Causality
Causality explores the chain of events and cause-and-effect relationships that shape outcomes. The podcast analyzes what went right and what went wrong, revealing how many results can be predicted, planned for, and even prevented. It delves into various scenarios to understand the underlying mechanisms of success and failure.
Episodes
64: Verrückt Waterslide
Spurred on to build the tallest and fastest Waterslide in the world by a Travel Channel show about Waterparks, the owners of the Kansas City Schlitterbahn Waterpark designed and built the Verrückt Waterslide in record time. A net enclosed the ride and on its third Summer Season a 10 Year Old boy died on impact with that netting mid-ride. We look at how design decisions, subsequent modifications an
63: Wittenoom
With demand for Asbestos in building products in the 1940s, a discovery in Western Australia's remote Pilbara region of Blue Asbestos led to the creation of a mining town called Wittenoom. Despite the growing list of illnesses and deaths of workers from the mine and milling operation, the company pressed on until it closed for 'financial' reasons. We look at the dangers of dust inhalat
62: OceanGate Titan
A young company pushing to re-invent deep sea exploration with an initial focus on opening up tourism to the wreck of the Titanic, OceanGate garnered the fascination of many around the world. With a different approach to their hull design they forged ahead despite many warnings from experts in the field, concerned about their design decisions and materials choices. When the submersible imploded ki
61: West Gate Bridge
Planned for nearly a century, when the time came to build a permanent link across the Lower Yarra River, a relatively new style of bridge, the box-girder, was chosen. Using new computer technology assisting the engineers to design a bridge that was too complex to calculate by hand, and using a unique lifting strategy promised time and cost savings. Ultimately though when the pieces didn't fit
60: Carnival Triumph
A leaking flexible pipe started a fire in the Engine Room aboard the Carnival Triumph during its return journey from Mexico in early 2013. The fire caused minor damage in one, very important section of the Engine Room leading to a total loss of Mains Power. With only intermittent Emergency Power and over 4,000 people on board the ship drifted with the currents before it was tugged finally to safet
59: Bayer CropScience
After an extended outage of the Methomyl Unit at the Bayer facility in Institute, West Virginia, the decision was made to commence a restart of the Unit even though the DCS upgrade was still incomplete and the newly replaced Residue Treater hadn't been fully recommissioned. An incident whose root cause was years in the making would ultimately cost two people their lives.With John Chidgey.Relat
58: West Fertilizer Company
In the early hours of the evening on the 17th of April, 2013 in the small city of West, Texas...smoke was seen emanating from the West Fertilizer Company building. In 20 minutes there was a massive explosion that levelled the facility and its surroundings, killing 15 people and injuring hundreds more. How this came to be, represented a failure of regulations, planning and grandfathering on every l
57: Stardust Nightclub
On Valentines Day in 1981 in the North of Dublin, Ireland a fire broke out in a nightclub just following a Disco Dancing competition. We look at how measures taken to prevent illegal entry and poor building material choices cost 48 young people their lives.With John Chidgey.Related Episodes:
Causality Episode 43: Triangle Shirtwaist Factory
Formal Reports:
Report of the Stardust Victims’
56: BP Husky Toledo
On the 20th of September, 2022 at the BP Husky Toledo refinery in Ohio, a level transmitter change out from a month prior triggered a chain of events that would cost two operators their lives. We look at how poor Management of Change, high alarm rates and a resistance to stopping the job, let a plant upset turn into a disaster.With John Chidgey.Formal Report:
U.S. Chemical Safety Board Issues Fin
55: CrowdStrike
On Friday the 19th of July, 2024 millions of CrowdStrike Falcon Agents the world over would lead to a Windows system crash on business machines throwing parts of the world into chaos. We look into exactly what caused it and how complacency and a lack of understanding amplified the effect of this wholly preventable incident.With John Chidgey.About Causality (TV):
Introducing Causality TV
Causality
54: Midland Resource Recovery
In 2017 during an Odoriser decontamination procedure in West Virginia, two people were killed when it unexpectedly exploded. Barely a month later, a similar procedure at the same site led to a second explosion, killing someone else. We examine how poor hazard analysis and legal interference led to yet another fatality...right in front of the eyes of the investigators on site.With John Chidgey.Form
53: Callide C Blackout
In 2021 the Callide C Power Station experienced a unit failure that tore the turbine-generator apart, resulted in hundreds of thousands of premises losing power, and cost hundreds of millions to repair. We look at how design errors and ultimately a lack of information led to the incident escalating out of control, when it could have been recovered.With John Chidgey.Formal Reports:
Callide Unit C4
52: Colonial Pipeline
In 2021 many of Colonial Pipelines IT systems were locked by malware and out of caution they shutdown the fuel pipelines feeding nearly half of the Eastern US leading to chaos at the gas pump and a state of emergency being declared. We look at how poor off-boarding hygiene led to an easily preventable cyber-attack.With John Chidgey.Hearing:
Hearing Before the Committee on Homeland Security House
51: I35 West
The I35W bridge over the Mississippi River carried 140,000 cars every day. Inspections in 1999 and 2003 showed damage to support plates that was dismissed as unimportant at the time. We look into how poor design checking and assumptions led to the bridge collapsing in 2007, costing the lives of 13 people.With John Chidgey.This show is Podcasting 2.0 Enhanced
Only a Handful of T-Shirts Left!
Report
50: 737 MAX Ethiopian Air
Five months after Lion Air 610 crashed, another 737-MAX went down with a similar cause. However the official report was at odds with two other internationally respected investigative organisations. We dig into the detail of how the AOA Sensor was claimed to have failed, and review checklist discrepancies to extract fact from opinion as to what most likely triggered this horrible chain of events.Wi
49: Carmel Fireworks Explosion
A fireworks company in Western Australia that had been in business for nearly a century, were preparing for a fireworks display in their packing shed when one ignited and set off a fire and an explosion. Onlookers were shocked when there was a subsequent explosion that was so big it was heard 30 kilometers away leaving the facility in ruins.With John Chidgey.This show is Podcasting 2.0 Enhanced
Ce
48: Instituto Goiano de Radioterapia
When a radiation therapy machine was left behind during a move between buildings in central Brazil, it set in motion a series of events that would lead to one of the worst radiological incidents in history. We look into how bureaucracy and misdiagnosis cost four people their lives and how the actions of a concerned mother with no medical experience, saved the lives of countless more.With John Chid
47: Hyatt Regency Kansas City
The tallest building in Missouri with a large atrium perfect for big bands and dancing, hosted a regular Tea Dance in the summer of 1981. When two walkways collapsed killing over a hundred people, the investigators found multiple fundamental design errors. We look at how assumptions, redrafting conventions and negligence led to an incident that has become the case study in how not to do civil stru
46: Mindbender
The longest, tallest, fastest indoor rollercoaster in the world was only open six months when the last carriage of a train came loose, killing three people and all that the day following an inspection that the ride was safe to operate. We look at how a design choice made maintenance more critical and then how wishing for a ride to be safe, doesn't really help.With John Chidgey.This show is Pod
45: Granville
In 1977, a commuter train from the Blue Mountains, destined for Sydney central station would derail just before Granville Station, causing a bridge to collapse and crush many aboard. It remains Australia's worst ever rail disaster that was predicted by 11 engineering department heads just a year earlier. We look at how management decisions led to a completely avoidable disaster.With John Chidg
44: Beirut Warehouse 12
In Beirut in August of 2020, an explosion at the Port of Beirut destroyed a huge part of the city. We look into how an oxidising agent, improperly handled can become an explosive and attempt to comprehend how something so dangerous was ignored repeatedly by key people, despite many warnings of an imminent disaster.With John Chidgey.This show is Podcasting 2.0 Enhanced
Links of Interest:
2020 Beir
43: Triangle Shirtwaist Factory
In 1911 in Manhattan, New York, a clothing factory went up in flames just before closing time. We look at how faulty equipment, poor design and a fear of theft contributed to a wholly preventable incident that had such terrible consequences, but would trigger reforms that still impact the United States, a century later.With John Chidgey.This show is Podcasting 2.0 Enhanced
Links of Interest:
Tria
42: Royal Canberra Hospital
The original Royal Canberra Hospital was flagged to be demolished in 1997 to make way for the new National Museum. A demolition via implosion was selected, but the implosion resulted in an explosion instead, and debris showered the huge crowd of onlookers with fatal consequences.With John Chidgey.This show is Podcasting 2.0 Enhanced
Report into the Incident:
Inquest Into The Death of Katie Bender
41: Florida International University
The university wanted a bridge for its students over a busy roadway that would appear intriguing from afar. Instead it collapsed before it was even finished. We look into how design errors, poor peer review and denial led to a collapse that claimed six peoples lives.With John Chidgey.This show is Podcasting 2.0 Enhanced
Report into the Incidents:
NTSB Final Report (PDF)
Design Criteria and Bid:
40: Ocean Ranger
The largest semi-submersible Offshore Drilling Rig of its day, sank in a storm in 1982 whilst two smaller nearby rigs survived with minimal damage. We dive into how not closing a portlight cover, triggered a series of events that cost 84 people their lives.With John Chidgey.This show is Podcasting 2.0 Enhanced
Report into the Incidents:
Official Report
Links of Potential Interest:
Ocean Ranger
39: Therac-25
The successor to the Therac-6 and Therac-20 RadioTherapy machines would integrate the powerful DEC PDP-11 mini-computer to control all of the Therac-25s functions, including the safety interlocks, for the first time. In two years the 11 machines in service would overdose six people across two countries, killing three of them before they figured out why.With John Chidgey.This show is Podcasting 2.0
38: Thunder River Rapids
A popular family-friendly ride at DreamWorld would claim the lives of four people in 2016. In nearly thirty years of operation the ride had several similar but non-fatal incidents with blame placed on the operator every time, when a three thousand dollar modification could have prevented a horrific incident.With John Chidgey.Investigation Report:
DreamWorld (PDF)
Links of Potential Interest:
Ri
37: Variola Birmingham
In 1978 on the cusp of the eradication of SmallPox a Medical Photographer became infected and would ultimately die from the Variola virus. We look at how admiration, promotion and delegation led to a wholly avoidable outcome.With John Chidgey.Investigation Report:
The Shooter Report (PDF)
Medical Analyses:
CDC Analysis of the R0 of SmallPox (PDF)
Links of Potential Interest:
SmallPox
History
36: Big Dig
A series of concrete ceiling tiles in a tunnel portal collapsed on a moving car killing the passenger in downtown Boston in 2006. The selection of the epoxy used in the ceiling tile anchors was unusual and a failure to heed the warning signs were at odds on a huge project under pressure to deliver when already twice over time and five times over budget.With John Chidgey.Investigation Report:
NTSB
35: San Bruno
A modification made in 1956 to a pipeline built in the 1940s would ultimately fail costing 8 people their lives in 2010. We look at what went wrong with PG&Es gas pipeline in San Bruno, California.With John Chidgey.Investigation and Reports:
NTSB Report (PDF)
Independent Review Panel Report on San Bruno Pipeline Explosion
Technical Links:
Material Fatigue
GIS (Geographic Information System)
34: Aberfan
One Friday morning in 1966 in a small town in Wales a mining spoils waste tip let go with a river of liquified rubble destroying buildings and a school. Killing 144 people, mostly children in their classrooms. The mechanics of how this happened are simple. The ignorance and economics of why this happened boggles the mind.With John Chidgey.Related episodes:
Causality Premium Giveaway
Causality Epi
33: 737 MAX
With two crashes in five months of the new 737 4th Generation a design flaw seemed likely. We look at how Boeings focus on cost-avoidance, grandfathering and bending probabilities during design would ultimately cost 346 people their lives.With John Chidgey.Related episodes:
Causality Episode 10: The Comet
Causality Episode 14: Concorde
Investigation and Reports:
FAA Finds New Safety Risk in Boe
32: Walkerton
In 2000 the small township of Walkerton Ontario witnessed the largest outbreak of E.Coli infections in Canada's history. The water utility claimed the town water was safe, but it wasn't and many people paid with their lives.With John Chidgey.Links of potential interest:
Walkerton Ontario
Toronto Ontario
Walkerton E. coli Outbreak
Death On Tap: The Poisoning Of Walkerton (Google Text-only
31: Black Energy
The evening before Christmas Eve in 2015 saw a widespread blackout of the power grid across the Ukraine. We look at how a cyber-attack on electric utility companies in Europe, changed how cyber-security is regarded in control systems, forever.With John Chidgey.Links of potential interest:
December 2015 Ukraine Power Grid Cyber-attack
Analysis of the Cyber Attack on the Ukrainian Power Grid [PDF]
30: Tim Maia
As part of Rio's preparations for the Olympics in 2016 a cycling pathway was built adjacent to a narrow, congested roadway along a picturesque shoreline. When a section collapsed only months before the opening ceremony killing two people, the world looked on with growing concerns about the imminent Olympics.With John Chidgey.Links of potential interest:
Deaths on Collapsed Rio de Janeiro Bike
29: Flight 1549
In 2009 an AirBus A320 departing LaGuardia Airport in New York suffered a dual engine failure due to a bird strike during takeoff. In a highly improbable event an equally highly improbable landing in the Hudson River shocked and amazed the world. We look at what went right on Flight 1549.With John Chidgey.Links of potential interest:
US Airways Flight 1549
The Miracle On The Hudson
NTSB Official
28: Hotel New World
In 1986 an unremarkable building in Singapore collapsed killing dozens of people. We look at how the supervision of the construction and the design itself resulted in a structure that was at best critically stable, and ultimately one that could only ever fail.With John Chidgey.Prior Episode References:
Causality Episode 5: Maccabiah
Causality Episode 15: Sampoong Department Store
Links of potent
27: Gare De Lyon
On the 27th of June, 1988 in central Paris a runaway train collided with a stationary train in Gare De Lyon station, claiming 56 lives and injuring 60 more. Whilst the court found the driver guilty and sent him to jail, was he solely to blame? We look at how poor design decisions made Gare De Lyon inevitable.With John Chidgey.Prior Episode References:
Causality Episode 6: Amagasaki
Links of pote
26: Bhopal
In December, 1984 in the city of Bhopal in central India, a Union Carbide Pesticide plant would fail and release tonnes of toxic gas into the city, killing thousands of people. It was the worst industrial disaster in human history. We follow the threads and trace back the root causes behind the incident at Bhopal.With John Chidgey.Links of potential interest:
Bhopal
Carbaryl
Methyl isocyanate
Bho
25: Deepwater Horizon
In 2010 an Oil Drilling Rig suffered a catastrophic well blowout, killing 11 people, destroying the rig and leading to the worst maritime oil spill in history. It all happened a few hours after the well was declared safe and ready for handover. We look at the human and financial factors that led to the incident at Macondo.With John Chidgey.Links of potential interest:
Deepwater Drilling
Semi-subm
24: Columbia
In 2003 the Space Shuttle Columbia launched successfully but after its mission was completed burned up on re-entry with the loss of all onboard. We look at how normalisation of deviation blinded many at NASA to a risk that had existed since 1981.With John Chidgey.Links of potential interest:
Space Shuttle Columbia
Space Shuttle Columbia Disaster
STS-107
When The Space Shuttle Didn’t Come Ho
23: Kipton
When two trains collided head on at Kipton, Ohio in 1891, it was a wake up call for the railroad industry in North America whose impacts would be far-reaching and would lead to a new timekeeping standard that was unprecedented.With John Chidgey.Links of potential interest:
US Timepiece Industry and Railroad Watch
Kipton Train Wreck Anniversary
The Great Kipton Train Wreck
Kipton Train Crash
Kipto
22: Chernobyl
The largest nuclear incident in human history released an estimated 400 times the radioactive material compared to Hiroshima and Nagasaki. It all happened because of a test that was delayed by one shift, or was it the ultimate inevitability of a flawed reactor design?With John Chidgey.Prior Episode References:
Causality Episode 3: Fukushima
Causality Episode 17: Three Mile Island
Technical Refer
21: Milford Haven
A turning point in control systems user interface design and alarm management happened in an unlikely place that few have ever heard of. We look at what went wrong at Milford Haven.With John Chidgey.Links of potential interest:
The explosion and fires at the Texaco Refinery, Milford Haven
Milford Haven HSE Accident Report [PDF]
Alarm Management
Abnormal Situation Management [PDF]
Support Causali
20: Stava Dam
On the 19th of July, 1985 in Tesero, Northern Italy, a tailings dam gave way and killed 268 people. With the most common tailings dam design in the world, what went wrong and how widespread are the risks?With John Chidgey.Links of potential interest:
Stava tailings dam failure
Water Management Considerations for Conventional Storage
Conventional Impoundment Storage - The current techniques
The St
19: Smiler
In 2015 at Alton Towers in the UK, The Smiler Rollercoaster experienced a major incident leading to severe injuries for multiple riders. We look at how pressure to get the ride running again and mis-communication defeated the system designed to protect the riders.With John Chidgey.Links of potential interest:
Alton Towers
The Smiler
How Alton Towers Smiler Crash Unfolded
Alton Towers Smiler Crash
18: The Fog
In 1952 a fog in London left 4,000 dead in just 4 days but many more would die before the causes could be rectified. Worse than that, it had happened before and it’s happening again right now, somewhere else.With John Chidgey.Links of potential interest:
Inversion (meteorology)
Great Smog of London
Battersea Power Station
Clean Air Act 1956
Trams in London
1948 Donora Smog
Pollution in China
Sup
17: Three Mile Island
On March 28, 1979 Unit 2 of the Three Mile Island Nuclear Plant in the United States of America an incident would lead to a partial reactor core meltdown. Many blamed the operators for stopping the reactor cooling system but the real root causes showed a known flaw in the design and alarm flooding had blinded the operators to what was actually happening.With John Chidgey.Related episodes:
Causali
16: Tenerife
In 1977 on the small island of Tenerife two 747 Jumbo Jets collided on the runway in poor visibility. A miscommunication clearly occurred, but even today, the same elements still exist and it could happen again.With John Chidgey.Links of potential interest:
Tenerife-North Airport
Teide
Surface Movement Radar
Air Travels Communications Killer
Flight Global
Another 737NG PFD Question
Support Causa
15: Sampoong Department Store
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
Support Causality on
14: Concorde
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 Concor
13: Costa Concordia
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&rsq
12: Mont Blanc Tunnel
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
Support Causality on PatreonEpisode Gold Producer:
'r'.Episode Silver
11: Flint Michigan
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 (PDF)
How L
10: The Comet
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
D
9: Hindenburg
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
Support Causality on PatreonEpisode Gold Producer:
'r'.Episod
8: Challenger
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
T
7: Piper Alpha
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
Support Causality on PatreonEpisode Gold Producer:
'r'.
6: Amagasaki
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
5: Maccabiah
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&hell
4: Titanic
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 Unsinka
3: Fukushima
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 o
2: Don't Roll On Me
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)
C
1: BP Texas City
The BP Texas City Oil Refinery disaster in 2005 shocked the world. With many 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 (PDF) (Archive.org)
Lesson
0: Trailer
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 electric
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