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Causality

Causality

Author: The Engineered Network

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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.
36 Episodes
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35: San Bruno

35: San Bruno

2020-07-2649:33

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
34: Aberfan

34: Aberfan

2020-05-0739:20

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 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!
33: 737 MAX

33: 737 MAX

2020-01-3001:09:54

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 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!
32: Walkerton

32: Walkerton

2019-12-0637:53

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 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!
31: Black Energy

31: Black Energy

2019-10-0326:13

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
30: Tim Maia

30: Tim Maia

2019-07-0425:05

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 Episode sponsors: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.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.
29: Flight 1549

29: Flight 1549

2019-06-0427:34

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 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.
28: Hotel New World

28: Hotel New World

2019-05-0928:27

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) 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.
27: Gare De Lyon

27: Gare De Lyon

2019-04-0431:20

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) 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.
26: Bhopal

26: Bhopal

2019-02-0738:34

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 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.
25: Deepwater Horizon

25: Deepwater Horizon

2019-01-0851:25

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 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!
24: Columbia

24: Columbia

2018-12-1330:20

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 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!
23: Kipton

23: Kipton

2018-08-3119:24

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
22: Chernobyl

22: Chernobyl

2018-07-0850:40

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 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.
21: Milford Haven

21: Milford Haven

2018-04-2935:17

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] 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.
20: Stava Dam

20: Stava Dam

2018-02-2421:45

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]
19: Smiler

19: Smiler

2017-11-2220:00

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
18: The Fog

18: The Fog

2017-09-1420:03

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
17: Three Mile Island

17: Three Mile Island

2017-06-0232:31

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
16: Tenerife

16: Tenerife

2017-03-1028:45

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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