Failure-mode case studies

Last reviewed: 2026-07-16. See the freshness policy.

Diagnose systems, not “bad AI”

Use this causal chain:

flowchart TB accTitle: AI failure analysis and redesign accDescr: An observed harm is traced through failed controls and enabling conditions to architecture and operating-model causes, which then produce corrective actions and regression evidence. H["Observed harm / missed outcome"] --> E["Event and evidence timeline"] E --> C["Failed or absent controls"] C --> A["Architecture assumptions and incentives"] A --> R["Contain, redesign, and assign owner"] R --> T["Regression test and effectiveness review"]

Case patterns

Failure Proximate symptom Deeper cause Redesign
Demo became product impressive examples, poor real quality no population, baseline, or eval gate scoped profile and representative evaluation
Vector-only enterprise RAG plausible wrong joins source semantics ignored hybrid typed planning and evidence lineage
“Human in loop” theater reviewers approve everything no time, evidence, authority, or accountability decision-bound approval UX and sampling
Autonomous action duplicate double refund after timeout transcript state and non-idempotent tool durable action ledger and reconciliation
Prompt patch security injection succeeds through document model asked to enforce trust boundary capability isolation, authorization, output validation
Multi-agent sprawl slow, costly, inconsistent runs roles added without distinct authority/value workflow or one bounded orchestrator
Cheapest-model routing quality and complaints worsen cost/token optimized instead of outcome qualified-task economics and critical-slice gates
Silent provider drift behavior changes without release mutable aliases and weak contract manifest, canaries, change detection, fallback
Shadow AI adoption sensitive data sent externally approved path too slow or absent usable paved road, inventory, training, enforcement
Pilot never scales no owner, SLO, funding, or integration project model instead of product lifecycle operating ownership and production gates

Pre-mortem

Before approval, assume the system caused harm or failed to deliver value six months later. Generate causes across purpose, people, data, model, retrieval, tools, identity, security, operations, vendor, cost, adoption, and governance. Rank by consequence, plausibility, detectability, and current control strength. Convert the top items into architecture changes, tests, monitors, or explicit accepted risk.

Corrective-action quality

“Improve the prompt” or “train users” is weak unless it addresses a demonstrated mechanism. Strong actions change authority, isolation, data quality, state, evaluation, or decision rights and include an owner, deadline, verification method, and rollback. Verify effectiveness after deployment and watch for risk transfer.

Northstar lab

Choose three patterns and write a causal timeline, five-whys/control analysis, containment, redesign, regression case, and organizational change. Include one case where stopping or narrowing is the correct action.

Check yourself

  1. Which enabling condition made the incident possible?
  2. Did the correction change an enforceable control?
  3. What regression evidence proves effectiveness?
  4. Did the redesign transfer harm to another group?

Further reading

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