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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.
54 Episodes
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53: Callide C Blackout

53: Callide C Blackout

2024-03-3050:521

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 PatreonEpisode 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.
52: Colonial Pipeline

52: Colonial Pipeline

2023-12-0926:12

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 PatreonEpisode 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.
51: I35 West

51: I35 West

2023-08-2736:00

The I35W bridge over the Mississippi River carried 140,000 cars every day. Inspections in 1999 and 2003 showed damage to support plates that was dismissed as unimportant at the time. We look into how poor design checking and assumptions led to the bridge collapsing in 2007, costing the lives of 13 people.With John Chidgey.This show is Podcasting 2.0 Enhanced Only a Handful of T-Shirts Left! Reports: Collapse of I-35W Highway Bridge Minneapolis, Minnesota August 1, 2007 (PDF) General 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 PatreonEpisode 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.With thanks to Joe Stariha for the topic suggestion.
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 PatreonEpisode 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.
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 PatreonEpisode 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.
When a radiation therapy machine was left behind during a move between buildings in central Brazil, it set in motion a series of events that would lead to one of the worst radiological incidents in history. We look into how bureaucracy and misdiagnosis cost four people their lives and how the actions of a concerned mother with no medical experience, saved the lives of countless more.With John Chidgey.This show is Podcasting 2.0 Enhanced Create your own Credited Soundbite Official Report: The 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 PatreonEpisode 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.
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 PatreonEpisode 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.
46: Mindbender

46: Mindbender

2022-05-1629:29

The longest, tallest, fastest indoor rollercoaster in the world was only open six months when the last carriage of a train came loose, killing three people and all that the day following an inspection that the ride was safe to operate. We look at how a design choice made maintenance more critical and then how wishing for a ride to be safe, doesn't really help.With John Chidgey.This show is Podcasting 2.0 Enhanced Links of Interest: Mindbender Geoffrey Kulak (Archive.org) Mindbender (Galaxyland) 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 (Video) Mindbender Accident Inquiry - Film & Video Stock (Video) News Articles: Coaster Ride’s Mastermind Fired Roller-coaster goes at full tilt Mindbender 25 Years Later (Archive.org) 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 (Dead Link)](LINK DEFUNCT “Original Link: https://apnews.com/8be3b0f7291c22472aa8c00790de1358") 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 (Archive.org) Schwarzkopf (Archive.org) Mindbender - Park Vault Anton Schwarzkopf Mindbender (Galaxyland) Legislature Assembly Minutes: 21st Legislature First Session Minutes (PDF) Support Causality on PatreonEpisode 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.
45: Granville

45: Granville

2022-04-0225:53

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 (Archive.org) 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 (Archive.org) 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 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 PatreonEpisode 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.
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 (PDF) 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 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) Support Causality on PatreonEpisode 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.
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 PatreonEpisode 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.
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 Support Causality on PatreonEpisode 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.
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 PatreonEpisode 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.
40: Ocean Ranger

40: Ocean Ranger

2021-05-2446:36

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 Called (Video) Ocean Ranger report blames equipment and training (Video) Hypothermia Table History of offshore drilling units Glossary of nautical terms Roustabout Davit 25 years later (Archive.org) Support Causality on PatreonEpisode 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.
39: Therac-25

39: Therac-25

2021-03-2353:11

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 Support Causality on PatreonEpisode 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.
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 PatreonEpisode Gold Producer: 'r'.Episode Silver Producers: Mitch Biegler, John Whitlow, Kevin Koch, Oliver Steele, Lesley Law Chan, Hafthor and Shane O'Neill.
37: Variola Birmingham

37: Variola Birmingham

2020-11-2634:30

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

36: Big Dig

2020-09-1531:471

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 Support Causality on PatreonEpisode 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.
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 Support Causality on PatreonEpisode 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.
34: Aberfan

34: Aberfan

2020-05-0734:44

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

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