (2005) — wrong-metric — the same substitution diagnosed here recurred five years later at Deepwater Horizon.
SPEC MET — OUTCOME MISSED
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39 · Fukushima Daiichi (2011) — capture — a regulator that had lost independence from the operator it was meant to check.
SPEC MET — OUTCOME MISSED
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40 · Piper Alpha (1988) — normalization-of-deviance — a permit-to-work procedure habitually departed from, never reconciled.
SPEC MET — OUTCOME MISSED
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41 · Bun Zig-to-Rust Rewrite (2026) — SUCCESS POLE — success-pole — a test oracle held apart from the rewrite, enforced implementer/reviewer separation, and a human holding the merge seam — with one unexpired standing waiver left over.
OUTCOME MET
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