Causality: Recent Episodes

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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 Incident Report
• Channel File 291 Incident Root Cause Analysis (PDF)

News Releases and Articles:

• CrowdStrike releases root cause analysis of the global Microsoft breakdown
• CrowdStrike Senior Executive Adam Meyers faces CyberSecurity Committee
• CrowdStrike exec apologises before US Congress for software glitch behind July global outage | Reuters
• 1 In 10 Orgs Dumping Their Security Vendors After CrowdStrike Outage

General Information:

• CrowdStrike
• 2024 CrowdStrike incident
• What is CrowdStrike?
• Falcon Content Update Remediation and Guidance Hub
• Antivirus XML Configuration File for CrowdStrike Falcon Sensor
• Named Pipes
• Pipes (Interprocess Communications)
• Wildcard character

Support Causality on Patreon

Episode Gold Producers: 'r', Steven Bridle and Kellen Frodelius-Fujimoto.
Episode Silver Producers: Mitch Biegler, Shane O'Neill, Jared Roman, Katharina Will, Chad Juehring and Ian Gallagher.

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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)
• Improving Reaction Hazard Management (PDF)

News Releases and Articles:

• Chemical Tank Explosion in Barbour County Kills Two Employees Plus One Severely Injured
• One Dead After Another Explosion at Midland Resource Recovery
• Midland Resources Recovery Explosion Kills 2, Injures 1
• McDonald Volunteer Fire Chief Laid To Rest After W.Va. Explosion
• Widow Blames Natural Gas Odorization Company for Husband’s Death
• CSB releases final report on explosions at Midland Resource Recovery Facility
• Midland Resource Recovery Explosion 2017
• Second Fatal Explosion at Midland Resources Recovery

General Information:

• About Midland Resource Recovery
• The Growing Importance of Mercaptans
• Sodium Hypochlorite (PDF)
• Principles of Natural Gas Odorization (PDF)
• Attorney-Work Product Privilege

Support Causality on Patreon

Episode Gold Producers: 'r', Steven Bridle and Kellen Frodelius-Fujimoto.
Episode Silver Producers: Mitch Biegler, Shane O'Neill, Lesley, Jared Roman, Katharina Will, Chad Juehring and Ian Gallagher.

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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 multiple generators and lines in Central Queensland and associated under-frequency load shedding on 25 May 2021 (PDF)

News Releases and Articles:

• CS Energy releases report into 2021 Callide C4 Unit Failure
• CS Energy releases technical report into 2021 Unit C4 incident
• Dr Sean Brady to lead independent investigation into Callide incident
• Battery failure led to power plant mass outage
• Both units trip at Callide C on Wednesday 13th January 2021
• Statement regarding IG Power
• Intergen voluntary administration
• Report says Callide C4 incident “could not have been anticipated”
• Callide explosion blamed on battery charger failure
• Callide Power Trading taken to court over system failure
• CS Energy says insurers won’t agree to $300m claim over power station
• Jim Soorley stands down from CS Energy
• CS Energy Post about Incident on LinkedIn

Super-Critical Boilers:

• Super-Critical Boiler Technology (PDF)
• Supercritical Fluids
• Supercritical Coal Plants

Electrical Engineering References:

• Hydrogen-cooled Turbo Generator
• Reverse Active Power Protection (ANSI 32P)

Court Action:

• Alleged failure to obtain regulatory approval to operate a generating system
• Notice of Filing: Australian Energy Regulator v Callide Power Trading Pty Ltd (PDF)
• Coal generator to face court over blackouts caused by catastrophic explosion

General Information:

• Callide Power Station
• Stanwell Power Station
• Tarong Power Station
• Callide Power Station
• CS Energy: Water Management

NOTE: Minor Corrections in audio updated: 31st March, 2024

Support Causality on Patreon

Episode Gold Producers: 'r' and Steven Bridle.
Episode Silver Producers: Mitch Biegler, Shane O'Neill, Lesley, Jared Roman, Joel Maher, Katharina Will, Chad Juehring, Kellen Frodelius-Fujimoto and Ian Gallagher.

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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 Cyber-Attack (PDF)
• Charles Carmakal Statement from Hearing (PDF)

General Information:

• Colonial Pipeline
• Colonial Pipeline Ransomware Attack
• How Three Major Cyber Attacks Could Have Been Prevented
• What IT security teams can learn from the Colonial Pipeline
• Evolution of the Chief Information Security Officer
• US Fuel Pipeline Hackers Statement
• DarkSide
• DarkSide Leaks Press Center (X)
• DarkSide Ransomware Gang Behind Pipeline Hack Quits
• TSA Renews Cyber-Security Guidelines for Pipelines
• DHS Announces New Cybersecurity Requirements for Critical Pipeline Owners and Operators
• Federal Motor Carrier Safety Administration
• Emergency Declaration for 17 States

Support Causality on Patreon

Episode Gold Producers: 'r' and Steven Bridle.
Episode Silver Producers: Mitch Biegler, Shane O'Neill, Lesley, Jared Roman, Joel Maher, Katharina Will, Chad Juehring, Dave Jones, Kellen Frodelius-Fujimoto and Ian Gallagher.

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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

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Reports:

• Collapse of I-35W Highway Bridge Minneapolis, Minnesota August 1, 2007 (PDF)

General Information:

• I-35W Mississippi River bridge
• URS Corporation
• Sverdrup & Parcel
• Gusset Plate

Articles:

• Design errors factor in 2007 bridge collapse
• NTSB releases final report
• Despite final NTSB report, some still have questions

Videos:

• Inside a Catastrophic Minneapolis Bridge Collapse (YouTube)

Litigation:

• NTSB is wrong about cause of bridge collapse
• Last Minneapolis Bridge Collapse Lawsuit Settled For $52.4 Million

Support Causality on Patreon

Episode Gold Producers: 'r' and Steven Bridle.
Episode Silver Producers: Mitch Biegler, Shane O'Neill, Lesley, Jared Roman, Joel Maher, Katharina Will, Chad Juehring, Dave Jones and Kellen Frodelius-Fujimoto.

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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!!

Previous Episode:

• Causality Episode 33: 737 MAX

Reports:

• EAIB: Aircraft Accident Investigation Report B737- MAX 8, ET-AVJ December 2022 (PDF)
• US Comments: ET302 Report March 2022 (PDF)
• US Comments: Response to EAIB Final Report (PDF)
• BEA: Accident du Boeing 737 immatriculé ET-AVJ et exploité par Ethiopian Airlines survenu le 10/03/2019 près de Bishoftu
• BEA: Incidents to the Boeing 737 - 800 registered F-GZHO operated by Transavia France on 07/02/2018 at Norwich (United Kingdom) and 08/02/2018 at Paris-Orly
• BEA: Incidents to the Boeing 737 - 800 registered F-GZHO operated by Transavia France (PDF)
• ICAO Annex 13: Aircraft Accident and Incident Investigation (PDF)

General Information:

• Ethiopian Airlines Flight 302
• Addis Ababa Bole International Airport
• Jomo Kenyatta International Airport
• Rotation (Aeronautics)
• Ground Proximity Warning System
• Boeing 737 MAX Groundings
• Federal Aviation Administration
• Impact of the COVID-19 Pandemic on Aviation
• Financial Impact of the Boeing 737 MAX Groundings
• ICAO
• N1 and N2
• March 10, 2019 Historical Weather at Addis Ababa Bole International Airport, Ethiopia
• ET-AVJ Flight Tracking and History
• Collins AOA Systems (PDF)
• Auto-Throttle and Auto-Thrust
• B737 Autothrottle (A/T) Normal and Non-Normal Operations
• Airworthiness Directives

Articles:

• The BEA Weighs In: Ethiopian Airlines Flight 302
• Controversy Surrounds Final Report on Ethiopian Air Flight 302
• More Omissions In Ethiopian 737 MAX Report
• US NTSB Criticises Ethiopian MAX Report
• House passes bill to reform plane certification process after two Boeing 737 Max crashes
• Government of Canada introduces additional requirements to allow for the return to service of the Boeing 737 MAX - Canada.ca
• EASA Decision Not to Adopt FAA AD 2020-24-02 (PDF)

Regulations:

• Aircraft Certification Reform and Accountability Act
• FAA Proposes New Policy that Would Fulfill One of the Key Requirements of the Aircraft Certification, Safety, and Accountability Act | Federal Aviation Administration
• Post MCAS Law Changes
• Boeing 737 Airworthiness Directives
• Airworthiness Directive 2018-23-51 (PDF)
• Airworthiness Directive 2020-24-02 (PDF)
• FAA: Boeing 737 MAX Reading Room
• Transport Canada: Boeing 737-MAX-8

Litigation:

• Boeing to pay more than $2.5 billion to settle criminal conspiracy charge over 737 Max
• Boeing Charged with 737 Max Fraud Conspiracy and Agrees to Pay over $2.5 Billion
• Boeing Directors Settle Shareholder Lawsuit Over 737 MAX Crashes For $237.5 Million
• Boeing: Directors to face investor lawsuit over fatal crashes
• Boeing, FAA slammed in House report over deadly 737 Max failures
• Boeing agrees deal with families of Ethiopia crash victims
• Boeing to compensate victims in Ethiopian Airlines 737 MAX crash

Support Causality on Patreon

Episode Gold Producers: 'r' and Steven Bridle.
Episode Silver Producers: Mitch Biegler, Shane O'Neill, Lesley, Jared Roman, Joel Maher, Katharina Will, Chad Juehring, Dave Jones and Kellen Frodelius-Fujimoto.

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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 accident at Carmel, Western Australia (PDF)
• Fire and Explosions at a Fireworks Storage Depot (PDF)

Links of Interest:

• Department of Mines, Industry Regulation and Safety
• Explosives Magazine Storage and Use
• Net Explosive Quantity
• Class 1 Dangerous Goods Explosive Substances and Articles
• Cardile Fireworks

News Articles:

• Carmel fireworks incident report has global implications
• Perth fireworks factory explodes
• A Fireworks Factory Exploded In Perth’s Hills (VIDEO)

About Pyrotechnics:

• The Illustrated Dictionary of Pyrotechnics (PDF)
• List of Pyro Chemicals and Terms
• Display Fireworks Glossary
• Pyrostar Glossary
• Fireworks Stars and Shells Garnitures
• All you wanted to know about fireworks fuses

Support Causality on Patreon

Episode Gold Producers: 'r' and Steven Bridle.
Episode Silver Producers: Mitch Biegler, Kevin Koch, Shane O'Neill, Lesley, Jared, Joel Maher, Katharina Will, Dave Jones and Kellen Frodelius-Fujimoto.

With thanks to Heather Shaw for the topic suggestion.

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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

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Official Report:

• The Radiological Accident in Goiânia (PDF)

Links of Interest:

• Goiânia Accident
• IGR - Instituto Goiano de Radiologia
• Teletherapy Capsule
• Becquerel
• The Goiânia Incident
• Caesium
• Gray

Other Reports and Articles:

• The most rambling and insane nuclear accident in history (Italian)
• Doctors and the radioactive accident (Portugese)
• Notes on nuclear energy. What lawyers should know about nuclear technology (Spanish)
• Goiânia Brazil 1987 - Rick On Theater
• Caesium Radiation Goiania Brazil - 1102
• The blue powder entranced…then it killed…
• The Response to Technological Accidents: The Case of Radioactive Accident in Goiania (PDF) (Portugese)

News Articles:

• Victims of Radiation Ostracised in Brazil
• A Brazilian burglar stole a capsule…
• The Perception of Individuals Involved in the Accident With Caesium-137
• Two Radiation Victims Die
• The Goiâna Incident - NCT Magazine

Related Incidents:

• List of orphan source incidents
• Samut Prakan radiation accident
• Origin of Cobalt-60 traced to Delhi University
• 1962 Mexico City radiation accident

Support Causality on Patreon

Episode Gold Producers: 'r' and Steven Bridle.
Episode Silver Producers: Mitch Biegler, Kevin Koch, Shane O'Neill, Lesley, Jared, Joel Maher, Katharina Will, Dave Jones and Kellen Frodelius-Fujimoto.

With thanks to Shane O'Neill for the topic suggestion.

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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 Soundbite

Links of Interest:

• Tea dance
• Fast-track construction
• Sheraton Kansas City Hotel at Crown Center
• Hyatt Regency Walkway Collapse
• Strength Requirements by Grades
• All Thread Rod
• Wide Flange Beam Dimensions Chart
• Obituary for Jack D. Gillum
• Hotel Horror from Kansas City History
• The Engineer of Record and Design Responsibility

Engineering Analysis:

• Investigation of the Kansas City Hyatt Regency Walkways Collapse (Link to PDF)
• Understanding the Tragic Hyatt Regency Walkway Collapse
• Hyatt Regency Walkway Collapse 1981
• Hyatt Regency Walkway Collapse
• The Hyatt Regency Disaster Revisited
• Hyatt Regency Walkway Collapse
• Ethics in Engineering Practice and Research by Caroline Whitbeck
• Chronology And Context Of The Hyatt Regency Collapse by Gregory P. Luth (PDF)

News Articles:

• The Kansas City Hyatt Disaster 30 Years Later
• Collapse Did Not Involve Safety Violations
• Walkway Swayed To The Rhythm Of Dancers
• 18th July 1981 Hyatt collapse
• Hyatt Regency Skywalk Collapse Memorial Dedicated In 2015
• 1981 Hyatt Regency Walkway Collapse
• Hyatt Regency Collapse Remains Among The Deadliest In USA History
• Engineers Are Held At Fault In 1981 Hotel Disaster

Support Causality on Patreon

Episode Gold Producers: 'r' and Steven Bridle.
Episode Silver Producers: Mitch Biegler, Kevin Koch, Shane O'Neill, Lesley, Hafthor, Jared, Bill, Joel Maher, Katharina Will and Dave Jones.

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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
• Mindbender (Galaxyland)
• Triple Five Group
• Roller coaster wheel assembly
• Bogie
• Schwarzkopf GmbH
• 6 Reasons Why Bolts Fail & How To Prevent It
• Testing for Amusement Rides and Theme Parks TÜV SÜD

Videos:

• Tragedy on the Mindbender
• Mindbender Accident Inquiry - Film & Video Stock

News Articles:

• Coaster Ride’s Mastermind Fired
• Roller-coaster goes at full tilt
• Mindbender 25 Years Later
• Roller-coaster Derailment Kills Three
• Survivor of 1986 mall coaster crash wants memorial
• 3 Hurled to Death in Canada as Roller Coaster Derails in Mall
• Authorities today investigated a weekend triple-loop ‘Mindbender’ roller coaster
• 3 Killed in RollerCoaster Crash
• Mall Owner Blames Manufacturer’s Defect for Roller Coaster Deaths

Rollercoaster Articles:

• 31 years ago today, the Mindbender rollercoaster at WEM crashed
• 10 Deadliest Roller Coaster Accidents
• List of incidents at independent amusement parks
• Amusement Ride Accidents
• The Mindbender Fantasy Roller Coaster Accident in Canada
• Worst Coaster Crash?
• Mindbender - Galaxyland - Roller Coasters
• Mindbender - Galaxyland Amusement Park
• American Dreier Looping
• Mindbender Edmonton
• Schwarzkopf
• mindbender
• Anton Schwarzkopf
• Mindbender (Galaxyland)

Legislature Assembly Minutes:

• 21st Legislature First Session Minutes (PDF)

Support Causality on Patreon

Episode Gold Producers: 'r' and Steven Bridle.
Episode Silver Producers: Mitch Biegler, Kevin Koch, Shane O'Neill, Lesley Law Chan, Hafthor, Jared, Bill, Joel Maher and Katharina Will.

With thanks to Quinton Zaborski for the topic suggestion.

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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 Roses
• Public Transport Commission of NSW
• Granville Train Disaster
• Turnouts
• CityRail
• Australia’s worst rail disaster
• The Granville Train Disaster Association
• Revisiting the Granville Train Disaster of 1977: Barry Gobbe
• Remembering the Day of the Roses
• Wheel was covered up
• 45 years since Granville Train Disaster
• Granville Train Disaster Memorial Garden
• The rail disaster that changed Australia
• Mixed response as NSW Government apologises for Australia’s worst train disaster
• Granville Railway Disaster
• Granville train disaster: victims speak out

Formal Investigation Extracts:

• Formal Investigation State Records Authority
• Report on the formal investigation UNSW Alma
• Formal Investigation extract: Research Data
• Research Data Australia Search

Informal Investigations:

• Permanent Way Institution Granville Search
• Granville: The Untold Story
• The Granville Train Disaster
• The Granville Disaster

Video:

• Granville Train Disaster Documentary (Video)

Support Causality on Patreon

Episode Gold Producers: 'r' and Steven Bridle.
Episode Silver Producers: Mitch Biegler, John Whitlow, Kevin Koch, Shane O'Neill, Oliver Steele, Lesley Law Chan, Hafthor, Jared, Bill, Joel Maher and Katharina Will.

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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 disaster
• Beirut Ammonium Nitrate Blast
• Government Amends Ammonium Nitrate Rules
• FBI probe shows amount of chemicals in Beirut blast was a fraction of original shipment
• Beirut Whistleblower Returns to Work
• Ideal Gas Law
• Gases, Liquids and Solids

Reports into the incident:

• Human Rights Watch (PDF)
• The Beirut Port Explosion, Forensic Architecture

Video and Images:

• Video of Explosion 1 (Twitter)
• Video of Explosion 2 (Twitter)
• Video of Wilsons Cloud Ring (Twitter)

Documentary:

• Beirut Blast: The Story Of Warehouse 12 (2021)
• Beirut Blast: The Story of Warehouse 12 (2021) - IMDb
• Beirut Blast: The Story of Warehouse 12 (Streamable outside Europe)

Ammonium Nitrate Information:

• Storage requirements for security sensitive ammonium nitrate (SSAN) | Resources Safety & Health Queensland
• Orica Mining Services, Report for Kooragang Island Uprate PHA MOD1 Report (PDF)
• Ammonium Nitrate Advisory USEPA (PDF)
• Orica ANFO MSDS (PDF)

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Episode sponsor:
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Episode Gold Producers: 'r' and Steven Bridle.
Episode Silver Producers: Mitch Biegler, John Whitlow, Kevin Koch, Shane O'Neill, Oliver Steele, Lesley Law Chan, Hafthor, Jared, Bill, Joel Maher and Katharina Will.

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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 Triangle Fire of 1911
• Sweatshop Tragedy
• Brown Building (PDF)
• Sweatshop Definition
• Machinery Needed for Garment Manufacturing
• Different Types of Sewing Line Layout
• World Tallest Building Passive Fire Prevention
• Early 19th Century Firefighting

Cornell University’s Excellent Resource on the Incident:

• The Triangle Factory Fire
• The Triangle Factory Fire: Report Summaries
• The Triangle Factory Fire: Timeline

Support Causality on Patreon
Episode sponsor:
Many Tricks:

If you’re looking for some Mac software that can do Many Tricks remember to specifically visit the URL below for more information about their amazingly useful apps. Check out their newest app Menuwhere, it’s amazing!

Visit manytricks.com/pragmatic and use the Coupon Code (listen to the episode to get the code) for 25% off the total price of your order. Hurry it's only for a limited time!

Episode Gold Producers: 'r' and Steven Bridle.
Episode Silver Producers: Mitch Biegler, John Whitlow, Shane O'Neill, Kevin Koch, Oliver Steele, Lesley Law Chan, Hafthor, Jared, Bill and Joel Maher.

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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 Hospital Implosion - TEN News 13 July 1997 - YouTube

Video of Interest:

• Miami Resort | Building Demolition | BlowDown

Links of Interest:

• Royal Canberra Hospital
• Building Implosion
• Royal Canberra Hospital Implosion
• Royal Canberra Hospital Implosion Images
• Project Coordination
• The 1996 Australian Federal Election
• Successful ACT WorkSafe prosecutions

Explosives Used In Demolition:

• Shaped Charge
• RIOGEL TRONER HE
• What is Powergel explosive?
• C-4 Explosive

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Episode sponsor:
Soulver.App:

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Episode Gold Producers: 'r' and Steven Bridle.
Episode Silver Producers: Mitch Biegler, John Whitlow, Shane O'Neill, Kevin Koch, Oliver Steele, Lesley Law Chan, Hafthor, Jared and Bill.

With thanks to Infamous Sphere for the topic suggestion.

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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)
• MCM / FIGG Proposal (PDF)

Civil Structural References:

• Truss
• Truss Bridges
• Steel Bridge Design
• What is Post-tensioning?
• Prestressed, Pretensioned and Post-Tensioned Concrete
• Engineer of Record Definition
• Non-Destructive Concrete Evaluation & testing

Companies Involved:

• Louis Berger is now part of WSP
• WSP Global
• FIGG Engineering
• FIGG Bridge Engineers

Links of Potential Interest:

• Florida bridge collapse has some hard lessons
• Florida International University pedestrian bridge collapse
• University-City Prosperity Project
• Meet the prominent Miami firm behind the collapsed FIU bridge
• Miami Bridge Failure Part 3: The Peer Review
• FHWA proposes 10-year debarment for FIGG Bridge Engineers
• Louis Berger only firm refusing to settle FIU bridge collapse
• Bankrupt construction company that built FIU bridge reaches deal to pay victims $42M
• Lessons learnt 3 years since Florida tragedy
• FHWA proposes 10-year debarment for FIGG Bridge Engineers
• Judge Rejects FIGG’s Motion to Halt 10-Year Debarment

Riverside Expressway:

• Glimmer of hope?
• Riverside Expressway

Support Causality on Patreon

Episode Gold Producers: 'r' and Steven Bridle.
Episode Silver Producers: Mitch Biegler, John Whitlow, Shane O'Neill, Kevin Koch, Oliver Steele, Lesley Law Chan, Hafthor and Bill.

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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 Commission
• Ocean Ranger report blames equipment and training
• Hypothermia Table
• History of offshore drilling units
• Glossary of nautical terms
• Roustabout
• Davit
• 25 years later

Support Causality on Patreon

Episode Gold Producers: 'r' and Chip Salzenberg.
Episode Silver Producers: Mitch Biegler, John Whitlow, Kevin Koch, Oliver Steele, Lesley Law Chan, Hafthor, Shane O'Neill and Bill.

With thanks to Gregory Hess for the topic suggestion.

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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: The Therac-25
• The Therac-25: 30 Years Later
• A Usage-Model Based Approach to Test Therac-25
• Good Computing: A Virtue Approach To Computer Ethics: Chapter 6

Links of Potential Interest:

• Therac-25
• The PDP-11 Assembly Language
• PDP-11
• Digital Equipment Corporation
• Programmed Data Processor
• Rad (unit)
• Order of Magnitude
• Myelitis
• Collimator
• Fatal Dose: Radiation Deaths linked to AECL Computer Errors
• Reactor Accidents: The Human Fallout
• An Overview on Radiotherapy: From Its History to Its Current Applications in Dermatology
• In MedTech History: Mammography
• The programmer behind the THERAC-25 Fiasco was never found
• AMA: My professor investigated the Therac-25 incident
• How history, principles and standards led to the safety PLC

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Episode sponsors:
Premium Jane:

Premium Jane are a US-based provider of organic CBD products that meet the highest standards of quality and purity.

Visit premiumjane.com and use the Coupon Code PJ20OFF for 20% off. Hurry it's only for a limited time!Many Tricks:

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Visit manytricks.com/pragmatic and use the Coupon Code (listen to the episode to get the code) for 25% off the total price of your order. Hurry it's only for a limited time!

Episode Gold Producers: 'r' and Chip Salzenberg.
Episode Silver Producers: Mitch Biegler, John Whitlow, Kevin Koch, Oliver Steele, Lesley Law Chan, Hafthor and Shane O'Neill.

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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 River Rapids Ride Deaths
• Class Action Over Dreamworld Deaths
• Shutdown Impacts Dreamworld’s Plans For New Rollercoaster
• Dreamworld Chief Resigns After Damning Evidence At Inquest
• Dreamworld Pays $1.8M In Termination Payouts
• Dreamworld’s Missing Accountability
• Dreamworld Accident Spurs Queensland Safety Crackdown

Support Causality on Patreon
Episode sponsor:
Many Tricks:

If you’re looking for some Mac software that can do Many Tricks remember to specifically visit the URL below for more information about their amazingly useful apps. Don’t forget the return of Usher with the Usher 2 Pre-Sale!

Visit manytricks.com/pragmatic and use the Coupon Code (listen to the episode to get the code) for 25% off the total price of your order. Hurry it's only for a limited time!

Episode Gold Producer: 'r'.
Episode Silver Producers: Mitch Biegler, John Whitlow, Kevin Koch, Oliver Steele, Lesley Law Chan, Hafthor and Shane O'Neill.

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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
• Review of Medical Errors in Laboratory Diagnostics and Where We Are Today
• Pathogens Sometimes Escape the Lab With Deadly Results
• 1970s Chinese pandemic was a lab mistake
• Bio-Unsafety Level 3: Could the Next Lab Accident Result in a Pandemic?
• SmallPox is not Dead
• Caroline Foulkes looks back at the 1978 outbreak
• Smallpox virus retention debate
• Lessons learned from smallpox outbreak

Support Causality on Patreon
Episode sponsors:
Soulver.App:

You’ve tried a calculator and a spreadsheet but if you haven’t tried Soulver yet you’re missing out on a great app that fits perfectly with the way your brain actually thinks. Soulver is available from Soulver.app and also through the Mac App Store.

Visit soulver.appto learn more.Many Tricks:

If you’re looking for some Mac software that can do Many Tricks remember to specifically visit the URL below for more information about their amazingly useful apps. Don’t forget the return of Usher with the Usher 2 Pre-Sale!

Visit manytricks.com/pragmatic and use the Coupon Code (listen to the episode to get the code) for 25% off the total price of your order. Hurry it's only for a limited time!

Episode Gold Producer: 'r'.
Episode Silver Producers: Mitch Biegler, John Whitlow, Kevin Koch, Oliver Steele, Lesley Law Chan, Hafthor and Shane O'Neill.

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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
• Collapse of Big Dig Ceiling in Boston Is Tied to Glue
• Public demand for Big Dig accountability
• ‘Epoxy Creep’ Main Factor in Big Dig Ceiling Panel Collapse
• $28M settlement in fatal Big Dig Collapse
• Big Dig Ramp Reopens
• HNTB
• The Big Dig Tunnels and Bridges

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Episode Gold Producer: 'r'.
Episode Silver Producers: Mitch Biegler, John Whitlow, Kevin Koch, Oliver Steele, Hafthor and Shane O'Neill.

With thanks to Sean for the topic suggestion.

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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:

• Pacific Gas and Electric Company
• San Bruno Pipeline Explosion
• Memorial for Anniversary of San Bruno Explosion
• San Bruno Pipeline Explosion
• Death Toll In San Bruno Climbs To 8
• Five Years After Deadly San Bruno Explosion
• PG&E Gets Maximum Sentence For San Bruno Crimes
• Crestmoor Neighborhood
• PG&E emerges from bankruptcy
• PG&E Completes Natural Gas Pipeline Safety Report
• PG&E Falsified Gas Pipeline Safety Records

Legal Links:

• Right Of Way
• A Legal Introduction to Easements
• California Law Study into Soverign Immunity (PDF)
• Cost Allocation in Public Utility Relocation in California

Support Causality on Patreon

Episode Gold Producer: 'r'.
Episode Silver Producers: Mitch Biegler, John Whitlow, Joseph Antonio, Kevin Koch, Oliver Steele and Shane O'Neill.

With thanks to John for the topic suggestion.

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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
• Aberfan: The Mistake That Cost A Village Its Children
• Terrifying Tale Of Bungling Ineptitude
• Aberfan Lessons Learned
• Aberfan: The Geological Society

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Episode sponsor:
Many Tricks:

If you’re looking for some Mac software that can do Many Tricks remember to specifically visit the URL below for more information about their amazingly useful apps.

Visit manytricks.com/pragmatic and use the Coupon Code (listen to the episode to get the code) for 25% off the total price of your order. Hurry it's only for a limited time!

Episode Gold Producer: 'r'.
Episode Silver Producers: Mitch Biegler, John Whitlow, Joseph Antonio, Kevin Koch and Oliver Steele.

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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 10: The Comet
• Causality Episode 14: Concorde

Investigation and Reports:

• FAA Finds New Safety Risk in Boeing 737 Max
• KNKT JT610 Final Report
• NTSB ASR-19-01 Safety Recommendation Report
• JATR Report: Boeing 737 MAX Flight Control System

History of Boeing:

• History of Boeing
• Boeing 737 Classic
• Boeing 737 Next Generation
• Boeing 737 MAX

Technical Information:

• 737 MAX: MCAS - The Boeing 737 Technical Guide
• Flight Controls - The Boeing 737 Technical Guide
• A quantum leap forward Aerospace Manufacturing Magazine
• Angle Of Attack
• Angle of Attack Sensor 0861FL1
• V Speeds
• Wing Root
• CFM International CFM56
• CFM International LEAP
• Fundamentals Of Airliner Performance: The Engine
• Maneuvering Characteristics Augmentation System: MCAS
• Using The 737-800 And 737-900 Flaps
• Understanding Flaps

Standards and Bulletins:

• AC 25.1309-1
• AC 25.1309-1A
• Hazard Classification Matrix Based On JAR AMJ 25.1309 Severity
• ICAO Annex 19: Safety Management
• EASA Type-Certificate Datasheet Boring 737
• FAA Advisory Circular 23.1309-1E
• FAA Advisory Circular 25-7C
• FAA System Safety Handbook Chapter 3: Principles of System Safety
• AMJ25.1309 Change 15

Fallout:

• Lion Air Flight 610
• American Airlines Fleet
• Southwest Airlines Fleet
• Southwest Airlines Pilots Sue Boeing Over 737 Max Grounding
• 737 Max Crisis: Boeing To Borrow $10B
• Boeing 737 Max Designed By Clowns
• Boeing 737 MAX Groundings
• Boeing 737 Max Plane Crash Victims Families Sickened By Fired Boeing CEOs Payout
• Boeing Announces Leadership Changes
• Boeing Statement On 737 MAX Return To Service
• Boeing Earnings Q2 2019
• Boeing Earnings Q3 2019
• Boeing Knew Of 737 Max Flaws Before Crash
• Boeing Left Safety Features Off 737 Max
• Boeing Misses On Earnings
• Boeing To Recommend Simulator Training For 737 Max Pilots
• Boeing Will Suspend 737 Max Production In January 2020
• Family Of Lion Air Co-pilot Sues Boeing
• Lion Air crash: Cockpit Voice Recorder Is Found By Divers

Forum Articles:

• What Are The Checklist Items For A Runaway Stabiliser Trim
• Why Can’t The 737 MAX’s Horizontal Stabilizer Autotrim Be Cut Out
• How To Disable The Stabilizer Trim Cutoff Switches
• What Is The Procedure To Disable MCAS
• How The Stabilizer Cutout Switch Functionality Changed From NG to MAX

Links of potential interest:

• Airline Pilot Salaries
• In Service Safety At Boeing: October 2014 Presentation
• Pilots Fought Automatic Safety System
• Boeing Statement on Lion Air Flight 610 Preliminary Report
• How A 50yr Old Design Came Back To Haunt Boeing
• AoA Vane Must Have Failed
• Flawed Assumptions Paved A Path To Disaster
• The 737 Max Has Cost Boeing $9.2B And Counting
• The Complaints Pilots Filed About Boeing’s 737 Max
• The Many Human Errors That Brought Down The Boeing 737 Max
• What Happened On Board The Lion Air Boeing 737 Max That Crashed

Support Causality on Patreon
Episode sponsor:
Many Tricks:

If you’re looking for some Mac software that can do Many Tricks remember to specifically visit the URL below for more information about their amazingly useful apps.

Visit manytricks.com/pragmatic and use the Coupon Code (listen to the episode to get the code) for 25% off the total price of your order. Hurry it's only for a limited time!

Episode Gold Producer: 'r'.
Episode Silver Producers: John Whitlow, Joseph Antonio, Kevin Koch and Shane O'Neill.

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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
• Toronto Ontario
• Walkerton E. coli Outbreak
• Death On Tap: The Poisoning Of Walkerton
• The Walkerton Inquiry Report
• Heavy Rainfall and Waterborne Disease Outbreaks: The Walkerton Example
• Factors That Led To The Walkerton Tragedy
• Walkerton Death Toll Revised
• Ontario Pays $72M To Victims Of Walkerton
• The Walkerton Tragedy
• Inside Walkerton: Canada’s Worst-ever E. coli Contamination
• Walkerton Water Crisis Follow-up
• Town Finds Crisis Sharply Painful
• Walkerton 2 years later
• Walkerton Water Declared Safe To Drink
• Definition of Incompetent
• Grandfather Clause

Support Causality on Patreon
Episode sponsor:
Many Tricks:

If you’re looking for some Mac software that can do Many Tricks remember to specifically visit the URL below for more information about their amazingly useful apps.

Visit manytricks.com/pragmatic and use the Coupon Code (listen to the episode to get the code) for 25% off the total price of your order. Hurry it's only for a limited time!

Episode Gold Producer: 'r'.
Episode Silver Producers: Carsten Hansen, John Whitlow, Joseph Antonio and Kevin Koch.

With thanks to Jon Paul for the topic suggestion.

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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:

• December 2015 Ukraine Power Grid Cyber-attack
• Analysis of the Cyber Attack on the Ukrainian Power Grid [PDF]
• Ukraine Report: When The Lights Went Out [PDF]
• Inside the Cunning, Unprecedented Hack of Ukraine’s Power Grid
• Cyber-Attack Against Ukrainian Critical Infrastructure
• Everything We Know About Ukraine’s Power Plant Hack
• BlackEnergy
• BlackEnergy, Grid-Disrupting Malware, Has a Successor, Researchers Warn
• Scary Questions in Ukraine Energy Grid Hack
• Ukraine Cyber Induced Power Outage: Analysis And Practical Mitigation Strategies [PDF]
• New Clues Show How Russia’s Grid Hackers Aimed for Physical Destruction
• Industroyer: An in-depth Look At The Culprit Behind Ukraine’s Power Grid Blackout
• Ukrainian Power Grids Cyber-attack
• Russian Translation: Obelnergo Message to Consumers
• MOXA UC-7408-LX Plus
• MOXA UC-7408-LX Plus Firmware Overwrite Vulnerability
• iRZ RUH2
• IRZ RUH2 3G Firmware Overwrite Vulnerability
• NCCIC: Ukrainian Power Attack
• US Wants To Isolate Power Grids With ‘Retro’ Technology To Limit Cyber-attacks
• LinkedIn Is A Hacker’s Dream Tool

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Episode Gold Producer: 'r'.
Episode Silver Producers: Carsten Hansen, John Whitlow, Joseph Antonio and Kevin Koch.

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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 imminent Olympics.
With John Chidgey.
Links of potential interest:

• Deaths on Collapsed Rio de Janeiro Bike Path Deal Safety Blow to Olympic Host
• Anger Grows Over Rio Bike Path Failure - WSJ
• Questions Continue After the Collapse of Rio’s Cycle Path
• Faulty Planning Blamed for Deadly Collapse
• Padlocked and Falling Apart: Rio’s Olympic Legacy
• Bike Lane Collapse Kills People on Beach
• Are Brazil’s Corruption Scandals Finally Hitting the Olympics?
• Rio, the Olympics, and Broken Promises
• Architects Say Rio’s Olympic Bike Path Was Destined to Collapse
• Petition Calls for Complete Demolition of Cycle-path
• Judge Orders Closure of Rio Cycleway

Photo Gallery Links:

• Gallery of A Stretch of Rio de Janeiro’s Tim Maia Bike Path Collapses
• The Collapsed Area of the new Cycle Lane

Links of Interest (Portuguese):

• Queda da Ciclovia: Doações à campanhas feitas pela CONCREMAT e os Grandes Jogos
• Tweet: “‘Podre, tem que fazer tudo outra vez’, diz vice-prefeito sobre ciclovia Tim Maia, no Rio”
• PETIÇÃO PARA A DEMOLIÇÃO DA CICLOVIA DA AVENIDA NIEMEYER

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Episode sponsors:
Backblaze:

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Visit backblaze.com/causalityto learn more.Soulver.App:

You’ve tried a calculator and a spreadsheet but if you haven’t tried Soulver yet you’re missing out on a great app that fits perfectly with the way your brain actually thinks. Soulver for iOS is available through the App Store and the newly updated Soulver 3 for Mac from Acqualias website.

Visit soulver.appto learn more.

Episode Gold Producer: 'r'.
Episode Silver Producers: Carsten Hansen, John Whitlow and Joseph Antonio.

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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 John Chidgey.
Links of potential interest:

• US Airways Flight 1549
• The Miracle On The Hudson
• NTSB Official Report (PDF)
• 49 CFR 830.2 Definitions
• CFM International CFM56
• Chesley Sullenberger
• Jeff Skiles
• What the ‘Sully’ Movie Gets Wrong
• LaGuardia Airport Diagram
• Cold Water Survival
• Medium Flocking Bird Test at Climb Condition

Support Causality on Patreon
Episode sponsor:
Backblaze:

Gimmick free, truly unlimited, cloud backup for your Mac or PC for just $6 a month with discounts for annual plans. Sign up via the following URL and for a 15 day no-risk free trial. Don’t take a chance with your data, start protecting your work and your memories today.

Visit backblaze.com/causalityto learn more.

Episode Gold Producer: 'r'.
Episode Silver Producers: Carsten Hansen, John Whitlow and Joseph Antonio.

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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 References:

• Causality Episode 5: Maccabiah
• Causality Episode 15: Sampoong Department Store

Links of potential interest:

• Hotel New World Collapse
• Collapse of Hotel New World
• Structural Load
• Report of the Inquiry into the Collapse of Hotel New World (Embedded PDF)

Support Causality on Patreon
Episode sponsor:
Clubhouse:

Looking for an easy to use software development project management solution that everyone in an organisation can use? Clubhouse was built with Agile Development in mind with an intense focus on intuitiveness and responsiveness, supporting seamless integrations with standard version control and messaging systems and an extensible REST API to integrate anything else you might need.

Visit clubhouse.io/TENto learn more.

Episode Gold Producer: 'r'.
Episode Silver Producers: Carsten Hansen, John Whitlow and Joseph Antonio.

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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 Lyon inevitable.
With John Chidgey.
Prior Episode References:

• Causality Episode 6: Amagasaki

Links of potential interest:

• Gare de Lyon Rail Accident
• SNCF
• SNCF Class Z 5300
• Gare de Lyon
• Paris Gare de Lyon - A brief station guide
• Réseau Express Régional
• Brake Problems Discovered 40 Minutes Before Crash
• French Rail Chief Quits After 2nd Fatal Crash in Paris - LA Times
• Train Driver Jailed for Crash That Killed 56 People
• PRISON FERME l’Humanite (French)

Support Causality on Patreon
Episode sponsor:
Clubhouse:

Looking for an easy to use software development project management solution that everyone in an organisation can use? Clubhouse was built with Agile Development in mind with an intense focus on intuitiveness and responsiveness, supporting seamless integrations with standard version control and messaging systems and an extensible REST API to integrate anything else you might need.

Visit clubhouse.io/TENto learn more.

Episode Gold Producer: 'r'.
Episode Silver Producers: Carsten Hansen and John Whitlow.

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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 incident at Bhopal.
With John Chidgey.
Links of potential interest:

• Bhopal
• Carbaryl
• Methyl isocyanate
• Bhopal Chronology [PDF]
• LABOR REPORT ON BHOPAL CITES PLANT MODIFICATION
• Eight convicted over India gas disaster

Support Causality on Patreon
Episode sponsor:
Clubhouse:

Looking for an easy to use software development project management solution that everyone in an organisation can use? Clubhouse was built with Agile Development in mind with an intense focus on intuitiveness and responsiveness, supporting seamless integrations with standard version control and messaging systems and an extensible REST API to integrate anything else you might need.

Visit clubhouse.io/TENto learn more.

Episode Gold Producer: 'r'.
Episode Silver Producers: Carsten Hansen and John Whitlow.

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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 to the incident at Macondo.
With John Chidgey.
Links of potential interest:

• Deepwater Drilling
• Semi-submersible Platform
• Macondo Prospect
• Macondo Prospect Gulf of Mexico
• Deepwater Horizon MC252 Data ERMA
• Tool Pusher
• Blowout (well drilling)
• Deepwater Horizon Explosion
• BP Oil Spill Report As It Happened
• How Prepared Are We For the Next Major Oil Spill
• Oil Spill Day 100 The 11 Men Who Died On The Deepwater Horizon
• Deepwater Horizon Oil Spill
• Letter To BP CEO Tony Hayward
• BP Manager Ignored Warnings Before Deepwater Horizon Blew
• BP And The Deepwater Horizon Disaster Of 2010
• DeepWater Horizon Explosion Was No Surprise
• Minerals Management Service
• Muster And Evacuation Regulation
• GPO Oil Commission
• BP Guilty Verdict
• BP Deepwater Horizon Costs Balloon To $65B USD

Support Causality on Patreon
Episode sponsor:
Many Tricks:

If you’re looking for some Mac software that can do Many Tricks remember to specifically visit the URL below for more information about their amazingly useful apps.

Visit manytricks.com/pragmatic and use the Coupon Code (listen to the episode to get the code) for 25% off the total price of your order. Hurry it's only for a limited time!

Episode Gold Producer: 'r'.
Episode Silver Producers: Carsten Hansen and John Whitlow.

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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:

• Space Shuttle Columbia
• Space Shuttle Columbia Disaster
• STS-107
• When The Space Shuttle Didn’t Come Home
• Columbia Space Shuttle Disaster Explained
• List of Space Shuttle Missions
• A New Vision for NASA
• STS-27
• Legendary Commander Tells Story Of Shuttle’s Close Call
• This Is Why The Space Shuttle’s External Fuel Tank Stopped Being Painted White
• NASA - Report of Columbia Accident Investigation Board, Volume I
• Soyuz
• Project Gemini

Support Causality on Patreon
Episode sponsor:
Many Tricks:

If you’re looking for some Mac software that can do Many Tricks remember to specifically visit the URL below for more information about their amazingly useful apps.

Visit manytricks.com/pragmatic and use the Coupon Code (listen to the episode to get the code) for 25% off the total price of your order. Hurry it's only for a limited time!

Episode Gold Producer: 'r'.
Episode Silver Producers: Carsten Hansen and John Whitlow.

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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 and Railroad Watch
• Kipton Train Wreck Anniversary
• The Great Kipton Train Wreck
• Kipton Train Crash
• Kipton Train Collision
• Railway Post Office

Support Causality on Patreon

Episode Gold Producer: 'r'.
Episode Silver Producers: Carsten Hansen and John Whitlow.

With thanks to Clinton Philips for the topic suggestion.

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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 Episode References:

• Causality Episode 3: Fukushima
• Causality Episode 17: Three Mile Island

Technical References:

• Iodine-135
• Periodic Table
• List of Chemical Elements
• Xenon Poisoning in Reactors
• Nuclear Energy Slides [PDF]
• Neutron Cross-Section
• Radiation burn
• RBMK Reactors Positive Void Coefficient

Timelines:

• Chernobyl Accident Timeline
• Chernobyl Timeline Of A Nuclear Nightmare
• What Caused The Disaster
• Timeline Of Events The Chernobyl Gallery
• Chernobyl Disaster
• Chernobyl Sequence of Events

Essays, Regulations and Miscellaneous:

• Chernobyl Essay [PDF]
• Regulation for 3rd and 4th Reactor [PDF]
• Regulations and ORM in Chernobyl’ disaster
• Individual involvement in the Chernobyl disaster
• New Safe Confinement
• Chernobyl New Safe Confinement
• Plans for New Nuclear Reactors Worldwide

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Episode sponsor:
Makers4Good:

Makers4Good are an innovative company based in Palo Alto, California and they’ve recently released the HELIO: A Solar Light, Torch and Powerbank that’s perfect for camping, hiking, emergencies, gazebos, use as a night light or wherever your adventures might happen to take you. All profits from the sale of the HELIO go to providing light and power for those in need.

Visit makers4good.com/engineered and use the Coupon Code ENGINEERED for 20% off the total price of your order.

Episode Gold Producer: 'r'.
Episode Silver Producers: Carsten Hansen and John Whitlow.

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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
• Milford Haven HSE Accident Report [PDF]
• Alarm Management
• Abnormal Situation Management [PDF]

Support Causality on Patreon
Episode sponsor:
Makers4Good:

Makers4Good are an innovative company based in Palo Alto, California and they’ve recently released the HELIO: A Solar Light, Torch and Powerbank that’s perfect for camping, hiking, emergencies, gazebos, use as a night light or wherever your adventures might happen to take you. All profits from the sale of the HELIO go to providing light and power for those in need.

Visit makers4good.com/engineered and use the Coupon Code ENGINEERED for 20% off the total price of your order.

Episode Gold Producer: 'r'.
Episode Silver Producers: Chris Stone and Carsten Hansen.

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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 Considerations for Conventional Storage
• Conventional Impoundment Storage - The current techniques
• The Stava Mudflow of 19 July 1985 PDF
• Liquefaction
• The Val di Stava Dam Collapse
• Mine Tailings Safety Stava Report PDF
• Val di Stava Dam Collapse
• Tailings Dam
• The Stava Tailings Dam Failure
• Fondazione Stava 1985 [Italian]

Support Causality on Patreon

Episode Gold Producer: 'r'.
Episode Silver Producers: Chris Stone, Eivind Hjertnes and Carsten Hansen.

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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 potential interest:

• Alton Towers
• The Smiler
• How Alton Towers Smiler Crash Unfolded
• Alton Towers Smiler Crash Footage Released
• Alton Towers Smiler Ride Reopens

Support Causality on Patreon

Episode Gold Producer: 'r'.
Episode Silver Producers: Chris Stone and Eivind Hjertnes.

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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 London
• Battersea Power Station
• Clean Air Act 1956
• Trams in London
• 1948 Donora Smog
• Pollution in China

Support Causality on Patreon

Episode Gold Producer: 'r'.
Episode Silver Producers: Chris Stone and Eivind Hjertnes.

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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 flooding had blinded the operators to what was actually happening.
With John Chidgey.
Related episodes:

• Causality Episode 3: Fukushima

Links of potential interest:

• Three Mile Island accident
• Three Mile Island Nuclear Generating Station
• Nuclear Regulator Commission renews Three Mile Island Unit 1s License
• Nuclear accident and recovery at Three Mile Island
• Three Mile Island Accident
• Measuring Radiation
• Three Mile Island Engineering Report
• Three Mile Island Accident Health Effects
• Facts and Information About Radiation Exposure

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Episode Gold Producer: 'r'.
Episode Silver Producers: Carsten Hansen, Eivind Hjertnes and Daniel Dudley.

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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 Movement Radar
• Air Travels Communications Killer
• Flight Global
• Another 737NG PFD Question

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Episode Gold Producer: 'r'.
Episode Silver Producers: Chris Stone, Eivind Hjertnes and Daniel Dudley.

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The Sampoong Department Store in South Korea collapsed in 1995 killing over 500 people. The investigators were shocked to find just how many rules had been broken but the true root cause might have been something more innocuous.
With John Chidgey.
Links of potential interest:

• Failures of the Sampoong Department Store
• Sampoong Department Store Collapse
• Sampoong Superstore PDF

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Episode Gold Producer: 'r'.
Episode Silver Producer: Chris Stone.

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The Concorde was the first commercially successful supersonic aeroplane that flew for nearly 25 years without a fatality and was considered the safest aeroplane in the world at the time until it crashed. The incident ended the lives of 113 people and it ultimately ended the Concorde itself.
With John Chidgey.
Links of potential interest:

• Tupolev Tu-144
• Concorde
• 40 Fascinating Facts About The Concorde
• The Concorde SST Accident Report
• The Untold Story of the Concorde Disaster
• Aircraft Runway Requirements
• V-Speeds
• Air France Flight 4590

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Episode Gold Producer: 'r'.
Episode Silver Producer: Chris Stone.

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A near-new modern cruise liner with all the navigational aids and maps struck rocks and sank killing over 30 people and the man most responsible still walks free today.
With John Chidgey.
Links of potential interest:

• Costa Concordia
• Costa Concordia Disaster
• Costa Concordia - What Happened
• The Costa Concordia Sinking
• Costa Concordia Maritime Accident Casebook
• Draft (hull)
• Costa Concordia Captain’s Appeal Rejected
• Italy Court Upholds Costa Concordia Captain’s Sentence

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Episode Gold Producer: 'r'.
Episode Silver Producer: Chris Stone.

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The Mont Blanc tunnel cut hours off the journey between Italy and France and in 1999 in a fire emergency services were unable to save 38 lives. We look at why.
With John Chidgey.
Links of potential interest:

• Mont Blanc Tunnel
• Culvert
• NFPA - Highway Vehicle Fires
• The Fire Triangle
• Carbon Monoxide Poisoning

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Episode Gold Producer: 'r'.
Episode Silver Producer: Chris Stone.

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For decades Flint Michigan derived safe drinking water from Detroit. When the supply was switched to save money a series of events unfolded and their supply became undrinkable. How could this happen?
With John Chidgey.
Links of potential interest:

• Lead and Copper Rule
• Here’s what drinking water pipes look like with and without corrosion control
• Flint Corrosion Control Presentation
• How Lead Ended Up In Flint’s Tap Water
• List of Five Basic & Immediate Needs for Physical Human Survival
• How Long Can Someone Go Without Breathing?
• How Long Can You Live Without Water?
• Chlorination of Drinking Water
• Lead Poisoning and Rome
• Lead Poisoning
• 2 Flint employees EM OK’d river water plan

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Episode Gold Producer: 'r'.
Episode Silver Producer: Chris Stone.

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The Comet was the worlds first commercial jet aeroplane and those that flew aboard it formed the so-called JetSet. When they started to crash, the world of aviation changed forever.
With John Chidgey.
Links of potential interest:

• de Havilland Comet
• ASN Aviation Safety Database
• Flying back to the Fifties
• Frank Whittle
• Effects of high altitude on humans
• Material Fatigue
• de Havilland
• BOAC Flight 781
• Disaster in the Air
• Non-destructive Testing Applications in Commercial Aircraft Maintenance

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Episode Gold Producer: 'r'.
Episode Silver Producer: Chris Stone.

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The largest airship ever constructed burst into flames when trying to land in 1937 in New Jersey in what has become one of the most striking disasters of modern times.
With John Chidgey.
Links of potential interest:

• LZ 129 Hindenburg
• Hindenburg Disaster
• R101
• Flash Point
• Hindenburg Passenger Ticket
• Herbert Morrison

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Episode Gold Producer: 'r'.
Episode Silver Producers: Chris Stone and John Whitlow.

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The Challenger Space Shuttle was directed to launch on the coldest day on record in Florida and 73 seconds after launch it exploded but the engineers saw it coming.
With John Chidgey.
Links of potential interest:

• The Challenger Crew Plunged to Their Deaths
• Moonraker - IMDb
• Space Shuttle
• Space Shuttle Challenger
• Space Shuttle Challenger Disaster
• NASA Shuttle Missions
• List of Space Shuttle Missions
• Thiokol
• Challenger: Twenty Years Later, Lessons Never Learned
• Space Ship Two
• Max Q
• The Challenger Launch Decision
• Weather and the Shuttle Challenger Disaster
• Weather Source: 1986 January
• “Star Trek: The Next Generation” Time’s Arrow: Part 1 (TV Episode 1992) - Quotes - IMDb
• Challenger Shuttle Engineer Sheds 30 Years Of Guilt

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Episode Gold Producer: 'r'.
Episode Silver Producer: Chris Stone.

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The Piper Oil field in the North Sea became the site of one of the worst Offshore Oil Rig disasters in history when Piper Platform Alpha went up in flames.
With John Chidgey.
Links of potential interest:

• Human Factors and Ergonomics for Shift Handover
• Piper Alpha
• Natural-gas Condensate

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Episode Gold Producer: 'r'.

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The Amagasaki rail crash was entirely caused by human error but was it a fear of punishment by the company that was ultimately the cause.
With John Chidgey.
Links of potential interest:

• Amagasaki Rail Crash
• Fukuchiyama Line
• ICAO - Annexes Booklet
• ICAO - Personnel Licensing FAQ
• JTSB Accident Report English Extract
• Aircraft and Railway Accidents Investigation Commission
• Fatigue
• JR West Punished Staff

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The 15th Maccabiah Games in 1997 had a temporary bridge for the opening ceremony. The world was shocked when it failed and it did so on every level.
With John Chidgey.
Links of potential interest:

• 1997 Maccabiah Games
• Maccabiah Games
• The Maccabiah Bridge Collapse
• Google Maps: The Site of the Disaster
• Australia/Israel Review: The Bridge Too Far
• Phil Moss Recalls the Tragic Death of Four Aussies…
• Maccabiah Tragedy
• Australian Jews blast Rehiring of Officials Responsible for the Maccabiah Tragedy
• Stage Design Israel
• American Jewish Year
• Maccabiah Bridge Collapse: Initial Investigations |
• The Jewish Olympics: The History of the Maccabiah Games

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Episode sponsor:
Extrasensory Devices:

Extrasensory Devices are an innovative company based in Palo Alto, California and they’ve recently released their all new Luxi For All: an incident light meter attachment for your smartphone or tablet. Taking better pictures starts with your Luxi.

Visit esdevices.com/engineered and use the Coupon Code ENGINEERED for 15% off the total price of your order.

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The Titanic famously sank on her maiden voyage with a huge loss of life. No ship is unsinkable.
With John Chidgey.
Links of potential interest:

• List of Ships Sunk by Icebergs
• Titanic Timeline
• Time Line
• Titanic: The Myth of the Unsinkable Ship
• Seamen’s Act
• RMS Titanic
• Titanic Facts: Statistics about The Sinking of the Ship
• Lifeboats of the RMS Titanic
• Was the Titanic Ever Publicised as Unsinkable?
• Why Did People Believe Titanic Was Unsinkable?
• Titanic Deckplans : Tank Top
• RMS Republic
• International Ice Patrol

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Episode sponsor:
Shopi:

Shopi is a collaborative shopping list app that’s simple and easy to use with great features like pocket-lock, smart ordering and real-time collaborative updating. A shopping list is a special To Do list and Shopi addresses that use case very well. It’s ad-free for the first month so why not check it out.

Visit sapient-pair.com/engineeredto learn more.

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What went wrong with Fukushima 1 Daiichi Nuclear Power Plant in 2011.
With John Chidgey.
Links of potential interest:

• List of Nuclear Power Stations
• Nuclear Reactor
• Water for Power Plant Cooling
• Why Fukushima Was Preventable
• Fukushima Daiichi Nuclear Disaster
• 2011 Toøhoku Earthquake and Tsunami
• Soøma, Fukushima
• Fukushima Daiichi Nuclear Power Plant
• S.C.R.A.M.
• Chicago Pile-1
• Zirconium Alloy
• Review of the Oxidation Rate of Zirconium Alloys
• IAEA Warned Japan Over Nuclear Quake Risk
• Timeline for the Fukushima Daiichi Nuclear Power Plant Accident
• Nuclear and Industrial Safety Agency
• Fukushima Accident
• The Fukushima Wasteland
• Electricity Generation

Support Causality on Patreon
Episode sponsor:
Extrasensory Devices:

Extrasensory Devices are an innovative company based in Palo Alto, California and they’ve recently released their all new Luxi For All: an incident light meter attachment for your smartphone or tablet. Taking better pictures starts with your Luxi.

Visit esdevices.com/engineered and use the Coupon Code ENGINEERED for 15% off the total price of your order.

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Roll cages in cars are supposed to improve safety but do they actually cause the problem they're trying to protect you from?
With John Chidgey.
Links of potential interest:

• Rollover
• A METHODOLOGY FOR ESTIMATING VEHICLE ROLLOVER PROPENSITY THAT COMBINES STABILITY FACTOR AND HANDLING METRICS (PDF)
• Fatality Analysis Reporting System (FARS) | National Highway Traffic Safety Administration (NHTSA)
• Center of Mass
• CDC Mining Risks
• Traffic Safety Facts: Pedestrians
• U.S Census Bureau Population Estimates (2004)
• List of Motor Vehicle Deaths in U.S. by Year
• Safety Cell 6 Point Internal ROPS
• BHP Accused of Rolling Over on Vehicle Safety
• Operator Roll-over Protection on Small Vehicles
• Roll-over Protection Structure
• ANCAP Frequently Asked Questions
• 5 Star ANCAP Rating Changes to BMA Site Vehicles (PDF)
• Follow Up Evaluation of Electronic Stability Control Effectiveness in Australasia
• Tilt test (vehicle safety test)

Support Causality on Patreon
Episode sponsor:
Extrasensory Devices:

Extrasensory Devices are an innovative company based in Palo Alto, California and they’ve recently released their all new Luxi For All: an incident light meter attachment for your smartphone or tablet. Taking better pictures starts with your Luxi.

Visit esdevices.com/engineered and use the Coupon Code ENGINEERED for 15% off the total price of your order.

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The BP Texas City Oil Refinery disaster in 2005 shocked the world. With safe-guards in place and lost-time injury rates so low, how could so many people be killed in a wholly preventable disaster?
With John Chidgey.
Links of potential interest:

• The U.S. Chemical Safety Board
• Texas City Refinery Explosion
• Isomerization
• Human Factors Influencing The Texas City Incident
• Lessons from Disaster: How Organizations Have No Memory and Accidents Recur
• Diesel Engine Runaway
• BP Completes Sale of Texas City Refinery
• The Refinery Today
• Texas City, Texas: Google Maps Location
• BPs Statement of Facts

Support Causality on Patreon
Episode sponsor:
Extrasensory Devices:

Extrasensory Devices are an innovative company based in Palo Alto, California and they’ve recently released their all new Luxi For All: an incident light meter attachment for your smartphone or tablet. Taking better pictures starts with your Luxi.

Visit esdevices.com/engineered and use the Coupon Code ENGINEERED for 15% off the total price of your order.

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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.
With John Chidgey.
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. This is Causality and I’m John Chidgey. An electrical engineer by degree, Chartered Professional Engineer in Electrical, Information, Telecommunications and Electronic Engineering, with a passion for fault finding, root cause analysis and above all else, learning lessons from our collective mistakes. Because when we don’t understand our collective history, we’re doomed to make the same mistakes, over and over again.

I’m the creator, writer, researcher, host, editor and producer of Causality. My goal: not only explore what went wrong with major incidents that occurred around the world throughout history, but to explore what people, real people that could have made a difference at the time, what could they have done differently to prevent that from happening. How can we design things better? How can prevent incidents from occurring. From Titanic to Challenger, from Piper Alpha to Flint Michigan, from Bhopal to Deepwater Horizon, there are always things we could have done, to prevent them.

No actors, no sound effects, no re-enactments, no nonsense. If you’re an engineer, an operator, a designer, a developer or a person that’s just curious and cares, I hope you’ll join me as we discover that many outcomes can be predicted, planned for and even prevented. I’m John Chidgey. This is Causality. Thanks in advance for listening.

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