Causality

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...

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: Riv...

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...

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: NTS...

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)...

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 Ep...

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 Boei...

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...

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]...

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 Bik...

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...

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...

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...

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 Bh...

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-sub...

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 H...

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 Kipt...

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...

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...

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 S...

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 Cras...

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...

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: Causal...

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...

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 P...