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Causality

The Engineered Networkengineered.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.
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Episodes

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 pressed on until it closed for 'financial' reasons. We look at the dangers of dust inhalation and try to determine if we have collectively learned anything from the disaster at Wittenoom. With John Chid...

Mar 07, 202631 min

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 the field, concerned about their design decisions and materials choices. When the submersible imploded killing all five aboard including the company CEO, the experts were only surprised about how OceanGate...

Feb 02, 202639 min

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 unique lifting strategy promised time and cost savings. Ultimately though when the pieces didn't fit together in the air, their attempts to make them fit, didn't work. We dive into what went wrong on Austr...

Nov 29, 202539 min

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 and over 4,000 people on board the ship drifted with the currents before it was tugged finally to safety. The Netflix Documentary 'Poop Cruise' looked at the human consequences...we dive into the enginee...

Aug 26, 202525 min

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 cause was years in the making would ultimately cost two people their lives. With John Chidgey. Related Episodes: Causality Episode 26: Bhopal Formal Reports: Bayer CropScience Pesticide Waste Tank Explo...

Apr 30, 202550 min

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 more. How this came to be, represented a failure of regulations, planning and grandfathering on every level. With John Chidgey. Related Episodes: Causality Episode 44: Warehouse 12 Formal Reports: Prelim...

Mar 31, 202531 min

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: Causality Episode 43: Triangle Shirtwaist Factory Formal Reports: Report of the Stardust Victims’ Compensation Tribunal (PDF) Report of the Tribunal of Inquiry on the fire at the Stardust News Releases and...

Jan 07, 202528 min

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 plant upset turn into a disaster. With John Chidgey. Formal Report: U.S. Chemical Safety Board Issues Final Report into Fatal 2022 Fire at BP-Husky Refinery Fatal Naphtha Release and Fire at BP-Husky Tole...

Dec 17, 202440 min

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 wholly preventable incident. With John Chidgey. About Causality (TV): Introducing Causality TV Causality TV Episode 1: CrowdStrike (Video Release) Formal Report: Falcon Content Update Preliminary Post In...

Oct 19, 202429 min

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 to yet another fatality...right in front of the eyes of the investigators on site. With John Chidgey. Formal Report: Midland Resource Recovery Explosion Midland Resource Recovery Factual Update (PDF) Impr...

Jun 25, 202428 min

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 escalating out of control, when it could have been recovered. With John Chidgey. Formal Reports: Callide Unit C4 Turbine Generator Failure 25 May 2021 (PDF) Animation of the Callide Unit C4 incident Trip of mult...

Mar 30, 202451 min

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 preventable cyber-attack. With John Chidgey. Hearing: Hearing Before the Committee on Homeland Security House of Representatives Transcript Threats to Critical Infrastructure: Examining the Colonial Pipeline C...

Dec 09, 202326 min

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 13 people. With John Chidgey. This show is Podcasting 2.0 Enhanced Only a Handful of T-Shirts Left! Reports: Collapse of I-35W Highway Bridge Minneapolis, Minnesota August 1, 2007 (PDF) General Informatio...

Aug 27, 202336 min

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 discrepancies to extract fact from opinion as to what most likely triggered this horrible chain of events. With John Chidgey. This show is Podcasting 2.0 Enhanced Celebrating Causality’s 50th Episode!! Previo...

Apr 22, 202352 min

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 kilometers away leaving the facility in ruins. With John Chidgey. This show is Podcasting 2.0 Enhanced Celebrating Causality’s 50th Episode!! Reports: Report of the investigation into the fireworks accid...

Jan 18, 202329 min

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 actions of a concerned mother with no medical experience, saved the lives of countless more. With John Chidgey. This show is Podcasting 2.0 Enhanced Create your own Credited Soundbite Official Report: The R...

Nov 18, 202233 min

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 conventions and negligence led to an incident that has become the case study in how not to do civil structural design. With John Chidgey. This show is Podcasting 2.0 Enhanced Create your own Credited Soun...

Jul 15, 202242 min

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 and then how wishing for a ride to be safe, doesn't really help. With John Chidgey. This show is Podcasting 2.0 Enhanced Links of Interest: Mindbender Geoffrey Kulak (Archive.org) Mindbender (Galaxyland...

May 16, 202229 min

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 earlier. We look at how management decisions led to a completely avoidable disaster. With John Chidgey. This show is Podcasting 2.0 Enhanced Links of Interest: Granville rail disaster The Day of the Rose...

Apr 02, 202226 min

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 imminent disaster. With John Chidgey. This show is Podcasting 2.0 Enhanced Links of Interest: 2020 Beirut Explosion Condensation Cloud Prill ANFO Ammonium Nitrate How an unscheduled port visit led to di...

Feb 10, 202232 min

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 States, a century later. With John Chidgey. This show is Podcasting 2.0 Enhanced Links of Interest: Triangle Shirtwaist Factory Fire Brown Building Shirtwaist Court Transcript of the Criminal Trial The T...

Nov 09, 202127 min

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 Chidgey. This show is Podcasting 2.0 Enhanced Report into the Incident: Inquest Into The Death of Katie Bender (PDF) Video Footage of the Demolition: Canberra Hospital Implosion 1997 - YouTube Royal Canberra H...

Sep 16, 202145 min

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 is Podcasting 2.0 Enhanced Report into the Incidents: NTSB Final Report (PDF) Design Criteria and Bid: FIU Pedestrian Bridge Design Criteria Rev 0 (PDF) FIU Pedestrian Bridge Design Criteria Rev 1 (PDF) ...

Jul 08, 202143 min

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 Podcasting 2.0 Enhanced Report into the Incidents: Official Report Links of Potential Interest: Ocean Ranger Hydrodynamic Model Studies of the Ocean Ranger Marine Disaster The Loss of the Ocean Ranger Royal Com...

May 24, 202147 min

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 countries, killing three of them before they figured out why. With John Chidgey. This show is Podcasting 2.0 Enhanced Reports into the Incidents: An Investigation of the Therac-25 Accidents ‎Medical Devices...

Mar 23, 202153 min

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 horrific incident. With John Chidgey. Investigation Report: DreamWorld (PDF) Links of Potential Interest: River Rapids Ride Thunder River Rapids Ride Dreamworld operator Ardent Leisure Fined $3.6M for Thunder ...

Jan 24, 202137 min

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) Medical Analyses: CDC Analysis of the R0 of SmallPox (PDF) Links of Potential Interest: SmallPox History of Smallpox Biosafety Level 4 A Bioweapon Expert Explains Four Ways A Pathogen Can Escape From A Lab Re...

Nov 26, 202035 min

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 deliver when already twice over time and five times over budget. With John Chidgey. Investigation Report: NTSB Report (PDF) Technical Links: Epoxy Tunnel Links of Potential Interest: Big Dig ceiling collapse C...

Sep 15, 202032 min

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 San Bruno Pipeline Explosion Technical Links: Material Fatigue GIS (Geographic Information System) Pup API 5L X42 Steel Pipe Specification in PSL1, PSL2 and Sour Service Links of Potential Interest: ...

Jul 26, 202050 min

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 happened boggles the mind. With John Chidgey. Related episodes: Causality Premium Giveaway Causality Episode 20: Stava Dam Investigation and Reports: Coal Mining Aberfan Disaster Aberfan Thirty-year Rule...

May 07, 202035 min
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