Case Studies Flashcards
What was the Kegworth Air
Disaster of 1989?
Describe the Details of what happened during this incident?
Date of incident; 8th of January 1989.
Short Description;
A Boeing 737-400 plane was on a flight from london heathrow to belfast.
Shortly after takeoff, during the process after climbing to its intended crusing altitude, one of the outer panel of one of the fan blades in the plane’s left hand (number 1) engine detached (i.e., the left engine of the plane had malfunctioned)
This caused significant vibrations on the plane, with the passengers heard auidable noises and reported seeing smoke and sparks coming from the left engine.
However, the pilots had misread the engine instruments and wrongly believed that it was the right hand engine that had been damaged, and turned it off to reduce the vibrations.
After diverting to East midlands airport, the left engine had soon lost power, and with the right engine gone, the plane had crashed on the M1 motorway.
Damage as result from accident;
39 deaths in the accident, further 8 died after injuries,
79 injured,
Factors leading to the crash;
- The crew had incorrectly diagnosed the problem. Despite the passengers reportedly seeing problems with the left engine, the crew mistaking fixed the right healthy engine. This was a Key mistake which led to the diasaster.
- The crew did noy receive simulator training on the EIS, as there was no EIS equipped flight simulator available.
- The crew had limited experience with the Boeing 737-400 series aircraft.
What was the Boeing 737MAX blowout (2024)?
Describe the Details of what happened during this incident?
Date of Incident;
January 5 2024
Short Description of incident;
On Jan. 5, on a flight from Portland to Ontario, an Alaska Airlines Boeing 737 MAX 9 had its a “plugged” emergency exit door fly off mid-flight, leaving a gaping hole in the plane while it was at an altitude of nearly 16,000 feet.
The aircraft immediately returned back to the airport for an emergency landing.
Damage as result from accident;
3 minor injuries;
$160 million in legal fees from Boeing.
Factors leading to the incident;
Four bolts that secure the door plug were missing when the plane left the Boeing factory. Investigators believe the bolts were removed during assembly and not reinstalled.
During the production of the new Emergency doors on the 737 Max, it was reported by a whistle-blower that there were multiple faults discovered in the design and implementation of the MEDS (they were poorly fitted and some being damaged).
Despite reporting these issues to the SAT (Situational Action Tracker), they largely ignored these issues as the company was more concerned about the financial side (for context: Boeing would get paid for selling the planes after completion) rather than the quality side.
Attempts at fixing these issues were poorly done or outright just wasn’t fixed. This led to a dispute between both the engineers and the management.
The plane was inevitable due to reckless management, sold to Alaska airlines without fixing the problem. This problem would soon lead to the crash months later.
What was the St Helena Airport case (2016)?
Describe the Details of what happened during this incident?
Date of Incident;
2016
Short Description;
In 2010, the UK government had approved development of an airport in St Helena, using public money.
However, shortly after opening, it was realised that the airport cannot be used after safety tests showed that commercial planes couldn’t land because the wind near the runway was too unpredictable [Dangerous wind conditions].
Loss result from project;
Cost of the airport are between £285 million.
Factors leading to incident;
The Department for International Development (DfID) ignored repeated warnings the airport was not safe.
What was the Renfe Spanish Trains Case (2023)?
Describe the Details of what happened during this incident?
Date of Incident;
2023
Short Description of the problem;
The Spanish Government had spent €258 million on trains that are too big to fit in its rail network’s tunnels.
31 commuter trains were ordered by Renfe. They are set to replace an ageing fleet in the poorly connected northern autonomous regions of Asturias and Cantabria.
It has also emerged that the manufacturer, Basque-based CAF, flagged the error back in March 2021.
Originally slated for completion in 2024, the much-needed update is now likely to be delayed until at least 2026.
As the trains were still in the design phase, they have not been manufactured yet.
While this minimises the cost of the error, the time-consuming process will need to be repeated, delaying the trains’ construction.
Questions are being asked as to why the issue took so long to emerge and as the news was announced, the three parties involved—Renfe, Spain’s national rail operator, Adif, the rail track company and the country’s coalition government.
What was the University of Edinburgh financial ERP migration case (2022)?
Describe the Details of what happened during this incident?
Date of Incident;
2022
Short Description of Incident;
In June 2019, The University of Edinburgh attempted to transition over to the Oracle ERP Cloud and Oracle HCM Cloud to ‘modernize’ its financial management and HR processes. The financial management system was scheduled to go live in August 2022.
However, the deadline-live date was delayed due to incomplete tasks and an overall lack of preparedness, leading to a backlog in payment processing and widespread operational disruptions.
What was the TSB Bank Migration Case (2018)?
Describe the Details of what happened during this incident?
Date of incident;
2018
Short Description;
TSB had attempted to migrate 5 million customers from Lloyds Banking Group systems, where they were hosted into a new core banking platform (Proteo4UK, created by Sabis, IT Supplier owned by TSB parent Sabadell).
As a result, the banking system was quote “unstable and almost unusable”. Millions of customers were reported to have their accounts locked out, and some saw their money disappearing from their accounts. Others reports cited that customers were able to see other people’s accounts.
When things went wrong, customers were not only unable to access their accounts, but were also increasingly targeted by “opportunistic fraudsters”.
Problems identified;
Problems identified during the investigation include the decision to perform a “big bang” migration without fully understanding the risks, a lack of assessing the capabilities of Sabis, and the fact that there were no expert external advisers for the project as a whole.
Proteo4UK is a UK-specific version of an existing core banking system used by TSB parent Sabadell. When Sabadell acquired TSB in 2015, it said it would move customers to a new banking platform, and TSB said this would cut its costs by £160m a year. It had previously paid Lloyds Banking Group, its previous owner, several hundred million pounds a year for a service.
What was the Ariane 5 failure (1996)?
Describe the Details of what happened during this incident?
What was the Ajax Tank Case?
Describe the Details of what happened during this incident?
What was the Crowdstrike/Microsoft Outage (2024)?
Describe the Details of what happened during this incident?
What was the Oldsmar, FL water supply hack (2021)?
Describe the Details of what happened during this incident?
What was the Relay attacks in cars?
Describe the Details of what happened during this incident?
Car thieves are using relay technology to receive the signal from the car key inside the victim’s home and transfer it to a portable device, allowing them to unlock and drive the car. This usually takes a couple of minutes (2-3 minutes).
Context:
Many new cars now have keyless entry systems, which allows car owners to open and start the car without using a button or turning a key so long as the fob is nearby. This allows thieves to exploit this, by using sophisticated technology to hack into your car’s computer (i.e., they don’t need a key-fob to start the vehicle).
Stats
- 96% of motorists are at risk of having their car stolen by criminals using the latest car theft technique.
Convenience was probably a huge driving point for customers to obtain.
Lack of security measures in the keyless entry systems make the cars suspectable to relay theft.
What was the The COVID Case Study: Lockdown model?
Describe the Details of what happened in this incident?
