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<FONT SIZE=+1><BLOCKQUOTE><CENTER>
<B><FONT SIZE=+1>Illustrative Risks to the Public</FONT></B><BR><B><FONT SIZE=+1>in the Use of Computer Systems</FONT></B><BR><B><FONT SIZE=+1>and Related Technology</FONT></B> <BR>Peter G. Neumann, Computer Science Laboratory, <BR>SRI International, Menlo Park CA 94025-3493<BR></CENTER></BLOCKQUOTE>
<FONT SIZE=+0><P>Risks cases as of <B>15 January 2001,</B>
Copyright 2001, Peter G. Neumann, SRI
International EL243, Menlo Park CA 94025-3493 (e-mail Neumann@csl.sri.com;
<A HREF="http://www.CSL.sri.com/neumann/">http://www.CSL.sri.com/neumann/</A>;
telephone 1-650-859-2375; fax 1-650-859-2844): Editor, ACM SIGSOFT Software
Engineering Notes, 1976-93, Assoc.Ed., 1994-; Chairman, ACM Committee on
Computers and Public Policy (CCPP); Moderator of the Risks Forum
(comp.risks); cofounder with Lauren Weinstein of People For Internet
Responsibility (<A HREF="http://www.pfir.org">http://www.pfir.org</A>,
announced in RISKS-20.65). See also Lauren's Privacy Forum Digest
(<A HREF="http://www.vortex.com">http://www.vortex.com</A>),
partially sponsored by the ACM CCPP.
<H1><A NAME="1">Contents</A></H1>
<MENU>
<LI><A HREF="#1">Contents</A>
<LI><A HREF="#2">Descriptor Symbols</A>
<LI><A HREF="#3">Items Listed by Categories</A>
<MENU>
<LI><A HREF="#4">Recent Items (yet to be merged in)</A>
<LI><A HREF="#5">Space</A>
<LI><A HREF="#6">Defense</A>
<LI><A HREF="#7">Military Aviation</A>
<LI><A HREF="#8">Commercial Aviation</A>
<LI><A HREF="#9">Rail, Bus, and Other Public Transit</A>
<LI><A HREF="#10">Automobiles</A>
<LI><A HREF="#11">Motor-Vehicle and related Database Problems</A>
<LI><A HREF="#12">Electrical Power (nuclear and other) and Energy</A>
<LI><A HREF="#13">Medical, Health, and Safety Risks</A>
<LI><A HREF="#14">Other Environmental Risks</A>
<LI><A HREF="#15">Robots and Artificial Intelligence</A>
<LI><A HREF="#16">Other Control-System Problems</A>
<LI><A HREF="#17">Other Computer-Aided-Design Problems</A>
<LI><A HREF="#18">Accidental Financial Losses, Errors, System Outages</A>
<LI><A HREF="#19">Financial Frauds and Intentionally Caused Losses</A>
<LI><A HREF="#20">Stock-Market Phenomena</A>
<LI><A HREF="#21">Telephone Frauds</A>
<LI><A HREF="#22">Other Telephone and Communication Problems</A>
<LI><A HREF="#23">Election Problems</A>
<LI><A HREF="#24">Insurance Frauds</A>
<LI><A HREF="#25">Security Problems</A>
<LI><A HREF="#26">Cryptography</A>
<LI><A HREF="#27">April Foolery and Spoofs</A>
<LI><A HREF="#28">Privacy</A>
<LI><A HREF="#29">Spamming, Junkmail, and Related Annoyances:</A>
<LI><A HREF="#30">Other Unintentional Denials of Service:</A>
<LI><A HREF="#31">Law Enforcement Abuses, False Arrests, etc..</A>
<LI><A HREF="#32">Identity Theft, Mistakes, Related Problems</A>
<LI><A HREF="#33">Other Legal Implications</A>
<LI><A HREF="#34">Other Aggravation</A>
<LI><A HREF="#35">Calendar/Date/Clock Problems including Y2K</A>
<LI><A HREF="#36">The Game of Chess:</A>
<LI><A HREF="#37">Further Miscellaneous Hardware/Software Problems</A>
<LI><A HREF="#38">Other Computer System Development Difficulties</A>
<LI><A HREF="#39">Achieving Better System Development and Operation</A>
<LI><A HREF="#40">The Proper Role of Technology?</A>
</MENU>
<LI><A HREF="#41">Reference Materials</A>
<MENU>
<LI><A HREF="#42">Books</A>
<LI><A HREF="#43">Inside Risks</A>
</MENU>
</MENU>
<P>This list summarizes items that have appeared in the Internet Risks Forum
Digest (RISKS) - which I moderate (comp.risks newsgroup) - and/or
published ACM SIGSOFT Software Engineering Notes (SEN). In this collection
of mostly one-liner summaries, (R i j) denotes RISKS volume i issue j; (S
vol no:page) denotes an issue of SEN, where there has been one volume per
year, with vol 25 being the year 2000; page numbers are given primarily only
from 1993 on; (SAC vol no) indicates an item in the quarterly SIGSAC
Security and Control Review, where vol 16 is 1998, which was the final
volume. The SEN material prior to 1995 is summarized in my Computer-Related
Risks book (see below). Later material is gradually being brought on-line,
as noted below.
<P>Some incidents are well documented, while others need further study. A few
are of questionable authenticity, and are noted as such ("bogus???").
Please send me corrections and new cases, along with suitable references.
This list is updated at least quarterly and is browsable on-line
(<CODE>ftp://ftp.CSL.sri.com/neumann/illustrative.html</CODE> courtesy of Otfried
Cheong's Hyperlatex), also printable in a two-column 8-point format
(<A HREF="illustrative.pdf">illustrative.pdf</A> and
<A HREF="illustrative.ps">illustrative.ps</A>). [Incidentally, Hyperlatex
is wonderful Free Software:
(<A HREF="http://www.cs.ust.hk/~otfried/Hyperlatex/">http://www.cs.ust.hk/~otfried/Hyperlatex/</A>,
and after September 2000:<BR><A HREF="http://www.cs.uul.nl/~otfried/Hyperlatex">http://www.cs.uul.nl/~otfried/Hyperlatex</A>).]
<PRE>
SEN regular issues, by year, volume&number
..1976,vol 1: #1 = May; #2 = Oct
==================================
..year 1977 78 79 80 81 82 83 84 85
volume 2 3 4 5 6 7 8 9 10
---------------------------------
Jan #1 1 1 1 1 1 1 1 1
Apr #3 2 2 2 2 2 2 2 2
Jul #4 3 3 3 3 3 3 4 3
Oct #5 4 4 4 5 4 5 5 5
==================================
..year 1986 87 88 89 90 91 92 93 94
volume 11 12 13 14 15 16 17 18 19
---------------------------------
Jan #1 1 1 1 1 1 1 1 1
Apr #2 2 2 2 2 2 2 2 2
Jul #3 3 3 5 3 3 3 3 3
Oct #5 5 4 6 5 4 4 4 4
==================================
..1995,vol20: #1=Jan; 2=Apr; 3=Jul; 5=Dec
..1996,vol21: #1=Jan; 2=Mar; 4=Jul; 5=Sep
..1997,vol22: #1=Jan; 2=Mar; 4=Jul; 5=Sep
..1998,vol23: #1=Jan; 3=May; 4=Jul; 5=Sep
..1999,vol24: #1=Jan; 3=May; 4=Jul; 5=Dec
..2000,vol25: #1=Jan; 2=Mar; 3=May; 4=Jul
..2001,vol26: #1=Jan; 2=Mar;
</PRE>
<P>Read the Risks Forum as comp.risks if you can, or
send e-mail to risks-request@csl.sri.com for a subscription, single text
line "subscribe" (append desired address only if not your From: address), or
"info" for info. Send contributions to risks@CSL.sri.com. Archives are
available from <CODE>ftp://ftp.sri.com/risks</CODE> or by "ftp ftp.sri.com",
"login anonymous", "cd risks" (which gets the "dir" for the current volume,
and "cd i" then gets you into the subdirectory for any preceding volume i =
1 to 19). A mirror at Newcastle
<A HREF="http://catless.ncl.ac.uk/Risks/">http://catless.ncl.ac.uk/Risks/</A>
is maintained by Lindsay Marshall, and includes a nice search facility.
Specific issues can be read directly as
<CODE>http://catless.ncl.ac.uk/Risks/I.J.html</CODE> [where I=volume#, J=issue#].
An Australian mirror is at
<A HREF="http://the.wiretapped.net/security/textfiles/risks-digest/">http://the.wiretapped.net/security/textfiles/risks-digest/</A>.
"Inside Risks" distills some of the discussion into a
monthly inside-back-cover column in the <I>Communications of the ACM.</I>
The list columns to date is given at the end of this list.
<P>My book (Peter G. Neumann, <I>Computer-Related Risks,</I> Addison-Wesley
(ISBN 0-201-55805-X) and ACM Press (ACM Order 704943), 1995) summarizes many
of these cases and provides additional analysis. (A few errata for the
first three printings are on my Web page, noted above.) Most of the (S vol
no) items listed below for i <I><</I> 20 are discussed in the book; more recent
items generally include the relevant on-line (R i j) references. If you
cannot find the book in a bookstore, it is on amazon.com, or call A-W within
the U.S. at 1-800-822-6339 - or if you are outside of the U.S.,
1-617-944-3770 and ask for International Orders. The book is now also
available in Japanese (ISBN 4-89471-141-9). Instead of trying to produce a
second edition in the face of a massive influx of new RISKS cases, the
fourth printing of the book gives the URL for the Addison-Wesley Web site
(<A HREF="http:www.awl.com/cseng/titles/ISBN-0-201-55805-X/">http:www.awl.com/cseng/titles/ISBN-0-201-55805-X/</A>),
which includes the first chapter of the book and an extended preface. That
Web site and my own contain more material that would otherwise have gone
into the second edition. See
<A HREF="http://www.csl.sri.com/neumann/risks-new.html">http://www.csl.sri.com/neumann/risks-new.html</A> for new material
and
<A HREF="http://www.csl.sri.com/neumann/cal.html">http://www.csl.sri.com/neumann/cal.html</A>
for an excerpted summary of Y2K and related calendar-clock problems.
<P>Henry Petroski (among others) has noted that we rarely learn from our
successes, and must learn more from our failures. The collection of cases
cited here provides rich opportunities for reflection that could help us to
avoid similar problems in the future. Unfortunately, it also demonstrates
that the same types of mistakes tend to recur.
<P><I>SEN</I> and RISKS also consider approaches for developing better computer
systems, e.g., safer, more reliable, more secure. There are many approaches
to developing sound systems; none is guaranteed. Whereas the emphasis in
the following list is on problems rather than on would-be solutions, the
pervasive nature of the problems suggests that techniques for the effective
development and operation of computer-related systems are frequently
ignored. Worse yet, even ideal systems can result in serious risks, through
unanticipated technological problems or human foibles. We include here
primarily cases that have been publically reported, although we know of
various additional cases whose existence for one reason or another has not
seen the light of day. A few successes are also included, although the
failures seem to predominate. We are always interested in hearing more
about successes. Although I receive occasional complaints about the
preponderance of failures in RISKS, there appear to be very few real
successes. Perhaps not enough folks are heeding some of the advice that you
can gather from RISKS and that are distilled in <I>Computer-Related
Risks.</I>
<H1><A NAME="2">Descriptor Symbols</A></H1>
The following descriptor symbols characterize each entry.
<P>! = Loss of life/lives; * = Potentially life-critical or safety problem
<P>V = Overall system or subsystem sur<B>V</B>i<B>V</B>ability problems
(with respect
to diVerse adVersities, including attacks <I>and</I> malfunctions).
Startlingly many cases fit this category; many V-unflagged cases also
represent failures to continue performing properly, or delays, or other
cases of misuse that could have led to much more serious survivability
problems.
<P>$ = Loss of resources, primarily financial
<P>S = <B>S</B>ecurity/integrity/misuse problem;
P = <B>P</B>rivacy/rights abuse or concern
<P>H = Intentional <B>H</B>uman misuse (e.g., user-administrator-operator-penetrator)
<P>h = Accidental <B>H</B>uman misuse or other inadvertence
<P>I = <B>I</B>nsider; O = <B>O</B>utsider; A = Inadequate <B>A</B>uthentication or
<B>A</B>ccess controls
<P>d = System <B>D</B>evelopment problems
<P>e = Improper <B>E</B>volution/maintenance/upgrade. (H,h,i,f,d,e involve human foibles.)
<P>r = Problems with <B>R</B>equirements for system or
operation (including the overall system concept)
<P>f = <B>F</B>laws (or <B>F</B>eatures in design, or hardware/software
implementation
<P>i = Mis<B>I</B>nterpretation/confusion/human errors at a man-system
<B>I</B>nterface
<P>m = Hardware <B>M</B>alfunction attributable to system deficiencies, the
physical environment, acts of God, etc.
<P>M = <B>M</B>alfunction specifically due to electronic or other interference
<P>+ = Beneficial; - = problematic with none of the above categories
<P>@ = This item is also listed in another category
<H1><A NAME="3">Items Listed by Categories</A></H1>
<H2><A NAME="4">Recent Items (yet to be merged in)</A></H2>
Vm
PGN's Univ. Maryland survivable systems course beset with survivability
problems (S 25 1:)
<P>fm
California government agencies' computers fail, cars impounded;
Pac*Bell blamed (R 20 62)
<P>Vfm
Software disaster leaves new Australian submarine unfit;
wide range of pervasive hardware/software failures reported (R 20 48)
<P>*fh
Cancelling errors, serendipity in avoiding risks, and Kepler:
note by Henry Baker (R 20 48,51)
<P>Vm
Weather-predicting Cray C90 supercomputer lost in
fire, weather predictions reduced (R 20 62)
<P>Vm
Netcom file-server hardware outage loses half of the e-mail
customers, depending on first letter of name (R 20 49)
<P>m
Airport security check powers up computer (R 20 55)
<P>f
MIT system weather command gives "Temp: 2147483647 F
(2147483647 C)"; yes, that's <I>2<sup>31</sup> - 1</I> (R 20 51-52);
<I>USA Today</I> weather page: high of 577 F (R 20 58)
<P>?
NOAA radio +61 degrees F, wind-chill -64 (R 20 57)
<P>f/m/h?
Date failure on weather.com: 28 Apr not 16 Sep (R 20 58)
<P>$fh
Dispute over membership software used by German SPD (R 20 41)
<P>$f
Reliability of NT in embedded applications (R 20 41)
<P>f
Microsoft Word footnote problems irks federal appeals court:
Word does not count words correctly (R 20 52)
<P>fe
IE2 cannot read www.microsoft.com for upgrade (R 20 55)
<P>if
More anomalies in Microsoft driving directions (R 20 62-63)
<P>?
Risks of "self-destructing e-mail" from Disappearing Inc.
(R 20 62)
<P>h,h
Linux banned after Samba misconfigation blocks NT authentication (R 20 61)
<P>rh
Vending machine default phone number 000 (Australian emergency number)
yields hundreds of false alarms (R 20 47)
<P>f
Kangaroo helicopter responses mess up Australian virtual-reality simulators
(R 20 47,76)
<P>hf
Can you trust AT&T Wireless PCS text messaging? (no)
(R 20 52-53)
<P>f
Risks of financial planning engines with bogus results
(R 20 48)
<P>h
EverQuest is the "digital version of crack" (R 20 52)
<P>rd
More on California's software woes: welfare system problems
(R 20 53)
<P>h (but blamed on computer)
Argos retail offered Sony Nicam TV for 3£ instead
of 300£ (R 20 57)
<P>f
E*Trade Market Watch shows Dow Jones average at $1,
down $10936.88 (R 20 56)
<P>Vmfm
Power coming back on causes UPS to lose power (R 20 55)
<P>+/-??
Programming competency and the use of FORTH (R 20 49-53)
<P>$f
Toyota smog-warning computer suit (R 20 48)
<P>fh
CNN report on Gary Shandling lawsuit
names him as "Changeling"; spelling corrected? (R 20 47)
<P>h White House admits over one year of VP's e-mail lost forever (S 25 4:8,
R 20 91)
<P>f Software fault stops 76,000 customers receiving phone calls (S 25 4:8,
R 20 87)
<P>h UCITA, the Uniform Computer Information Transactions Act (Schneier,
S 25 4:8 and R 20 87, and Simons in August 2000 <I>CACM</I> Inside Risks)
<P>f Microsoft Explorapedia Nature: earth rotates in wrong direction (R 20 87)
<P>+ Patent office revamps Web patent reviews (R 20 87)
<P>h-
50 million U.S. adults at risk for Internet illiteracy (R 21 08-09; S 26 1:18)
<P>(f/m/h?)
Computer-related sewage release into Massachusetts Bay
(R 21 08; S 26 1:18)
<P>fid
Not-so-smart weapons in Kosovo (R 21 01; S 26 1:18)
<P>de
Satellite system outage hits Associated Press (R 21 04; S 26 1:18)
<P>m/f/h?
Root servers used by Network Solutions failed (R 21 03; S 26 1:18-19)
<P>$dh
$35M San Mateo CAlifornia health system upgrade is a downer;
receivables backlog over $40M; blame scattered (R 20 98)
<P>$d
WA King County blew $38 million on canceled payroll system (R 21 01; S 26 1:19)
<P>eh
Northeastern University admits 25% too many students (600 extra) after
DB upgrade loses potential applicants (R 21 01; S 26 1:20)
<P>f CSX crew spots problem signal, averts collision; insulation
problem? (R 21 04; S 26 1:20)
<P>e
Upgrade to Guildford Station (Surrey, UK) software
disables hundreds of train tickets for automated gates (R 20 94: S 26 1:20)
<P>fi
DC Metro can't label rerouted holiday trains on 4 Jul 2000: confusion
(R 20 95; S 26 1:20)
<P>m
Computer crash caused loss of scheduled cab pickups (R 20 98; S 26 1:20)
<P>m
Sliced fiber-optic cable in Lancaster PA disrupts local and long-distance
phone service NY to MD (R 20 93; S 26 1:20-21); another outage in Massachusetts
(R 20 97)
<P>m
Heavy rains take out State Department phone service for 2 hours,
backup batteries out because of earlier fire (R 20 93; S 26 1:21)
<P>$mh
Drop of welding material causes fire that affected 27 cables, telephone
service for 25,000 (R 20 93; S 26 1:21)
<P>m
Remote line break leaves San Juan Puerto Rican without power (R 21 04; S 26 1:21)
<P>-
Booming computer firms are running out of power (R 20 98)
<P>-
Russian troops override power shutoff for unpaid bill affecting
missile base (R 21 05; S 26 1:21)
<P>!h
Illinois man dies after utility cuts power for arrears (R 20 95; S 26 1:21)
<P>f
New Pentium III chip recalled (R 21 04; S 26 1:21-22)
<P>*h
F-117 stealth fighter in near-miss with UAL jet (R 21 04; S 26 1:22)
<P>*SHA
Fake air controllers alert in UK (R 21 04; S 26 1:22)
<P>f/m?
Collapse of UK air-traffic control computer (R 20 93-94);
known bugs reduced from 500 to 200 (R 21 01)
<P>def
U.S. west-coast ATC woes 19 Oct (hundreds of flights affected)
and 23 Oct 2000 (loss of flight plans for Northern CA and Western NV)
(R 21 09; S 26 1:22)
<P>mf
FADEC computers cause uncommanded shutdowns of aircraft engines in flight;
linked to power transistor (R 21 05; S 26 1:22)
<P>m
Total primary/secondary power outage at Sydney Airport leaves 20 planes
circling (R 20 94; S 26 1:22-23)
<P>m/f?
Sydney Airport's new $43M baggage system fails for second time in five days
(R 21 02; S 26 1:23)
<P>h
Oregon lottery coincidence reported by Infobeat caused by computer crash:
winning numbers published before they were drawn by editor mistakenly
using Virginia numbers after a crash! (R 20 94)
<P>ef
DB upgrade causes crash of Italian online stock trading (R 20 95)
<P>f
Fox network misprograms time on US VCRs for a year
(R 20 95)
<P>fh
Army Automated Time and Attendance Production System (ATAAPS)
loss of data for 10 days (R 20 97)
<P>f
Computerized air-conditioning bugs chill employees (R 21 05; S 26 1:26)
<P>-
ISP whacks game fan with $24,000 bandwidth fine (R 21 08; S 26 1:26)
<P>e
Memorial Society software upgrade loses some life-time members
(R 21 08; S 26 1:26)
<P>!!(f/h?)
Russian nuclear sub explosion (missile test awry) kills crew
of over 100 in Barents Sea, 13 Oct 2000. Also, <I>Izvestia</I> reported over 507 sub crew members had died
previously. (R 21 01)
<P>*f
Sydney train system traps man's leg (R 21 01)
<P>f
New UK Millennium Bridge closed after one day, alarming
instability despite extensive simulation; resonant
frequencies at walking speeds!
(R 20 93,95)
<P>+/-
People For Internet Responsibility (PFIR) Statement
on Internet Policies, Regulations, and Control
(http://www.pfir.org/statements/policies) (R 20 96)
<P>S
Navy to use Windows 2000 on aircraft carriers (R 20 95)
<P>f
Microsoft Windows Update Corporate Web site "features more than 1,000 system
updates and drivers for the Windows 2000 platform"!!! (R 21 04)
<P>f
Y2K-leapyear hangover: CDMA GTE wireless date 31 Jun 00
(R 20 92)
<P>+/-
Stephen King's not scared of trusting online readers (R 20 98)
<P><B>END of yet-to-be-merged recent material ...</B><H2><A NAME="5">Space</A></H2>
<P>..... <B>Manned/Womanned [Peopled?] Space Exploration:</B>
<P>!!$Vrfh Shuttle Challenger explosion, 7 killed. [Removed booster sensors
might have permitted early computer detection of leak?] [28Jan1986] (S 11 2)
[Probably not? See Paul Ceruzzi, Beyond the Limits - Computers Enter the
Space Age, MIT Press, 1989, Appendix.]
<P>* Mercury astronauts forced into manual reentry? (S 8 3)
<P>$f STS-1 1st Space Shuttle Columbia backup launch-computer synch problem.
See Jack Garman, "The bug heard 'round the world" (S 6 5:3-10) Oct. 1981.
<P>*f STS-2 shuttle simulation: bug found in jettisoning an SRB (S 8 3)
<P>*f STS-2 shuttle operational simulation: tight loop upon cancellation of
an attempted abort; required manual override (S 7 1)
<P>*Vf STS-6 shuttle bugs in live Dual Mission software precluded aborts (S 11 1)
<P>*m STS-9 Columbia return delayed by multiple computer malfunctions (S 9 1)
<P>*f STS-16 Discovery landing gear - correlated faults (S 10 3)
<P>*if STS-18 Discovery positioned upside down; mirror to reflect laser beam from
Mona Kea aimed upward (+10,023 miles), not downward (... feet) (S 10 3)
<P>*$ STS-20 Two-day delay of Discovery launch: backup computer outage
(NY Times 26 Aug 1985); Syncom 4 satellite failure as well (S 10 5)
<P>$f SRS-36 Atlantis launch delayed [25Feb1990]; "bad software" in backup
tracking computer system, but no details given. (S 15 2)
<P>h Shuttle Discovery shutdown procedure for two computers reversed (S 16 1)
<P>*hife STS-24 Columbia near-disaster, liquid oxygen drained mistakenly
just before launch, computer output misread (S 11 5)
<P>*f Columbia orbiter suddenly rotates, due to telemetry noise (S 15 3)
<P>$m Columbia delayed by computer, interface, sensors; then navigation (S 16 3)
<P>$f Shuttle Endeavour computer miscomputes rendezvous with Intelsat satellite;
nearly identical values interpreted as identical; those SW problems force
spec changes (AviatWkSpT 29May/8Jun1992, S 17 3 duplic S 17 4)
<P>* Shuttle computer problems, 1981-1985; 700 computer/avionics
anomalies logged; landing gear problems in STS-6 and -13; multiple
computer crashes in STS-9, cutting in backup system would have
been fatal; thermocouple failure in STS-19 near disaster (S 14 2)
<P>m Atlantis spacecraft computer problem fixed in space (S 14 5)
<P>$f Untested for change, SW delays shuttle launch; 3-min on-line fix (S 15 3)
<P>$(m/f?)V Shuttle Atlantis launch scrubbed: "faulty engine computer" (S 16 4)
<P>$*V Columbia launch scrubbed at T-3sec 22Mar93, leaky valve (S 18 3:A14)
<P>$*V STS-56 Discovery launch scrubbed at T-11sec 5Apr93, main propulsion
system high-point bleed valve open-indicator went to <I>off,</I>
closed-indicator did not switch to <I>on</I>. Indicator problem?
program error? (S 18 3:A14)
<P>h Discovery SRB recovered with missing pair of pliers (S 18 3:A14)
<P>fm Channel blocked, Discovery exhausts storage for ozone data (S 18 3:A14)
<P>H Experimental Space Shuttle e-mail address divulged, bombarded (S 16 4)
<P>m Woodpeckers delay shuttle launch (S 20 5:8)
<P>*m Docking problem aboard Soviet space station Mir (S 15 5)
<P>m Mir Space Station computer problems add to difficulties; main computer failed
during docking attempt, 19 Aug 1997 (R 19 31,32), with detailed analysis
by Dennis Newkirk (R 19 33)
<P>m Mir computer failure affects steering; replacement computer fails to load
(end of May 1998, just before Discovery launch) (R 19 78)
<P>*$d GAO reports on NASA Space Station: increased safety risks, costs (S 17 4)
<P>* Risks of junk in space much greater than previously thought (S 17 4)
<P>*f$ Potential software nightmare for International Space Station,
with considerable discussion (R 19 49-51)
<P>..... <B>Satellites, Probes, Others:</B>
<P>$f Hubble Space Telescope problems, soaring costs, missed deadlines,
reduced goals, etc. (S 15 2); sensors misdirected because of wrong sign
on precession in star data; antenna # 2 limited by misplaced cable, #1
limited because software had only one limit stop, same for both (S 15 3)
No system test. 1mm error in monitor program of mirror polisher (S 15 5)
See M.M. Waldrop, Science 249, 17Aug1990, pp.735-736.
<P>Vf/m Hubble Space Telescope antenna swing causes shutdown (S 17 1)
<P>fh More Hubble SW: misloaded ephemeris table, bad macro (S 18 1:24)
<P>$fhV $150M Intelsat 6 comm satellite failed; booster wiring error, payload in
wrong bay; miscommun. between electricians and programmers (S 15 3)
<P>$mV Canadian TeleSat Aniks die: solar coronal hole electron flux (S 19 2:3)
Anik E-2 control restored, but with shorter life ($203M asset) (S 20 2:11)
<P>fmV SOHO Mission Interruption Preliminary Status and Background Report
documents apparently unconnected multiple failures that caused
the satellite to lose control (R 19 87)
<P>fhV Final report on the Solar and Heliospheric Observatory (SOHO) spacecraft
failure: software flaw and improper command (R 19 90); mis-identification
of a faulty gyroscope, staffing problems, inadequate training, ambitious
schedule, unreviewed procedure changes, etc. (R 19 90, 94); contact
finally reestablished. (S 24 1:31)
<P>hm 5 printers off-line or jammed, Voyager 1 data lost over weekend (S 15 5)
<P>f Voyager 2 software faults at launch, 20 Aug 1977 (S 14 6)
<P>V$ Titan 34D, Nike Orion, Delta-178 failures follow Challenger (S 11 3)
<P>V$* Titan 4 rocket test-stand SRB explosion; simulation missed failure mode
(S 16 4)
<P>V(m/f?) Final Titan 4A launch explodes with Vortex satellite;
total cost over $1B, Aug 1998 (S 24 1:32, R 19 91)
<P>mV Titan 4B leaves missile warning satellite in useless orbit (R 20 36)
<P>Vm/f? Titan 4B with Milstar communications satellite separates four hours
early, resulting in a useless low orbit, 30 Apr 1999 (S 24 4:26, R 19 36)
<P>Vhm$
6 successive Theater High-Altitude Area Defense (THAAD) failures,
including three typos; then a "success" (R 20 43,45); Titan 4B failure (R 20
39) blamed on shifted decimal point in upper-stage software (R 20 45)
<P>Vf,f Delta III launch ends after 71 seconds due to software flaw;
two weeks later, Delta III leaves Loral Orion comm satellite
in useless low orbit 4 May 1999 (R 20 38)
<P>Vmfh
Centaur/Milstar upper-stage failure due to
attitude-control system software (R 20 49);
roll-rate filter constant .1 factor (-0.1992476, not
-1.992476) (R 20 57,59)
<P>Vm$
Private imaging satellite
Ikonos 1 disappears 8 minutes after launch (S 24 4:26, R 20 36);
loss blamed on an electrical problem that prevented the
aerodynamic payload cover from coming off.
Subsequent Ikonos launched successfully (R 20 60):
<P>f Terra spacecraft navigation software problems (S 25 3:18, R 20 78)
<P>V$(m?f?) Two satellite failures (R 21 19, S 26 2:)
<P>Vm/f? Russian rocket blows 12 Globalstar satellites (S 24 1:32, R 19 95)
<P>V$(f?m?) Computer blamed for Russian rocket crash (R 21 18, S 26 2:)
<P>h
Boeing space station tanks accidentally taken to Huntsville dump (R 20 83)
<P>Vh
Space Station endangered by NASA flight controllers' blunder in
maneuvering around space junk; predicted distance also way off (R 20 46-47)
<P>SH Space Station Problem Reporting Database hacked (R 20 47-48)
<P>$Vmf Space Station risks (R 21 14, S 26 2:)
<P>V$ehf Canaveral Rocket lost; wrong key hit in loading guidance SW (S 16 4)
<P>df NASA finds problems in EOSDIS Earth Observing System (EOS) spacecraft flight
operations software development, expected to delay launch (R 19 67)
<P>m+ Apollo 11 lunar module, pen used to replace circuit breaker (S 18 3:A14)
<P>Vr* Lightning hits Apollo 12. "Major system upsets, minor damage". See article
by Uman and Krider, Science 27 Oct 1989, pp. 457-464. (S 15 1)
<P>V$m Lightning changed Atlas-Centaur program (51 sec). $160M lost (S 12 3,
15 1)
<P>@V*$m Lightning hits launch pad, launches 3 missiles at Wallops Island (S 12 3)
<P>V$f Mariner 1 Venus probe: HW fault plus programmer missed superscript bar in
`R dot bar sub n'. See Paul Ceruzzi, Beyond the Limits - Flight Enters
the Computer Age, Smithsonian, 1989, Appendix (S 14 5). (Earlier reports
had suggested DO I=1.10 bug (see next item) or a garbled minus sign (or
hyphen.) (S 8 5, 11 5, S 13 1)
<P>$f Project Mercury had a FORTRAN syntax error such as DO I=1.10
(not 1,10). The comma/period interchange was detected in software
used in earlier suborbital missions, and would have been more serious
in subsequent orbital and moon flights. Noted by Fred Webb. (S 15 1)
<P>*f Gemini V 100mi landing err, prog ignored orbital motion around sun (S 9 1)
<P>V$f Atlas-Agena software missing hyphen; $18.5M rocket destroyed (S 10 5)
<P>@VSH Lauffenberger convicted of logic bombing GD's Atlas rocket DB (S 17 1)
<P>Vm Navy Atlas rocket places satellite in worthless orbit (S 18 3:A14)
<P>V$f Aries with $1.5M payload lost: wrong resistor in guidance system; (S 11 5)
<P>V*f TDRS relay satellite locked on wrong target (S 10 3)
<P>Vm AT&T Telstar 401 satellite failure (S 22 4:26, R 18 76)
<P>Vm Ariane 5 test problems: motor failures, nitrogen leak (S 20 5:9, R 18 27,28)
<P>V$f New Ariane 5 failure (S 21 5:15);
More on Ariane 5: conversion from 64-bit floating to 16-bit signed caused
Operand Error (R 18 27-29,45,47);
Note: Matra made software for Ariane5 and Taipei subway system (S 21 5:15);
Incidentally, Robert L. Baber, Univ. Witwatersrand, Johannesburg,
suggests you browse http://www.cs.wits.ac.za/ bob/ariane5.htm - showing
how a simple correctness proof could have avoided this problem. (R 18 89-91)
<P>*Mm Cosmic rays hit TDRS, Challenger comm halved for 14hrs [8Oct1984](S 10 1)
<P>$Mr Sunspot activity: 1979 Skylab satellite dragged out of orbit (S 13 4)
<P>hM 1989 pulsar discovery now attributed to TV camera interference (S 16 3)
<P>V$hfe Soviet Phobos I Mars probe lost (Sep 1988): faulty SW update (S 13
4); cost to USSR 300M rubles (Aviation Week, 13 Feb 89); disorientation
broke radio link, discharged solar batteries before reacquisition. [<I>Science,</I> 16Sep1988] More on Phobos 1 and 2 computer failures (S 14 6)
<P>V$? Soviets lose contact with Phobos II Mars probe. Automatic reorientation
of antenna back toward earth failed. (S 14 2)
<P>V$f 1971 Soviet Mars orbiter failed after "unforgivable" SW bug; new info
(S 16 3)
<P>f Assessment of predictions on the Russian Mars Probe crash site (S 22 2:22)
<P>V$fm 1993 Mars Observer lost entering Mars orbit (S 18 4:11; R 14 87,89;
15 01); loss blamed on fuel line leak (Washington Post, 10 Jan 1994)
<P>f What really happened on Mars Rover Pathfinder?
David Wilner on VxWorks system resets and preemptive priority scheduling,
and Glenn Reeves - first-hand commentary must be read (R 19 49,50,53,54)
and further discussion of priority inversion (R 19 50,53,54,56)
<P>V$fm
Mars Climate Orbiter lost, dipped too close to Mars
due to English/Metric confusion; Mars Polar Lander reprogrammed
to report back directly on 3 Dec 1999 (R 20 59-62); Mars Lander
then lost entirely on landing attempt, search abandoned after a month.
Crash finally blamed on software shutting engines off prematurely (R 20 84,86)
<P>$f/h?
NASA HESSI shake test 10 times too strong, damaging spacecraft (S 25 3:15,
R 20 86)
<P>$f
Sea Launch rocket drops satellite into Pacific Ocean (S 25 3:15, R 20
84,86); single line of code allowed launch with second-stage valve open,
causing helium leak
(R 20 97)
<P>Vfm$
Electronics startup transient opened telescope cover prematurely,
destroying Wide Field Infrared Explorer (WIRE) spacecraft (R 20 47-48)
<P>V$m $1.4B Galileo antenna jammed, en route to Jupiter (S 18 4:11)
<P>V$m Landsat 6 vanishes; space junk tracked by mistake (S 19 1:10)
<P>V$f Magellan space software problems: serious design flaw fixed (S 14 5)
Nonatomic setting of scheduled and active flags interrupted.
See H.S.F. Cooper, Jr., The Evening Star: Venus Observed,
Farrar Straus Giroux, 1993. Discussion in J.M. Rushby, SRI-CSL-95-01.
<P>$m Magellan spacecraft manual guidance overcomes faulty computer chip (S 15 2)
<P>V*h Soyuz Spacecraft reentry failed, based on wrong descent program,
(orbiting module had been jettisoned, precluding redocking) (S 13 4)
<P>V$fe Viking had a misaligned antenna due to a faulty code patch (S 9 5)
<P>*f Ozone hole over South Pole observed, rejected by SW for 8 years (S 11 5)
<P>? Global-warming data confusion (R 19 91-92)
<P>@Vfm Channel blocked, Discovery runs out of storage for ozone data (S 18 3:A14)
<P>* Continuing trend toward expert systems in NASA (S 14 2)
<P>f SW bug on TOPEX/Poseidon spacecraft "roll momentum wheel saturated"
alarm aborted maneuver. It was recoverable, however. (S 18 1:24)
<H2><A NAME="6">Defense</A></H2>
<P>V!hhh U.S. F-15s take out U.S. Black Hawks over Iraq in Friendly Fire; 26
killed, attributed to coincidence of many human errors. (Other cases of
friendly fire included 24% of those killed in the Gulf War.) (S 19 3:4)
According to a seemingly reliable private correspondent who has read through
at least 62 volumes of investigation reports, the public was seriously
misled on this situation and there was a considerable cover-up. For now,
contact me if you want further background.
<P>!!$rhi Iran Air 655 Airbus shot down by USS Vincennes' missiles (290 dead);
Human error plus confusing and incomplete Aegis interface (S 13 4);
Commentary on Tom Wicker article on Vincennes and SDI (S 13 4);
Aegis user interface changes recommended; altitude, IFF problems (S 14 1);
Analysis implicates Aegis displays and crew (Aerospace America, Apr 1989);
Discussion of further intrinsic limitations (Matt Jaffe, S 14 5, R 8 74);
USS Sides Cmdr David Carlson questions attack on Iranian jet (S 14 6)
<P>!!$rfe Iraqi Scud hit Dhahran barracks (28 dead, 98 wounded); not detected
by Patriot defenses; clock drifted .36 sec. in 4-day continuous siege,
due to SW flaw, preventing real-time tracking. Spec called for aircraft
speeds, not mach 6, only 14-hour continuous performance, not 100. Patched
SW arrived via air 1 day later (S 16 3; AWST 10Jun91 p.25-26);
Shutdown and reboot might have averted Scud disaster (S 16 4)
Patriot missiles misled by `accidental' decoys; T.A. Postol report (S 17 2);
summary of clock drift, etc. GAO/IMTEC-92-26, February 1992 (S 17 2);
reprisals against Postol for his whistleblowing (R 13 32, S 17 2);
Army downgrades success to about 10% rather than 80% (R 13 37, S 17 2, 17 3)
GAO report documents clock problem in detail (S 17 3)
24-bit and 48-bit representations of .1 used interchangeably (S 18 1:25)
<P>*f
Patriot system fails again (S 25 3:18, R 20 85)
<P>*f Software snafu slowed critical data during Iraq raid (S 24 3:25, R 20 23)
<P>!!V$h? Sheffield sunk during Falklands war, 20 killed. Call to London
hindered antimissile defenses on same frequency? [AP 16May1986](R 2 53, S 11
3) An "official" version disputes this conclusion - see "The Royal Navy
and the Falkland Islands" by David Brown, written at the request of the
Royal Navy. Page 159 of that report discusses another problem with the Sea
Wolf system, occurring several days later.
<P>!V$ British Falklands helicopter downed by British missile. 4 dead (S 12 1)
<P>!!V$f USS Liberty: 3 independent warning messages to withdraw were all lost;
34 killed, more wounded. Intelligence implications as well. (S 11 5)
<P>!Vhfi? Stark unpreparedness against Iraqi Exocets blamed on officers, not
technology, but technology was too dangerous to use automatically (S 12 3);
Captain blamed deficient radar equipment; official report says
radar detected missiles, misidentified them. (S 13 1)
<P>Vrf$ USS Yorktown Aegis missile cruiser dead in water for 2.75 hours
after unchecked divide by zero in application on Windows NT Smart
Ship technology (S 24 1:31, R 19 88-94); letter to <I>Scientific
American</I>: it was an explicit decision to "stimulate" [sic]
machinery casualties? (S 24 4:26, R 20 37)
<P>$hfe Navy software problems in upgrading software on battle cruisers
USS Hue City and USS Vicksburg (S 23 5:25, R 19 86-87)
<P>*Vf 5th Bell V22 Osprey crash: assembly error reversed polarity in gyro
(S 16 4); Bell V-22 Osprey - correct sensor outvoted (S 17 1)
<P>!V$(f?m?h?) Another Osprey crash (R 21 14, S 26 2:)
<P>*H Fraudulent test SW in Phalanx anti-missile system, Standard missile (S 13 4)
<P>Hhf West German flies Helsinki-Moscow through Soviet Air Defense (S 12 3)
<P>Hhf Soviet Air Defense penetrated again by amateur pilot (S 15 5)
<P>$h Russian missile-site power outage due to unpaid utility bill? (S 20 1:17)
<P>**f Returning space junk detected as missiles. Daniel Ford, The Button, p.85
<P>** WWMCCS false alarms triggered scrams 3-6 Jun 1980 (S 5 3, Ford pp 78-84)
<P>** DSP East satellite sensors overloaded by Siberian gas-field fire (Daniel
Ford p 62); Ford summarized (S 10 3)
<P>**f BMEWS at Thule detected rising moon as incoming missiles [5Oct1960]
(S 8 3). See E.C. Berkeley, The Computer Revolution, pp. 175-177, 1962.
<P>** SAC/NORAD: 50 false alerts in 1979 (S 5 3), incl. a simulated attack whose
outputs accidentally triggered a live scramble [9Nov1979] (S 5 3)
<P>*** Serious false 2200-missile-alert incident 3 Jun 1980 described by
Stansfield Turner, mentioning thousands of other false alarms (S 23 1:12,
R 19 43)
<P>*fmh Russian early-warning system close to retaliatory strike: Norwegian
weather rocket mistaken for American Trident (R 19 85)
<P>m Report from Kommersant Vlast on Serbukov-15 base false detection of
ICBMs en route to Moscow on 25 Sep 1983; human intervention stopped
retaliation; system allegedly misbehaved due to radiation (R 19 97)
<P>*$VfM Libyan bomb raid accidental damage by "smart bomb" (S 11 3)
F-111 downed by defense-jamming electromagnetic interference (S 14 2)
More on U.S. radio self-interference in 1986 Libyan attack (S 15 3)
<P>* Iraq using British Stonefish smart mines, with "sensitive" SW (S 15 5)
<P>*SP Britain bugged radio equipment sold to Iraq (S 16 4)
<P>*SP Trojan horse implants in DoD weapons (S 16 4)
<P>*SP Trojan horse inserted in locally netted printer sold to Iraq? (S 17 2)
<P>*Vm Arabian heat causing problems with US weapons computers (S 15 5)
<P>*V$m Lightning hits launch pad, launches 3 missiles at Wallops Island (S 12 3)
<P>* Frigate George Philip fired missile in opposite direction (S 8 5)
<P>*h? Unarmed Soviet missile crashed in Finland. Wrong flight path? (S 10 2)
<P>*Vf 1st Tomahawk cruise missile failure: program erased [8Dec1986] (S 11 2)
<P>*Vm 2nd Tomahawk failure; bit dropped by HW triggered abort (S 11 5, 12 1)
<P>f/m? CALCM cruise missile software bugs revisited (S 22 2:22)
<P>hi Accidental launch of live Canadian Navy missile: color-code mixup (S 22
1:18)
<P>*$rf Program, model flaws implicated in Trident 2 failures (S 14 6)
<P>*VrmM RF interference caused Black Hawk helicopter hydraulic failure (S 13 1);
More on Black Hawk EMP problems and claimed backwards pin (R 17 39,42)
<P>*VSM RF interference forces RAF to abandon ILS in poor weather (R 21 17)
<P>*f Sgt York (DIVAD) radar/anti-aircraft gun - software problems (S 11 5)
<P>$f Software flaw in submarine-launched ballistic missile system (S 10 5)
<P>V$f AEGIS failures on 6 of 17 targets attributed to software (S 11 5)
<P>Vf WWMCCS computers' comm reboot failed by blocked multiple logins (S 11 5)
<P>$ WWMCCS modernization difficulties (S 15 1)
<P>*$f Gulf War DSN 20-30% call completion persists 3 mos. until SW patch (S 17 4)
<P>$f Armored Combat Earthmover 18,000 hr tests missed serious problems (S 11 5)
<P>$rfi Stinger missile too heavy to carry, noxious to user (S 11 5)
<P>**V$Sr Strategic Defense Initiative - debate over feasibility (S 10 5);
Pentagon says SDI complexity comparable to nuclear reactors (Newsweek, S 17 3)
See <I>Way Out There in the Blue: Reagan, Star Wars, and the End of
the Cold War,</I> Frances FitzGerald, Simon & Schuster, 2000 for a fine
retrospective analysis.
<P>$d SDI costs, budget issues, risks discussed (S 17 4)
<P>$ StarWars satellite 2nd stage photo missed - unremoved lens cap (S 14 2)
<P>f StarWars FireFly laser-radar accelerometer wired backwards (S 19 2:2)
<P>$* 1.7M resistors recalled. Used in F-15, Patriot, radar, comm aircr. (S 16 3)
<P>$hd DoD criticized for software development problems (S 13 1)
<P>* US Navy radar jammers certified despite software errors, failed tests (S 17 3)
<P>$ USAF software contractors score poorly on selections (S 14 1)
<P>$d ADATS tank-based anti-copter missile system development problems,
$5B overrun, unreliability, ... (S 16 1)
<P>$d British air defense system ICCS SW causes ten-year delay (S 15 5)
<P>*Sf US Army Maneuver Control System vulnerable to software sabotage (S 15 5)
<P>$d US-supplied Saudi Peace Shield air defense software problems (S 15 5)
<P>$d Serious software problems in UK Trident nuclear warhead control (S 15 5)
<P>*m Russian nuclear warheads armed by computer malfunction (R 19 14)
<P>*h Outdated codes made US missiles useless until annual inspection (S 14 5)
<P>S Classified data in wrong systems at Rocky Flats nuclear weapons plant (S 16 4)
<P>SPh Classified disks lost by Naval commanders on London train (R 17 54)
<P>hi? Listing of US Navy safety problems in two-week period (S 15 1)
<P>Vm Rain shuts down Army computers; lightning effects and prevention (S 15 1)
<P>* Role of e-mail, Internet, FAX in defeating 1991 Soviet coup attempt (S 16 4);
(S) power surges used to fry faxes and computers in countermeasure (S 16 4)
<P>* Russian auto-response missile system still in place in Oct 1993 (S 19 1:10)
<P>!! Analysis of U.S. peacetime submarine accidents
<A HREF="http://freeweb.pdq.net/gstitz/Peace.htm">http://freeweb.pdq.net/gstitz/Peace.htm</A>
<H2><A NAME="7">Military Aviation</A></H2>
<P>!!V$f Handley Page Victor tailplane broke, crew lost. 3 independent test
methods, 3 independent flaws, masking flutter problem (S 11 2-12, correction
S 11 3)
<P>!Vf Harrier ejection-seat parachute system accidentally deployed, blew through
the canopy, but without ejecting the seat and pilot, who was killed (S 13 3)
<P>f Harrier targets police radar gun; fortunately not armed! (S 21 4:14)
<P>*V(h/m?) Japanese pilot accidentally ejected into the Pacific (S 19 4:12)
<P>*V$h Sea Harrier 1 accidentally bombs its own carrier, Ark Royal (S 17 3)
5 injured. Auto aim-off SW blamed for the Ark Royal bombing (S 18 1:23)
<P>*V$f SAAB JAS 39 Gripen crash caused by flight control software (S 14 2, 14 5)
<P>*V$fmhi 2nd JAS 39 Gripen crash 8Aug1993 blamed on pilot/technology (S 18
4:11); interface difficulties, complicated analysis (S 19 1:12)
<P>*V$rf Software problems in B-1B terrain-following radar, flight-control;
electronic countermeasures (stealth) jam plane's own signals (S 12 2)
<P>*V$h B-1B swept wing punctures gas tank on the ground; blamed on low
lubricant; problem found in 70 of 80 B-1Bs inspected (S 14 2)! No computer
sensors?
<P>$fd Stealth development problems including SW miscalculation in wiring (S 15 1)
<P>$f UHB demonstrator flight aborted by software error at 12,000 feet (S 12 3)
<P>*V$fh F-22 prototype crash first blamed on computer SW, then on pilot (S 17 3)
<P>*V$f F-18 crash due to missing exception cond. Pilot OK (S 6 2, more SEN 11 2)
<P>*Vhi F-18 missile thrust while clamped, plane lost 20,000 feet (S 8 5)
<P>*f F-16 simulation: plane flipped over whenever it crossed equator (S 5 2)
<P>*f F-16 simulation: upside-down, deadlock over left vs. right roll (S 9 5)
<P>$Vhi F-16 landing gear raised while plane on runway; bomb problems (S 11 5)
<P>*Vfh Unstallable F-16 stalls; novice pilot found unprotected maneuver (S 14 2)
<P>$d USAF ECM systems: software 2 years late for F-16 and F-111 (S 15 5)
<P>*hif Accidental shootdown of one Japanese F-15 by another (R 17 65, R 18 18);
controversy continues (R 18 41,57)
<P>*V$f? F-14 off aircraft carrier into North Sea; due to software? (S 8 3)
<P>*V$f F-14 lost to uncontrollable spin, traced to tactical software (S 9 5)
<P>Vf YF-23 fly-by-wire prototype attempted tail corrections while taxiing.
Same problem on first X-29. (AFTI/F-16 had weight-on-wheels switch.) (S 16 3)
AFTI/F-16 DFCS redundancy management: ref to J.Rushby SRI-CSL-91-3 (S 16 3)
<P>+- Historical review of X-15 and BOMARC reliability experiences (S 17 3)
<P>$ Systems late, over budget (what's new?); C-17/B-1/STC/NORAD/ASJP (S 15 1)
<P>V*$fd C-17 SW/HW problems documented in GAO report; 19 on-board computers,
80 microprocessors, six programming languages; complexity misassessed
GAO: "The C-17 is a good example of how <I>not</I> to approach software
development when procuring a major weapons system." (S 17 3)
Chairman John F. McDonnell's reply (S 17 4)
<P>f C-130 testbed uncovers 25-yr-old divide-by-zero bug in X-31 SW (S 16 3)
<P>*Vmf X-31 crash, 19 Jan 1995 (R 17 45,46,47,60,62; 60=Pete Mellor)
<P>V(f?) Unplanned 360-degree roll of NASA's X-38 in test (R 21 10)
<P>*VM US missile-warning radar triggers accidental explosions in friendly
aircraft; radar must be turned off when planes land! (S 14 2)
<P>* AF PAVE PAWS radar can trigger ejection seats, fire extinguishers (S 15 1)
<P>!$h 1988 RAF Tornados collided, killing 4; flying on same cassette! (S 15 3)
<P>V$ef DarkStar unmanned aerial vehicle (UAV) crash from software change, cost
$39M (S 22 1:17-18)
<P>mM? Air Force bombs Georgia - stray electromagnetic interference? (S 14 5)
<P>*hme, etc. Navigation, GPS, and risks of flying (R 19 73,75,77);
Implications of the U.S. Navy no longer
teaching celestial navigation (R 19 75,77-79,81-82)
<H2><A NAME="8">Commercial Aviation</A></H2>
<P>..... Commercial flight incidents
<P>!!$V(hi?) Korean Airlines KAL 007 shot down killing 269 [1Sept1983];
autopilot on HDG 246 rather than INERTIAL NAV? (NYReview 25 Apr 85; SEN 9 1,
10 3, 12 1) or espionage mission? (R.W. Johnson, "Shootdown") Further
information from Soviets, residual questions (S 16 3); Zuyev reports Arctic
gales had knocked out key Soviet radars; Oberg believed Sakhalin air defense
forces were "trigger-happy" following earlier US Navy aircraft overflight
incursions [Reuters 2Jan1993]; Analysis of recent articles on KAL 007
(Ladkin, R 18 44)
<P>!!Vfe Korean Airlines KAL 901 accident in Guam, killing 225 of 254;
worldwide bug discovered in barometric altimetry in Ground Proximity
Warning System (GPWS) (S 23 1:11, R 19 37-38)
<P>!!Vm
Alaska Airlines flight 261, 31 Jan 2000, dove into Pacific Ocean after
jackscrew failure in stabilizer assembly; hearing results show loss of
paper trail (R 21 15)
<P>!!V(m?h?) TWA Flight 800 missile-test accident hypothesis causing near-empty
fuel-tank explosion off Long Island widely circulated in Internet e-mail,
causing considerable flap. Missile theory officially discredited.
Minireview of James Sander's <I>The Downing of TWA Flight 800</I> (R 19 12);
speculative discussion on the downing of TWA 800 (R 19 13); possibility of
EMI raised in article by Elaine Scarry, <I>New York Review of Books,</I> 9
Apr 1998 (R 19 64-66). <I>Harvard Magazine</I> Jul-Aug 1998, pp. 11-12,
diagram shows TWA 800 at 13,700 feet between a P3 Orion directly overhead at
20,000 feet, Black Hawk helicopter and HC-130 at 3,000 feet both directly
below (with a C-141 and C-10 nearby). But this seems unlikely. (R 19 86)
Report from Commander William S. Donaldson III, USN Ret., 17 July 1998,
claiming a hostile missile attack
<A HREF="http://www.aci.net/kalliste/donaldson.htm">http://www.aci.net/kalliste/donaldson.htm</A>.
<P>!!V$rh Air New Zealand crashed into Mt Erebus, killing 257 [28Nov1979];
computer course data error detected but pilots not informed (S 6 3, 6 5)
<P>!!V$f/m? Lauda Air 767-300ER broke up over Thailand. 223 dead. Cockpit voice
recorder: thrust reverser deployed in mid-air. Precedents on 747/767
controlled; investigation in progress. (S 16 3, AWST 10Jun91 pp.28-30)
Suitcase full of cheap lithium-battery Chinese watches exploded? Earlier
lithium battery problems: South African 747 in 1987, killed 159; Cathay
Pacific 1990 emergency landing (S 16 3, Sunday Times, London, 23 Jun 91)
Many other planes may be flying with the same thrust-reverser defect;
FAA, Boeing simulations, suggest 757 less aerostable than though (S 16 4)
Ex-Boeing expert had warned of software flaw in 747/767 proximity switch
electronics unit; he claims he was ordered to suppress data. (S 17 1)
<P>!!Vhifmr Northwest Air flight 255 computer failed to warn crew of unset
flaps misset, thrust indicator wrong; 156 dead (S 12 4); circuit breaker
downed the warning system that should have detected those problems. [But
who checks the checker?] Simulator, plane behave differently (S 13 1)
Report blames pilot error, unattributed circuit outage (S 13 3) Report that
the same pilots had intentionally disconnected the alarm on another MD-80
two days before raises suspicions. (S 14 5, R-08.65) NW sues CAE over spec
error in flight training simulator (S 15 5) A Federal jury ruled on 8 May 91
that the crew was to blame.
<P>!!V$mf/h/i? British Midland 737 crash, 47 killed, 74 seriously injured; right
engine erroneously shut off in response to smoke, vibration (Flight
International 1 Apr 89); suspected crosswiring detected in many OTHER
planes (S 14 2); low-probability, high-consequence accidents (S 14 5);
random memory initialization in flight management computers (S 14 5);
Kegworth M1 air crash inquest: many improvements suggested (S 15 3);
Criticism of "glass cockpits" (S 15 3);
UK AAIB fingers 737-400 liquid crystal display layouts (S 16 3);
now-retired British vicar Reverend Leslie Robinson
claims a witches' coven was operating under the flight path (R 20 12)
<P>!!Vh Aeromexico flight to LAX crashes with private plane, 82 killed (S 11 5)
<P>!!Vh Metroliner&transponderless small plane collide 15 Jan 87. 10 die (S 12 2)
<P>!!Vh Two planes collide 19 Jan 87. Altitude data not watched by ATC. (S 12 2)
<P>!!Vfih 1994 China Air A300-600 Nagoya accident killing 264: final report
blames pilots and autopilot human-computer interface (R 18 33); (see
also R 16 05-07, 09, 13-16)
<P>!Vh Air France Airbus A320 crash blamed on pilot error, safety controls off
(S 13 4); 3 killed. Airbus computer system development criticized (S 13 4);
Subsequent doubts on computers reported: inaccurate altimeter readings;
engines unexpectedly throttling up on final approach; sudden power loss
prior to landing; steering problems while taxiing (S 14 2); reportage by
Jim Beatson (R 08 49, 08 77), barometric pressure backset? (S 14 5)
investigators blame pilot error; pilots charge recorder tampering (S 15 3)
Pilots convicted for libel in blaming technical malfunctions! (S 16 3)
<P>!!V? Indian Airlines Airbus A320 crashes 1000 ft short of runway; 97 die (S
15 2) A320 flight modes (S 15 3); apparent similarities in crashes (S 15 3)
Air India unloading their A320s (S 15 5)
<P>V(m?) Air India Airbus 320 autopilot failure [19Apr1999]? (S 24 4:26, R 20 32)
<P>!!Vhmi French Air Inter A320 crash on approach to Strassbourg airport
[20Jan1992]; 87 dead, 9 survivors; 2,000-foot altitude drop reported (R 13
05); crash site at 2496 feet. Report fingers mixture of human and technical
error, airport ill equipped, serious failings in altimeter system, pilot
unable to stop descent (S 17 2); Air Inter official charged with negligent
homicide (S 18 2:9); Commission of Enquiry blamed Pilot Error (S 18 4:12);
New case of A320 descent-rate instability identified approaching Orly,
related to Air Inter crash (S 18 1:23); Final report blames crew training
and interface problems (S 19 2:11)
<P>!Vf 1994 Toulouse A330 accident blamed on experimental SW. 7 died (S 19 4:11)
<P>* A320 flight-control computer anomalies summarized by Peter Ladkin (R 18 78)
<P>!*(V,etc.) Compendium of commercial fly-by-wire problems (Peter Ladkin) (S
21 2:22)
<P>@!!$hi Iran Air 655 Airbus shot down by USS Vincennes' Aegis system (above)
<P>?h Qantas airliner challenged by US Cowpens, Aegis missile cruiser (S 17 4)
<P>!V(f/h/i?) Varig 737 crash (12 dead) flightpath miskeyed? (S 15 1)
<P>!V 707 over Elkton MD hit by lightning in 1963, everyone killed (S 15 1)
<P>!V$m AA DC-10 stall indicator failed; power was from missing engine (S 11 5)
<P>!V Bird strikes cause crash of Ethiopian Airlines 737, killing 31 (S 14 2)
<P>!V Dominican Republic 757 crash 6 Feb 1996, cause unclear (S 21 4:13, R 17 84)
<P>!V BirgenAir crash at Puerto Plata killed 189 (R 17 87)
<P>!!V$hi Further discussion of American Airlines Cali and Puerto Plata B757
crashes (R 18 10); in Cali crash, killing 159 of 163: same abbreviated
code used for different airports (S 22 1:17); in a trial, evidence
was given that 95 of 8,000 navigational beacons were not included in the
airline database, including Cali's Rozo (R) - see media reports 17 Apr
2000. US Federal jury allocated responsibility 17% to Jeppessen,
8% to Honeywell, 75% to American Airlines (R 20 92; S 26 1:23)
<P>!fi
EFIS failure main suspect in Crossair crash (S 25 3:17-18, R 20 78)
<P>!Vh 1996 B757 Aeroperu Flight 603: duct tape over left-side
static port sensors? (S 22 2:22; R 18 51,57,59)
Peru Transport Ministry verified this [Reuter, 18Jan1997]
<P>Vm Migratory birds jam FAA radar in Midwest (R 17 44)
<P>m Lovesick cod overload Norwegian submarine sonar equipment (R 20 07)
[Who needs a cod peace?]
<P>!!V Chinese Northwest Airlines BA-146 Whisperjet crashed on second takeoff
attempt, killing 59; cause not available [23Jul1993] (S 18 4:12)
<P>!V Ilyushin Il-114 crash due to digital engine control failure (S 19 1:9)
<P>*V mi Dec 1991 SAS MD-81 crash (ice damaged engine) due to auto thrust
restoration mechanism not previously known to exist by SAS (S 19 1:12)
<P>*Vf 11 cases of MD-11s with flap/slat extension problem, including China
Eastern Airline plane that lost 5000 feet on 6 Apr 1993 (S 18 4:11)
<P>Vf/m/h? Chinook helicopter engine software implicated (S 23 3:23, R 19 51);
more on the Chinook enquiry (R 21 14,18-20)
<P>*Vrh Lessons of ValueJet 592 crash: William Langewiesche in <I>Atlantic
Monthly</I> (R 19 62,63)
<P>*Vf DC-9 chip failure mode detected in simulation (S 13 1)
<P>!!V$f Electra failures due to simulation omission (S 11 5)
<P>!V$f Computer readout for navigation wrong, pilot killed (S 11 2)
<P>*Vhi South Pacific Airlines, 200 aboard, 500 mi off course near USSR [6Oct1984]
<P>*Vhi China Air Flight 006 747SP 2/86 pilot vs autopilot at 41,000 ft with
failed engine, other engines stalled, plane lost 32,000 feet [19Feb1985] (S
10 2, 12 1)
<P>*V Simultaneous 3-engine failure reported by Captain of DC-8/73 (S 14 2)
<P>*Vfm Boeing KC-135 autopilot malfunction causes two engines to break off (S
16 2)
<P>*Vf Avionics failed, design used digitized copier-distorted curves (S 10 5)
<P>*Vf Lufthansa A320 overruns runway in Warsaw; actuator delay blamed (S 19
1:11); Logic flaw in braking system; fix required fooling the logic! (S 19
2:11)
<P>mV A320 engine-starter unit overheats after takeoff, trips breakers,
gave false thrust-reverser indications, engine control failure (S 19 2:12)
<P>*V$f 727 (UA 616) nose-gear indicator false positive forces landing (S 12 1)
<P>*Vhi USAir 737-400 crash at NY LGA; computer interface, pilot blamed (S 15 1)
<P>!Vi Crash of USAir Flight 427 nearing Pittsburgh, 8 Sep 1994:
see Jonathan Harr, (<I>The New Yorker,</I> 5 Aug 1996 (S 22 1:17)
<P>*V Tarom Airbus automatic mode switch escaped pilot's notice (S 20 1:16)
<P>*Vf British Airways 747-400 throttles closed, several times; fixed? (S 15 3)
<P>*Vf JAL 747-400 fuel distribution stressed wings beyond op limits (S 16 3)
<P>*Vf Older Boeing 747 planes suspected of diving due to autopilot design flaw;
747-400 speed reduction of 50 knots ordered; 747-200 sudden increase in
thrust, another pitched upwards; etc. (S 17 3); FAA report on possible
747 autopilot faults relating to altitude losses (S 18 3:A15)
<P>Vf 747 tail scrapes runway; center of gravity miscalculated by
improper program upgrade (R 19 11)
<P>*Vf Boeing 757/767 Collins autopilot anomalies discussed (S 19 1:10)
<P>**V 767 (UA 310 to Denver) four minutes without engines [August 1983] (S 8 5)
<P>*Vf 767 failure LA to NY forced to alternate SF instead of back to LA (S 9 2)
<P>*Vm Martinair B767 Aircraft suffers EFIS failure; instruments blank (S 21 5:15)
<P>*V(f/m?) B777 autopilot/flight-director problems [Oct1996]? (S 22 4:29, R
18 83)
<P>V$ Boeing 777 landing-gear weakness; strength off by factor of 2 (R 17 04)
<P>*he
Australian Ansett B767 fleet grounded due to maintenance breaches (R 21 17)
<P>*Vf 11 instrument software failures in BA aircraft in Jul-Aug 1989 (S 15 5)
<P>*fhi Analysis of potential risks of the Enhanced Ground Proximity Warning
System (EGPWS), by Jim Wolper (R 19 56); pilots computer literacy?
(R 19 57); relationship with GPS accuracy (R 19 57)
<P>* Missile passes American Airlines Flight 1170 over Wallops Island (S 22 1:18)
<P>m Fire alarms on Boeing 777 triggered by tropical fruit and frog cargo (S 22 1:17)
<P>M
Cell phone ringing in Adria Airways luggage alarms avionics;
plane returns (R 21 20)
<P>*m INCETE power ports in use in at least 1700 aircraft can result in
exploding batteries? (R 19 94)
<P>m*
High-flying hijinks: canine passenger sinks teeth into plane
(R 20 54)
<P>..... Private plane incidents
<P>!Vrhi
John Denver plane crash linked to unlabelled implementation change over
spec: lever up for off, down for right tank, to the right for left tank;
not very intuitive! (R 20 43)
<P>..... Airport problems
<P>m Power failure disrupts Ronald Reagan National Airport 10 Apr 2000 for
almost 8 hours; backup generator failed (R 20 87)
<P>$fd $200M Denver airport baggage system seriously delays opening (S 19 3:5);
costly stopgap old-fashioned system planned in the "interim" (S 19 4:6); new
software problems for incoming baggage (R 17 61); city overruled
consultant's negative simulation results (R 18 66)
<P>Vdfm$ Kuala Lumpur International Airport: Risks of being a development
pioneer (R 19 68); airport opens 30 Jun 1998, but baggage and check-in
systems failed for several days (R 19 84); similar events at the opening
of the new Hong Kong airport a few days later (R 19 85)
<P>Vm Amsterdam Schiphol airport computer down for 30 minutes, major
delays (R 19 85); unchecked out-of-range value (R 19 93)
<P>V$fe American Airlines' SABRE system down 12 hours; new disk-drive SW launched
"core-walker" downing 1080 old disk drives, stripped file names ... (S 14 5)
<P>Vm American Airlines' Sabre system software problem down for four hours
(30 Jun 1998, evening rush hour) affected hundreds of flights across
50 airlines; second crash in a week (R 19 84)
<P>f/m SAS new baggage system miseries at Copenhagen Airport (R 19 97)
<P>h SAS reprinted summer airline timetables for the winter, but
Internet version was correct (R 20 05)
<P>mh Boston airport electronic display fiasco on flight to Philly (R 19 96)
<P>..... Masquerading
<P>*VSH Miami air-traffic controller masquerader altered courses (S 12 1)
<P>*VSH Roanoake Phantom spoofed ATC, gave bogus information to pilots for 6 wks,
caught (S 19 2:5); out-of-work janitor pleads guilty (R 15 39)
<P>VSH Manchester (UK) air-traffic-controller message spoofer (UK) (S 21 2:21)
<P>..... Other air-traffic control problems
<P>*h 20-foot aircraft separation near-collision over LaGuardia Airport, 3 Apr
1998, due to controller being distracted by spilled coffee (R 19 79,84)
together with increased error rates and radar dropouts results in
FAA ordering retraining of air-traffic controllers (R 19 79)
<P>fe Westbury Long Island TRACON upgrade failed test, but backup to old
software backfired (R 19 79)
<P>*Vfm Radar blip lost Air Force One (S 23 4:21, R 19 63)
<P>Vm* Air Force One disappeared from the Gibbsboro NJ radar twice on 5 Jun 1998,
with President Clinton en route to MIT for the commencement speech; also
reported was near-collision with a Swissair 747, missed by radar, Oct 1997
(R 19 79); Air Force Two disappeared from radar, 7 Jun 1998, and the
same radar failed with AF2 overhead 17 Jun 1998 (R 19 82)
<P>m?f? San Francisco Airport radar phantom flights (R 21 20, S 26 2:)
<P>f Air-traffic control woes (R 21 09, S 26 2:)
<P>Vm Aviation near-crashes in Kathmandu (R 21 09, S 26 2:)
<P>*V(m?f?) Indianapolis FAA route center running on generators for a week
(R 21 11, S 26 2:)
<P>*h Delta plane 60 miles off course, missed Continental by 30 feet (S 12 4)
<P>Vf SW fault in aircraft nondirectional beacon landing approach system (S 16 3)
<P>V* New San Jose CA ATC system still buggy, plane tags disappear (S 14 2)
<P>*Vf ATC computers cause phantom airplane images (S 16 3)
<P>Vf West Drayton ATC system bug found in 2-yr-old COBOL code (S 16 3)
<P>*Vh Open cockpit mike, defective transponder caused 2 near-collisions (S 12 1)
<P>*Veh ATC equipment test leads to Sydney landing near-collision (R 20 24)
<P>*Vmf More ATC problems, fall 1998:
New air-traffic control radar systems fail, losing aircraft at O'Hare
(R 20 07); Dallas-FortWorth ARTS 6.05 TRACON gives ghost planes,
loses planes (one for 10 miles), one plane on screen at 10,000 feet
handed off and showing up at 3,900 feet! 200 controller complaints
ignored, system finally backed off to 6.04 (R 20 07); near-collision
off Long Island attributed to failure at Nashua NH control center
(R 20 11); TCAS system failures for near-collision over Albany NY
(R 20 11); two more TCAS-related incidents reported (R 20 12);
landing-takeoff near-miss on runway at LaGuardia in NY (R 20 13);
discussion on trustworthiness of TCAS by Andres Zellweger, former
FAA Advanced Automation head (R 20 13)
<P>V(f/m?)
Faulty TCAS behavior. Australian report shows two
faulty TCAS cases: Jan 1998 near Hawaii, TCAS off by
1500 feet vertically, caused false maneuvers; Jun 1999
over China, TCAS had higher plane descending toward
the lower (R 20 60,62);
<P>*Vfm Complete ATC power failure in the U.S. Northwest, 15 Jan 1999,
discussion by Seattle controller, Paul Cox (R 20 19)
<P>*Vmh Dulles radar fails for half-hour 23 Nov 1998 (R 20 10);
discussion of air-traffic control safety implications (R 20 11),
and ensuing comments from a controller (R 20 12)
<P>*Vh Risks of runway crossings with tight takeoff/landing schedules (R 20 10)
<P>f Airline clock wraparound in displays: UA Flight 63 from SFO
"Delayed 1 hr 39 min, Arrive Honolulu Intl 12:01am
Tues Early 22 hr 35 min" (R 20 15);
More United Airlines Website flight curiosities (R 20 44)
<P>h Couple join Mile-High Club, disrupt British air-traffic control (S 19 1:10)
<P>h Accidentally enabled sex-aid vibrator in hand luggage
causes bomb scare on Monarch Air flight; apparently not unusual (R 20 34)
<P>*Vm Air-traffic control data cable loss caused close calls (S 10 5)
<P>V$SHm Attack on fibre-optic cables causes Lufthansa delays (S 20 2:12)
<P>VmM Display lasers affect aircraft: pilots blinded over Las Vegas (R 17 55)
<P>*d Reports on new En Route Centre NERC for UK ATC (R 19 18,23,69)
<P>*Vfm Review on air-traffic control outages by Peter Ladkin (S 23 3:26, R 19 59)
<P>*fhm, etc.
UK air-traffic control problems summarized at www.pprune.org (R 21 11)
<P>*VM More on EMI and RF interference from passenger devices in aircraft
systems (Ladkin) (R 19 24); still more, including discussion of
Elaine Scarry article in 26 Sep 2000 <I>The New York Review of Books</I>(
and follow-ups (R 21 04,08,11)
<P>VSfM Case of GPS jamming of Continental flight by failed Air Force
computer-based test (R 19 71)
more on GPS jamming/spoofing: British Airways flight lost all three GPS
systems while French military was testing jammers; Continental DC-10
lost all GPS signals while Rome Lab was experimenting with jammers
(R 19 74,85)
<P>Vf/h?
GPS kills 8 in air (R 20 44-45) and radar-assisted collisions (R 20 45)
<P>@*VM Cell-phone linked to London to Istanbul crash-landing? (R 19 34,36,37)VM Australia's Melbourne Airport RF interference affected communications,
traced to an emanating VCR! (R 17 44)
<P>*VM Osaka Int'l Airport's radar screens jammed by TV aerial booster (S 12 3)
<P>*M Cellular telephone activates airliner fire alarm (S 14 6)
<P>Vfmhi? Aviation Risks using Windows NT avionics systems (S 23 3:27, R 19 46)
<P>*Vfi Flawed ATC radars: planes disappear from screens; other problems (S 12 1)
<P>hi Controller screwup causes NW 52 to Frankfurt to land in Brussels
(R 17 38,40)
<P>*Vdef Risks in the new Sydney airport control system (R 17 43)
<P>*m Computer outage in Concorde leads to rocky nonautomatic landing (S 12 4)
<P>*Ve British ATC 2-hr outage, 6-hr delays: faulty HW/SW upgrade (S 12 1)
Computer problems down FL ATC, slow airline flights in Southern U.S. (S 19
1:11)
<P>*Vfmd Air-traffic-control snafus in Chicago, Oakland, Miami, Washington DC,
Dallas-FortWorth, Cleveland, New York, western states, Pittsburgh! (S 20 5:12);
Another Oakland airport radar outage 28 Nov 1995, two hours (R 17 49)
<P>V*fm
Philadelphia airport radar problems, May 1999 (R 20 42)
More radar glitches at Philadelphia airport 10 Mar 2000 (S 25 3:18, R 20 84)
<P>Vhm Brief KC power outage triggers national air-traffic snarl
(S 23 3:23, R 19 51)
<P>!Vm New York air traffic slowed for 10 hrs by construction contamination
(R 19 41)
<P>*f Fall 1998 air-traffic control upgrade problems: New Hampshire (R 19 93),
Salt Lake ATC (R 20 05); Dallas-FortWorth ARTS 6.05 (S 24 1:31, R 20 07),
Chicago (R 20 07)
<P>Vm Effects on automated traffic controls of plane crashing into 500Kv power
line near Cajon Pass; more than 1000 traffic lights out (R 19 29,30);
earlier effects of power failure in Perth (R 19 30); risks of major outages
(R 19 32,33)
<P>*Vhe Southern Cal plane crash due to software change? (S 12 1)
<P>*Vmf Alaskan barometric pressure downs altimeters; FAA grounds planes (S 14 2)
<P>*Vfm FAA Air Traffic Control: many computer system outages
(e.g., SEN 5 3, 11 5), near-misses not reported (S 10 3)
<P>*Vf ATC computer system blamed for various near-misses, delays, etc. (S 12 4)
<P>*Vhi Air-traffic controller errors. O'hare near-miss: wrong plane code (S 12 3)
<P>V(f/m/h?) 2 jets in near-miss approaching LAX; Brazilian VASP MD-11 pilot
blames autopilot, others blame pilot (R 19 10)
<P>*Vh F-16 incidents, TCAS: 4 separate risky military approaches
(S 22 4:28, R 18 83)
<P>*V$fm FAA report lists 114 major telecom outages in 12 months 1990-91;
Secretary Pena blames air-traffic woes on computer systems (S 19 4:11)
20 ATCs downed by fiber cable cut by farmer burying cow [4May1991] (S 17 1);
Kansas City ATC downed by beaver-chewed cable [1990] (S 17 1);
Other outages due to lightning strikes, misplaced backhoe buckets,
blown fuses, computer problems (S 17 1)
3hr outage, airport delays: Boston unmarked components switched (S 17 1)
More on the AT&T outage of 17Sep91 noted below (5M calls blocked, air travel
crippled, 1,174 flights cancelled/delayed) (S 17 1)
<P>fh WashingtonDC air traffic slowed 11 Jun 1997: old wiring error (S 22 5:13)
<P>V$fe SW bug downs Fremont CA Air Traffic Control Center for 2 hours
[8Apr1992]; 12 of 50 radio frequencies died [17Apr1992], reason unspecified
(S 17 3)
<P>V$d New Canadian air-traffic control system SW problems, system late,
it crashes, planes flying backwards, frozen displays, no radar,... (S 17 4)
<P>*Vm NY Air Route Traffic Control Center computer failure (S 21 5:15)
<P>*Vef Computer glitches foul up flights at Chicago airports (S 24 4:26,R 20 38)
<P>@See below, general telephone problems that affected traffic control.
<P>*$ Discussion of the implications, needs for oversight, assurance (S 17 1)
<P>*V$m FAA ATC computers in Houston down for 3 hours; long delays (S 12 2)*
<P>*V$rm El Toro ATC computer HW fails 104 times in a day. No backup. (S 14 6)
<P>Vhfm Accidental power outage affects Pacific Northwest air traffic (S 21 2:21)
<P>Vm Dallas-FortWorth ATC system power outage affects southwest (R 17 40)
<P>Vm Las Vegas approach radar outage (R 17 41)
<P>*V$m London ATC lost main, standby power, radar; capacitor blamed! (S 12 2)
<P>*f London ATC goof - US ATC program ignores East longitude (S 13 4)
<P>*f Software misdirects air-traffic controller data in Boston (S 13 4)
<P>@d New £300 million UK air-traffic control system confronts complexity
(S 22 1:18)
<P>*Vh Commercial plane near-collisions up 37.6% in 1986; 49 critical (S 12 2)
<P>*H Radar center controllers (So.Cal) concealed collision course info (S 12 2)
<P>*V Jetliners in near-miss over Cleveland; wrong freq assigned, neither
plane in contact with controllers (S 16 4)
<P>*Vid Complexity of the airplane pilot's interface increasing (R 18 63)
<P>*V Computer errors involved in plane crashes? (Aftonbladet) (R 18 65,66)
<P>* Problems with below-sea-level aircraft altitudes (R 18 72,74)
<P>h Plane takes off, flies for two hours, without pilot (R 19 47)
<P>*Vf `TCAS Sees Ghosts' (see IEEE SPECTRUM, August 1991, p.58) (S 16 4);
Traffic Alert Collision Avoidance System blasted by ATC people (S 17 1);
See also relevant discussion on human errors by Don Norman (S 17 1:22)
<P>Vih? TCAS related collision-avoidance mistake discussed (S 18 1:24)
<P>*f Air-traffic controller reports on potential TCAS problem (S 18 3:A15)
<P>Vf TCAS blamed for near collision over Portland WA; previous reports of
phantom planes and misdirected avoidance maneuvers (S 19 2:12);
Followup report (S 19 3:9)
<P>*f?/+ TCAS incidents: northwestern U.S., Tehran (S 20 5:13)
<P>? Discussion of TCAS near-miss in Southern Calif. (R 19 55,56)
<P>*Vf Chicago's O'Hare Airport radar lost planes, created ghosts (S 17 1)
<P>*h GAO faults FAA for inadequate system planning in Los Angeles area (S 15 5)
<P>$ FAA drops navigation system contract (S 21 5:16)
<P>*Vhi Four 1986 British near misses described - all human errors (S 12 2)
<P>*Vf/m? Leesburg VA Air Traffic primary, backup systems badly degraded (S 15 1)
<P>*Ve? DFW ATC 12-hour outage after routine maintenance (S 15 1)
<P>*V$ Computer outages force delays in So. Cal, Atlanta (S 12 2)
<P>* Macaque reaches 747 cockpit controls; monkey loose on Cosmos 1887 (S 12 4)
<P>$ Travicom computerized air cargo system withdrawn; £5M lost (S 12 2)
<P>$H Computer hides discount airline seats from agents; lost sales (S 12 2)
<P>$f Pricing program loses American Airlines $50M in ticket sales (S 13 4)
<P>f,h,i Ordering airline tickets on-line: Nonatomic transaction gave tickets but
no reservation (R 19 27); name confusions on e-tickets, with
similar names (R 19 28) and identical names (R 19 29)
<P>$d American Airlines reservation system SW woes adding cars, hotels (S 17 4)
<P>V$m Power outage causes Australian airline reservation system "virus" (S 13 3)
<P>f Delayed DoT airline complaint report blamed on computer (S 12 3)
<P>$ First-day snafu at new Pittsburgh Airport; BA luggage uncoded (S 18 1:25)
<P>Vm Hong Kong Flying Service computers corroded by hydrogen sulphide (R 19 41)
<P>$f*h British Air 10M-pound inventory system loses parts, earnings,
convictions, user confidence, nearly causes deaths, and costs legal expenses
(S 18 1:9)
<H2><A NAME="9">Rail, Bus, and Other Public Transit</A></H2>
<P>!Vh 42 die in Japanese train crash under manual standby operation (S 16 3)
<P>!$Vm Loose wire caused Britrail Clapham train crash, 35 killed (S 14 6)
<P>!!$Vhi Canadian trains collide despite "safe" computer; 26 killed (S 11 2)
<P>*Vmh Rail Canada train derailed 3 Sep 1997; early warning alarm ignored
by untrained crew, who disconnected it (R 19 94-95,97)
<P>!Vh Southern Pacific Cajon crash kills 3; tonnage computations wrong (S 14 6)
<P>!Vm Cannon St train crash in London, 1 dead, 348 injured, brakes failed (S 16 2)
<P>!Vm Kings Cross passenger trapped in automatic door, killed; no alarm (S 16 2)
<P>!V*h London commuter train crash out of Euston Station, 8 Aug 1996 (S 22 1:18)
<P>V!*h
Ladbroke British train collision, Oct 1999; driver ran red Signal 109
(R 20 59-60, 62-63)
<P>*V(r?f?) London underground train went 4 stops with fail-safe doors open
(S 16 2)
<P>*Vrf London Docklands Light Railway crash; protection system incomplete (S 12 4)
<P>*Vh DLR unmanned trains crash under standby manual control (S 16 3)
<P>e DLR train stopped at station not yet built to avoid changing SW (S 16 3)
<P>*hf London Underground wrong-way train in rush-hour (S 15 3)
<P>*fh London Underground train leaves ... without its driver (S 15 3)
<P>*fh Another London Underground driver leaves train, which takes off (S 19 2:2)
<P>@SH London Underground hacked by insider posting nasty messages (R 17 36)
<P>*h 1928 British rail interlocking frame problem revisited (S 15 2)
<P>*f British Rail signalling software problems, trains disappear (S 15 5)
<P>*Vm Leaves on track cause British Rail signal failure (S 17 1)
<P>*Vf Removal of train's dead-man's switch leads to new crash cause (S 17 1)
<P>*f/h? Severn Tunnel rail crash (100 injured) under backup controls (S 17 1)
<P>V*fm
Intercom hang-up caused 1997 Toronto train collision, 19 Nov 1997;
50 hospitalized; "dwarf signals" (R 20 49)
<P>!Veihh Head-on train collision in Berlin killed 3, injured 20; track controls
mistakenly set to one-way traffic, overseer overrode halt signal (S 18 3:A3)
<P>!Vm German high-speed train disaster Jun 1998 and implications;
automated system with inadequate sensors and overrides (R 19 80,81,83,89)
<P>Vfm Berlin new automated train switching system (Siemens Generation C)
fails from the outset of its use (R 19 77)
<P>f Berlin S-Bahn stopped by switching SW stack overflow (S 22 2:19)
<P>*feh NY City subway crash due to operator, outdated parameters (S 20 5:8)
<P>*m Runaway train on Capitol Hill (S 24 3:26, R 20 13)
<P>m Computer crash freezes train traffic in 8 US states (S 20 3:8)
<P>$Vdef Stack overflow shuts down new Altona switch tower on first day (S 20 3:8)
<P>m Paper-clip causes hard-drive overflow, triggering traffic-control computer
failure stopping trains in south Finland for an hour (R 19 10)
<P>* Train Accident in China due to safety systems known not to work (S 17 1)
<P>*m Control faults cause Osaka train to crash, injuring 178 (S 19 1:4)
<P>f/m?
Computer glitch causes severe train delays in Melbourne (R 20 48)
<P>Vm Electrocuted snake cancels 34 trains in northern Japan (R 19 88)
<P>*hi Amtrak mainline train collision in Maryland, Feb 1996 (S 21 4:13)
<P>Vf/m? Amtrak ticket system breaks down (S 22 2:19)
<P>Vrm
Hurricane Floyd had widespread effects, Amtrak
operations center problems in Jacksonville affected trains in
Eastern Seaboard, Chicago, Michigan; also DC commuter rail (R 20 58);
ISDN lines, ATMs, EDS (R 20 62);
nationwide AT&T cellphone service interruptions (R 20 59);
<P>Vm/f
Emergency Alert System interrupts hurricane
announcement, and crashes for 20 minutes (R 20 58)
<P>f/m Train-ticket vending machine bogus tickets; innocent victim harassed (R
19 20)
<P>Vm Swedish central train-ticket sales/reservation system and its backup both
fail (R 20 05)
<P>!i Washington D.C. Metro crash kills operator (S 21 4:13)
<P>Vmf Washington D.C. Metro Blue Line delay 6 Jun 1997; system+backup failed
(R 19 22)
<P>Vmfe Computer crash impacts Washington DC Metro (S 23 3:25, R 19 50)
<P>Vf/m?
Computer problems foul up the Washington D.C. Metro system;
graphics system froze (R 20 60)
<P>*h Atlanta MARTA commuter train jumps track, injuring 19 (S 21 5:14)
<P>*f LIRR trains fail to trigger computerized crossing gates (S 22 1:18)
<P>m Lightning knocks down wall of an English pub, and closes fail-safe
railroad crossing that blocked fire engines (R 19 72)
<P>Vfm Computer crash shuts down Taipei subway (S 21 5:14)
Note: Matra made software for both Ariane5 and Taipei subway system (S 21 5:15)
<P>V$mf Swiss locomotives break down in cold weather; SW fails (S 20 2:11)
<P>*f Flaw discovered in Swedish rail control system after near miss (R 19 22)
<P>fh Union Pacific merger aftermath: gridlock, lost trains (S 23 1:11, R 19 41)
<P>* Japanese railway communications jammed by video game machines (S 12 3)
<P>* Japanese train doors opened inadvertently several times; EMI? (S 12 3)
<P>*f SF BART train doors opened between stations during SF-Oakland leg (S 8 5)
<P>f SF BART automatic control disastrous days of computer outages (S 6 1)
<P>*V$m BART power mysteriously fails and restores itself 5 hours later (S 12 3)
battery charger short and faulty switch subsequently identified (S 12 4)
<P>m BART ghost train, software crash, 3 trains fail, system delays (S 22 2:19)
<P>f BART ghost trains; 567 cases in two years (R 20 31-32)
<P>f SF Muni Metro: Ghost Train recurs, forcing manual operation (S 8 3)
<P>f SF Muni Metro: Ghost Train reappears; BART problems same day (S 12 1)
<P>mM San Francisco Muni adds new communicating streetcars, has to remove old
ones blocking comms to increase service (R 19 95); Muni driver leaves
car, which went on driverless! (R 19 95)
<P>*fm Chunnel has ghost trains, emergency stops (due to salt water?) (S 20 3:9)
<P>Vf Phantom trains down Miami's Metromover inner loop for 2 days (S 20 5:8)
<P>$*H SF Muni Metro crash; operator disconnected safety controls (S 18 3:A3)
<P>$d Washington D.C. Metro stops payments on troubled computer (S 23 4:21)
<P>h LA Rapid Transit District computer loses bus in repair yard (S 12 2)
<P>$f LA RTD phantom warehouse in database "stores" lost parts (S 12 2)
<P>fhi Analysis of the Chicago train/bus crash (R 17 43)
<P>$*f Puget Sound ferry computer failures - 12 crashes; settlement vs builder
$7 million; cost of extra $3 million for manual controls! (S 12 2);
Electronic "sail-by-wire" replaced with pneumatic controls (S 14 2,15 2)
<P>*Vm Water seepage stops Sydney automated monorail computer controls (S 13 4)
<P>Vfh Daylight savings time changeover halts train for an hour (S 15 3)
<P>m
Risks of the modern train: lots of inconveniences (R 20 54)
<H2><A NAME="10">Automobiles</A></H2>
<P>!hi Driver kills cyclist while trying to save Tamagotchi virtual pet on
her key ring (R 19 67)
<P>!$h Wilson (draw)Bridge warnings not set, truck plows into car (S 17 1);
See relevant discussion on human errors by Don Norman (S 17 1-22)
<P>!$f? Mercedes 500SE with graceful-stop no-skid brake computer left 368-foot
skid marks; passenger killed (S 11 2)
<P>!$f? Audi 5000 accelerates during shifting. 2 deaths. Microprocessor? (S 12 1)
<P>*$f? Microprocessors in 1.4M Fords, 100K Audis, 350K Nissans, 400K Alliances/
Encores, 140K Cressidas under investigation (S 11 2)
<P>fmM More on risks of microprocessors in cars (S 16 2)
<P>*V(f?) Saturn auto assumption cuts off engine at high speed (R 21 10);
Nissan also (R 21 13)
<P>*SM Sudden auto acceleration due to interference from CB transmitter (S 11 1);
<P>*M Sudden acceleration of Dutch bus commonplace: interference (S 23 1:11,
R 19 40)
<P>M GM sudden acceleration (31 deaths, 1121 injuries between 1973 and 1986)
linked to EMI in court; Audi cases still suspected; cars less protected
than aircraft (R 19 38); note from Adam Cobb in Australia (R 19 42)
<P>M Remote-control car starter also controls car doors, turns on
heater, defroster, or air-conditioner, up to 400 feet away (R 19 37)
<P>f(i?) BMW under GPS navigation driven into Havel River (R 20 14)
<P>M Swedish policeman's handheld digital radio triggered his car airbag, which
hit him with the radio unit (R 19 43)
<P>SMr Cell phones can interfere with auto systems (R 19 63)
<P>SM Czechs ban mobile phones in gas stations (interference) (R 19 68-69)
<P>Sf Denver car-emission testing program bypass (S 21 4:17, SAC 14 3)
<P>f Germany to rely on on-board diagnostics for vehicle emission checks
(R 21 15, S 26 2:)
<P>f$ Emissions software glitch falsely fails hundreds of older cars in Atlanta
(R 20 04)
<P>*? Fly-by-wire SAAB: joystick, no mechanical linkage, keyboard, screen (S 17 3)
<P>*Vefm Jaguar loses all power due to faulty car phone installation (S 15 5)
<P>*f 1986-87 Volvos recalled for cruise control glitch (S 13 3)
<P>* General Motors recalls almost 300K cars for engine software flaw (R 18 25)
<P>f*$ General Motors recalled almost one million cars (1996-97 Chevies,
1995 Cadilacs) for undesired airbag deployments; Chevy fix involved
software change (R 19 85)
<P>- Comments on software explosion in new automobiles (S 22 2:23)
<P>*H Home-reprogrammed engine micro makes 1984 Firebird into race car (S 12 1)
<P>SH Hacking of car engine computers reaches Australia (S 13 4)
<P>*f Anti-skid brakes and computer controlled race cars? (S 12 1)
<P>*Vrf Car with computerized steering loses control when out of gas (S 12 4)
<P>*Vf Non-fail-safe power-outage modes - car locks (S 13 1)
<P>*Vrm Experimental semi-truck micro died (EMI) when near airport radar (S 12 1)
<P>*$f El Dorado brake computer bug caused recall of that model [1979] (S 4 4)
<P>i?m?f? Ford/VW/Nissan cars with Microsoft dashboard Windows PCs
(S 23 3:25, R 19 54)
<P>*$f Ford Mark VII wiring fires: flaw in computerized air suspension (S 10 3)
<P>*Vf Cadillac recalling 57,000 cars for headlights-out computer problem (S 12 3)
<P>V$f Oldsmobile design lost: hard disk wiped, backup tapes blank! (S 12 4)
<P>f GM blames smelly Astros and Safaris on faulty computer fuel mix (S 13 4)
<P>*mh Computer blamed for unbalancing of tires (S 14 6)
<P>$drf Computer traffic/revenue model problems delay Denver highway (S 17 3)
<P>m True Value 500 lap-counters in 5 cars fail during race; no time
for backup (S 22 5:13)
<P>*m Automated Pentagon car barrier hoisted limousine, injuring Japanese
Defense Minister and five others, Sep 1998; faulty sensor
(R 19 97); same gate malfunctioned, Aug 1990, injures German defense
attaché and American aide (R 21 06; S 26 1:26)
<P>*f
Problems with the Wide Area Augmentation System (WAAS)
(S 25 3:17, R 20 84)
<P>..... <B>Roller-coaster accidents</B>
<P>*m? 42 Japanese injured in roller-coaster car crash (EMI?) (S 12 3)
<P>*$f Computer-controlled Worlds of Fun roller coaster trains collide (S 15 3)
<P>*$f Dorney Park roller coaster crashes; same design flaw, builder (S 18 4:2)
<P>* Roller Coaster controls balance scariness and safety? (S 15 5)
<P>*e Astroworld ride jams at top with reporters; untested SW change (S 16 3)
<P>*f Blackpool roller-coaster (1) fault traps 30; (2) 2 trains collide (S 19 4:5)
<P>+? More on making roller coasters idiot-proof: automation (R 19 93)
<H2><A NAME="11">Motor-Vehicle and related Database Problems</A></H2>
<P>!!h Bus c