PODCAST · society
Causality
by The Engineered Network
Chain of Events. Cause and Effect. We analyse what went right and what went wrong as we discover that many outcomes can be predicted, planned for and even prevented.
Episodes
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65: Gimli Glider
In 1983 a newly introduced 767 ran out of fuel mid-flight and the pilots were able to land completely dead-stick. Whilst 0.8kg/L and 1.77lbs/L represent the same density, when the wrong one was used in a refuelling calculation they came up well short. Why they were forced to manually calculate...
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64: Verrückt Waterslide
Spurred on to build the tallest and fastest Waterslide in the world by a Travel Channel show about Waterparks, the owners of the Kansas City Schlitterbahn Waterpark designed and built the Verrückt Waterslide in record time. A net enclosed the ride and on its third Summer Season a 10 Year Old boy...
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63: Wittenoom
With demand for Asbestos in building products in the 1940s, a discovery in Western Australia's remote Pilbara region of Blue Asbestos led to the creation of a mining town called Wittenoom. Despite the growing list of illnesses and deaths of workers from the mine and milling operation, the company...
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62: OceanGate Titan
A young company pushing to re-invent deep sea exploration with an initial focus on opening up tourism to the wreck of the Titanic, OceanGate garnered the fascination of many around the world. With a different approach to their hull design they forged ahead despite many warnings from experts in…
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61: West Gate Bridge
Planned for nearly a century, when the time came to build a permanent link across the Lower Yarra River, a relatively new style of bridge, the box-girder, was chosen. Using new computer technology assisting the engineers to design a bridge that was too complex to calculate by hand, and using a...
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60: Carnival Triumph
A leaking flexible pipe started a fire in the Engine Room aboard the Carnival Triumph during its return journey from Mexico in early 2013. The fire caused minor damage in one, very important section of the Engine Room leading to a total loss of Mains Power. With only intermittent Emergency Power...
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59: Bayer CropScience
After an extended outage of the Methomyl Unit at the Bayer facility in Institute, West Virginia, the decision was made to commence a restart of the Unit even though the DCS upgrade was still incomplete and the newly replaced Residue Treater hadn't been fully recommissioned. An incident whose root...
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58: West Fertilizer Company
In the early hours of the evening on the 17th of April, 2013 in the small city of West, Texas...smoke was seen emanating from the West Fertilizer Company building. In 20 minutes there was a massive explosion that levelled the facility and its surroundings, killing 15 people and injuring hundreds...
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57: Stardust Nightclub
On Valentines Day in 1981 in the North of Dublin, Ireland a fire broke out in a nightclub just following a Disco Dancing competition. We look at how measures taken to prevent illegal entry and poor building material choices cost 48 young people their lives. With John Chidgey. Related Episodes:...
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56: BP Husky Toledo
On the 20th of September, 2022 at the BP Husky Toledo refinery in Ohio, a level transmitter change out from a month prior triggered a chain of events that would cost two operators their lives. We look at how poor Management of Change, high alarm rates and a resistance to stopping the job, let a...
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55: CrowdStrike
On Friday the 19th of July, 2024 millions of CrowdStrike Falcon Agents the world over would lead to a Windows system crash on business machines throwing parts of the world into chaos. We look into exactly what caused it and how complacency and a lack of understanding amplified the effect of this...
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54: Midland Resource Recovery
In 2017 during an Odoriser decontamination procedure in West Virginia, two people were killed when it unexpectedly exploded. Barely a month later, a similar procedure at the same site led to a second explosion, killing someone else. We examine how poor hazard analysis and legal interference led…
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53: Callide C Blackout
In 2021 the Callide C Power Station experienced a unit failure that tore the turbine-generator apart, resulted in hundreds of thousands of premises losing power, and cost hundreds of millions to repair. We look at how design errors and ultimately a lack of information led to the incident…
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52: Colonial Pipeline
In 2021 many of Colonial Pipelines IT systems were locked by malware and out of caution they shutdown the fuel pipelines feeding nearly half of the Eastern US leading to chaos at the gas pump and a state of emergency being declared. We look at how poor off-boarding hygiene led to an easily...
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51: I35 West
The I35W bridge over the Mississippi River carried 140,000 cars every day. Inspections in 1999 and 2003 showed damage to support plates that was dismissed as unimportant at the time. We look into how poor design checking and assumptions led to the bridge collapsing in 2007, costing the lives of…
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50: 737 MAX Ethiopian Air
Five months after Lion Air 610 crashed, another 737-MAX went down with a similar cause. However the official report was at odds with two other internationally respected investigative organisations. We dig into the detail of how the AOA Sensor was claimed to have failed, and review checklist...
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49: Carmel Fireworks Explosion
A fireworks company in Western Australia that had been in business for nearly a century, were preparing for a fireworks display in their packing shed when one ignited and set off a fire and an explosion. Onlookers were shocked when there was a subsequent explosion that was so big it was heard 30...
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48: Instituto Goiano de Radioterapia
When a radiation therapy machine was left behind during a move between buildings in central Brazil, it set in motion a series of events that would lead to one of the worst radiological incidents in history. We look into how bureaucracy and misdiagnosis cost four people their lives and how the...
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47: Hyatt Regency Kansas City
The tallest building in Missouri with a large atrium perfect for big bands and dancing, hosted a regular Tea Dance in the summer of 1981. When two walkways collapsed killing over a hundred people, the investigators found multiple fundamental design errors. We look at how assumptions, redrafting...
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46: Mindbender
The longest, tallest, fastest indoor rollercoaster in the world was only open six months when the last carriage of a train came loose, killing three people and all that the day following an inspection that the ride was safe to operate. We look at how a design choice made maintenance more critical...
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45: Granville
In 1977, a commuter train from the Blue Mountains, destined for Sydney central station would derail just before Granville Station, causing a bridge to collapse and crush many aboard. It remains Australia's worst ever rail disaster that was predicted by 11 engineering department heads just a year...
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44: Beirut Warehouse 12
In Beirut in August of 2020, an explosion at the Port of Beirut destroyed a huge part of the city. We look into how an oxidising agent, improperly handled can become an explosive and attempt to comprehend how something so dangerous was ignored repeatedly by key people, despite many warnings of an...
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43: Triangle Shirtwaist Factory
In 1911 in Manhattan, New York, a clothing factory went up in flames just before closing time. We look at how faulty equipment, poor design and a fear of theft contributed to a wholly preventable incident that had such terrible consequences, but would trigger reforms that still impact the United...
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42: Royal Canberra Hospital
The original Royal Canberra Hospital was flagged to be demolished in 1997 to make way for the new National Museum. A demolition via implosion was selected, but the implosion resulted in an explosion instead, and debris showered the huge crowd of onlookers with fatal consequences. With John…
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41: Florida International University
The university wanted a bridge for its students over a busy roadway that would appear intriguing from afar. Instead it collapsed before it was even finished. We look into how design errors, poor peer review and denial led to a collapse that claimed six peoples lives. With John Chidgey. This show…
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40: Ocean Ranger
The largest semi-submersible Offshore Drilling Rig of its day, sank in a storm in 1982 whilst two smaller nearby rigs survived with minimal damage. We dive into how not closing a portlight cover, triggered a series of events that cost 84 people their lives. With John Chidgey. This show is...
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39: Therac-25
The successor to the Therac-6 and Therac-20 RadioTherapy machines would integrate the powerful DEC PDP-11 mini-computer to control all of the Therac-25s functions, including the safety interlocks, for the first time. In two years the 11 machines in service would overdose six people across two...
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38: Thunder River Rapids
A popular family-friendly ride at DreamWorld would claim the lives of four people in 2016. In nearly thirty years of operation the ride had several similar but non-fatal incidents with blame placed on the operator every time, when a three thousand dollar modification could have prevented a…
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37: Variola Birmingham
In 1978 on the cusp of the eradication of SmallPox a Medical Photographer became infected and would ultimately die from the Variola virus. We look at how admiration, promotion and delegation led to a wholly avoidable outcome. With John Chidgey. Investigation Report: The Shooter Report (PDF)…
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36: Big Dig
A series of concrete ceiling tiles in a tunnel portal collapsed on a moving car killing the passenger in downtown Boston in 2006. The selection of the epoxy used in the ceiling tile anchors was unusual and a failure to heed the warning signs were at odds on a huge project under pressure to…
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35: San Bruno
A modification made in 1956 to a pipeline built in the 1940s would ultimately fail costing 8 people their lives in 2010. We look at what went wrong with PG&Es gas pipeline in San Bruno, California. With John Chidgey. Investigation and Reports: NTSB Report (PDF) Independent Review Panel Report on...
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34: Aberfan
One Friday morning in 1966 in a small town in Wales a mining spoils waste tip let go with a river of liquified rubble destroying buildings and a school. Killing 144 people, mostly children in their classrooms. The mechanics of how this happened are simple. The ignorance and economics of why this...
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33: 737 MAX
With two crashes in five months of the new 737 4th Generation a design flaw seemed likely. We look at how Boeings focus on cost-avoidance, grandfathering and bending probabilities during design would ultimately cost 346 people their lives. With John Chidgey. Related episodes: Causality Episode…
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32: Walkerton
In 2000 the small township of Walkerton Ontario witnessed the largest outbreak of E.Coli infections in Canada's history. The water utility claimed the town water was safe, but it wasn't and many people paid with their lives. With John Chidgey. Links of potential interest: Walkerton Ontario…
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31: Black Energy
The evening before Christmas Eve in 2015 saw a widespread blackout of the power grid across the Ukraine. We look at how a cyber-attack on electric utility companies in Europe, changed how cyber-security is regarded in control systems, forever. With John Chidgey. Links of potential interest:...
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30: Tim Maia
As part of Rio's preparations for the Olympics in 2016 a cycling pathway was built adjacent to a narrow, congested roadway along a picturesque shoreline. When a section collapsed only months before the opening ceremony killing two people, the world looked on with growing concerns about the…
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29: Flight 1549
In 2009 an AirBus A320 departing LaGuardia Airport in New York suffered a dual engine failure due to a bird strike during takeoff. In a highly improbable event an equally highly improbable landing in the Hudson River shocked and amazed the world. We look at what went right on Flight 1549. With…
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28: Hotel New World
In 1986 an unremarkable building in Singapore collapsed killing dozens of people. We look at how the supervision of the construction and the design itself resulted in a structure that was at best critically stable, and ultimately one that could only ever fail. With John Chidgey. Prior Episode...
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27: Gare De Lyon
On the 27th of June, 1988 in central Paris a runaway train collided with a stationary train in Gare De Lyon station, claiming 56 lives and injuring 60 more. Whilst the court found the driver guilty and sent him to jail, was he solely to blame? We look at how poor design decisions made Gare De…
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26: Bhopal
In December, 1984 in the city of Bhopal in central India, a Union Carbide Pesticide plant would fail and release tonnes of toxic gas into the city, killing thousands of people. It was the worst industrial disaster in human history. We follow the threads and trace back the root causes behind the...
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25: Deepwater Horizon
In 2010 an Oil Drilling Rig suffered a catastrophic well blowout, killing 11 people, destroying the rig and leading to the worst maritime oil spill in history. It all happened a few hours after the well was declared safe and ready for handover. We look at the human and financial factors that led…
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24: Columbia
In 2003 the Space Shuttle Columbia launched successfully but after its mission was completed burned up on re-entry with the loss of all onboard. We look at how normalisation of deviation blinded many at NASA to a risk that had existed since 1981. With John Chidgey. Links of potential interest:...
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23: Kipton
When two trains collided head on at Kipton, Ohio in 1891, it was a wake up call for the railroad industry in North America whose impacts would be far-reaching and would lead to a new timekeeping standard that was unprecedented. With John Chidgey. Links of potential interest: US Timepiece Industry...
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22: Chernobyl
The largest nuclear incident in human history released an estimated 400 times the radioactive material compared to Hiroshima and Nagasaki. It all happened because of a test that was delayed by one shift, or was it the ultimate inevitability of a flawed reactor design? With John Chidgey. Prior...
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21: Milford Haven
A turning point in control systems user interface design and alarm management happened in an unlikely place that few have ever heard of. We look at what went wrong at Milford Haven. With John Chidgey. Links of potential interest: The explosion and fires at the Texaco Refinery, Milford Haven…
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20: Stava Dam
On the 19th of July, 1985 in Tesero, Northern Italy, a tailings dam gave way and killed 268 people. With the most common tailings dam design in the world, what went wrong and how widespread are the risks? With John Chidgey. Links of potential interest: Stava tailings dam failure Water Management...
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19: Smiler
In 2015 at Alton Towers in the UK, The Smiler Rollercoaster experienced a major incident leading to severe injuries for multiple riders. We look at how pressure to get the ride running again and mis-communication defeated the system designed to protect the riders. With John Chidgey. Links of...
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18: The Fog
In 1952 a fog in London left 4,000 dead in just 4 days but many more would die before the causes could be rectified. Worse than that, it had happened before and it’s happening again right now, somewhere else. With John Chidgey. Links of potential interest: Inversion (meteorology) Great Smog of...
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17: Three Mile Island
On March 28, 1979 Unit 2 of the Three Mile Island Nuclear Plant in the United States of America an incident would lead to a partial reactor core meltdown. Many blamed the operators for stopping the reactor cooling system but the real root causes showed a known flaw in the design and alarm…
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16: Tenerife
In 1977 on the small island of Tenerife two 747 Jumbo Jets collided on the runway in poor visibility. A miscommunication clearly occurred, but even today, the same elements still exist and it could happen again. With John Chidgey. Links of potential interest: Tenerife-North Airport Teide Surface...
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ABOUT THIS SHOW
Chain of Events. Cause and Effect. We analyse what went right and what went wrong as we discover that many outcomes can be predicted, planned for and even prevented.
HOSTED BY
The Engineered Network
CATEGORIES
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How many episodes does Causality have?
Causality currently has 66 episodes available on PodParley. New episodes are automatically indexed when they're published to the podcast feed.
What is Causality about?
Chain of Events. Cause and Effect. We analyse what went right and what went wrong as we discover that many outcomes can be predicted, planned for and even prevented.
How often does Causality release new episodes?
Causality has 66 episodes. Check the episode list to see recent publication dates and frequency.
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Who hosts Causality?
Causality is created and hosted by The Engineered Network.
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