Also, when at TI I reported a quality violation by my manager. Later I got low reviews and I was eventually forced to resign. Hopefully TI, has gotten better since I left that place. I hope this environment did not lead to this person's death.
I used to work at TI and the culture there is to put the schedule first. (If you miss a schedule for any reason - you are rated low and tend to be laid off or fired.) I hope that was not the cause of this incident.
There is a problem with the phrase "...there is no such thing as an accident;" the problem is that it is not true. What people often refer to as an "accident" often is not one, as you note: a root cause investigation will show a flaw somewhere, but a meteor falling on my head could only be deemed preventable if I had a meteor-proof roof over my head at all times.
we have had this discussion in SEMI Standards meetings for risk assessment: some folks have contended that there must be zero risk of fatality; others take the position that there is never zero risk of fatality. The risk assessment process can quantify the hazards and residual risk and help identify ways to reduce that risk to "acceptable" levels. We all do that assessment every time we drive. It is usually an unconsious process, watching 2 or 3 cars ahead of you, plus left & right, and there still is a risk of injury.
Not sure the type of fab has anything to do with the accident. This type of device relies on high pressure gradients to generate ultra-pure water, so there are many potential root causes of the accident. It sounds like something was exposed to a pressure it was not designed for or could not tolerate - operational error, fabrication flaw or design error. The fact that it was in this particular fab is incidental.
Then again, there is no such thing as an accident - this kind of thing is ALWAYS preventable, provided people use the correct procedures and the equipment is capable of operating under the conditions it is exposed to.
Blog Make a Frequency Plan Tom Burke 17 comments When designing a printed circuit board, you should develop a frequency plan, something that can be easily overlooked. A frequency plan should be one of your first steps ...