
Although published last year, I only learned about this report this year.

Las Alamos National Labs published an update to the 1967 publication
Review of Criticality Accidents.  Ok, I know, what does a study about
nuclear reactions has to do with Internet network operations.  The
answer is found by looking at the underlying causes of the accidents.

Unless you are a nuclear engineer, you can skip directly to the 
chapter "C.OBSERVATIONS AND LESSONS LEARNED FROM PROCESS CRITICALITY
ACCIDENTS"

   It is important to note that there have been no
   accidents that were caused by a single failure.That is,
   there were always multiple causes for each of the 22
   accidents.It is also noteworthy that equipment failure
   or malfunction was either a minor or a non-contribut-
   ing factor in all of the accidents.


   All accidents have been dominated by design, managerial,
   and operational failures. The focus for accident prevention
   should be on these issues.

http://lib-www.lanl.gov/la-pubs/00538245.pdf





