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17
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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.
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 Silver Producers: Mitch Biegler, John Whitlow, Joseph Antonio, Kevin Koch and Oliver Steele. Episode Gold Producer: 'r'.
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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!
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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 338 people their lives.
Related episodes:
Causality Episode 10: The Comet
Causality Episode 14: Concorde
Investigation and Reports:
FAA Finds New Safety Risk in Boeing 737 Max
KNKT JT610 Final Report
NTSB ASR-19-01 Safety Recommendation Report
JATR Report: Boeing 737 MAX Flight Control System
History of Boeing:
History of Boeing
Boeing 737 Classic
Boeing 737 Next Generation
Boeing 737 MAX
Technical Information:
737 MAX: MCAS - The Boeing 737 Technical Guide
Flight Controls - The Boeing 737 Technical Guide
A quantum leap forward Aerospace Manufacturing Magazine
Angle Of Attack
Angle of Attack Sensor 0861FL1
V Speeds
Wing Root
CFM International CFM56
CFM International LEAP
Fundamentals Of Airliner Performance: The Engine
Maneuvering Characteristics Augmentation System: MCAS
Using The 737-800 And 737-900 Flaps
Understanding Flaps
Standards and Bulletins:
AC 25.1309-1
AC 25.1309-1A
Hazard Classification Matrix Based On JAR AMJ 25.1309 Severity
ICAO Annex 19: Safety Management
EASA Type-Certificate Datasheet Boring 737
FAA Advisory Circular 23.1309-1E
FAA Advisory Circular 25-7C
FAA System Safety Handbook Chapter 3: Principles of System Safety
AMJ25.1309 Change 15
Fallout:
Lion Air Flight 610
American Airlines Fleet
Southwest Airlines Fleet
Southwest Airlines Pilots Sue Boeing Over 737 Max Grounding
737 Max Crisis: Boeing To Borrow $10B
Boeing 737 Max Designed By Clowns
Boeing 737 MAX Groundings
Boeing 737 Max Plane Crash Victims Families Sickened By Fired Boeing CEOs Payout
Boeing Announces Leadership Changes
Boeing Statement On 737 MAX Return To Service
Boeing Earnings Q2 2019
Boeing Earnings Q3 2019
Boeing Knew Of 737 Max Flaws Before Crash
Boeing Left Safety Features Off 737 Max
Boeing Misses On Earnings
Boeing To Recommend Simulator Training For 737 Max Pilots
Boeing Will Suspend 737 Max Production In January 2020
Family Of Lion Air Co-pilot Sues Boeing
Lion Air crash: Cockpit Voice Recorder Is Found By Divers
Forum Articles:
What Are The Checklist Items For A Runaway Stabiliser Trim
Why Can’t The 737 MAX’s Horizontal Stabilizer Autotrim Be Cut Out
How To Disable The Stabilizer Trim Cutoff Switches
What Is The Procedure To Disable MCAS
How The Stabilizer Cutout Switch Functionality Changed From NG to MAX
Links of potential interest:
Airline Pilot Salaries
In Service Safety At Boeing: October 2014 Presentation
Pilots Fought Automatic Safety System
Boeing Statement on Lion Air Flight 610 Preliminary Report
How A 50yr Old Design Came Back To Haunt Boeing
AoA Vane Must Have Failed
Flawed Assumptions Paved A Path To Disaster
The 737 Max Has Cost Boeing $9.2B And Counting
The Complaints Pilots Filed About Boeing’s 737 Max
The Many Human Errors That Brought Down The Boeing 737 Max
What Happened On Board The Lion Air Boeing 737 Max That Crashed
Support Causality on Patreon
Episode Silver Producers: Carsten Hansen, John Whitlow, Joseph Antonio and Kevin Koch. Episode Gold Producer: 'r'.
To access Premium content Login or Subscribe via MyLibSyn Account
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!
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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.
Links of potential interest:
Walkerton Ontario
Toronto Ontario
Walkerton E. coli Outbreak
Death On Tap: The Poisoning Of Walkerton
The Walkerton Inquiry Report
Heavy Rainfall and Waterborne Disease Outbreaks: The Walkerton Example
Factors That Led To The Walkerton Tragedy
Walkerton Death Toll Revised
Ontario Pays $72M To Victims Of Walkerton
The Walkerton Tragedy
Inside Walkerton: Canada’s Worst-ever E. coli Contamination
Walkerton Water Crisis Follow-up
Town Finds Crisis Sharply Painful
Walkerton 2 years later
Walkerton Water Declared Safe To Drink
Definition of Incompetent
Grandfather Clause
Support Causality on Patreon
Episode Silver Producers: Carsten Hansen, John Whitlow, Joseph Antonio and Kevin Koch. Episode Gold Producer: 'r'.
To access Premium content Login or Subscribe via MyLibSyn Account
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!
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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.
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
Support Causality on Patreon
Episode Silver Producers: Carsten Hansen, John Whitlow, Joseph Antonio and Kevin Koch. Episode Gold Producer: 'r'.
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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 Path Deal Safety Blow to Olympic Host
Anger Grows Over Rio Bike Path Failure - WSJ
Questions Continue After the Collapse of Rio’s Cycle Path
Faulty Planning Blamed for Deadly Collapse
Padlocked and Falling Apart: Rio’s Olympic Legacy
Bike Lane Collapse Kills People on Beach
Are Brazil’s Corruption Scandals Finally Hitting the Olympics?
Rio, the Olympics, and Broken Promises
Architects Say Rio’s Olympic Bike Path Was Destined to Collapse
Petition Calls for Complete Demolition of Cycle-path
Judge Orders Closure of Rio Cycleway
Photo Gallery Links:
Gallery of A Stretch of Rio de Janeiro’s Tim Maia Bike Path Collapses
The Collapsed Area of the new Cycle Lane
Links of Interest (Portuguese):
Queda da Ciclovia: Doações à campanhas feitas pela CONCREMAT e os Grandes Jogos
Tweet: “‘Podre, tem que fazer tudo outra vez’, diz vice-prefeito sobre ciclovia Tim Maia, no Rio”
PETIÇÃO PARA A DEMOLIÇÃO DA CICLOVIA DA AVENIDA NIEMEYER
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Visit backblaze.com/causalityto learn more.Soulver.App:
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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 Report (PDF)
49 CFR 830.2 Definitions
CFM International CFM56
Chesley Sullenberger
Jeff Skiles
What the ‘Sully’ Movie Gets Wrong
LaGuardia Airport Diagram
Cold Water Survival
Medium Flocking Bird Test at Climb Condition
Support Causality on Patreon Episode sponsor: Backblaze:
Gimmick free, truly unlimited, cloud backup for your Mac or PC for just $6 a month with discounts for annual plans. Sign up via the following URL and for a 15 day no-risk free trial. Don’t take a chance with your data, start protecting your work and your memories today.
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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 potential interest:
Hotel New World Collapse
Collapse of Hotel New World
Structural Load
Report of the Inquiry into the Collapse of Hotel New World (Embedded PDF)
Support Causality on Patreon Episode sponsor: Clubhouse:
Looking for an easy to use software development project management solution that everyone in an organisation can use? Clubhouse was built with Agile Development in mind with an intense focus on intuitiveness and responsiveness, supporting seamless integrations with standard version control and messaging systems and an extensible REST API to integrate anything else you might need.
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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 potential interest:
Gare de Lyon Rail Accident
SNCF
SNCF Class Z 5300
Gare de Lyon
Paris Gare de Lyon - A brief station guide
Réseau Express Régional
Brake Problems Discovered 40 Minutes Before Crash
French Rail Chief Quits After 2nd Fatal Crash in Paris - LA Times
Train Driver Jailed for Crash That Killed 56 People
PRISON FERME l’Humanite (French)
Support Causality on Patreon Episode sponsor: Clubhouse:
Looking for an easy to use software development project management solution that everyone in an organisation can use? Clubhouse was built with Agile Development in mind with an intense focus on intuitiveness and responsiveness, supporting seamless integrations with standard version control and messaging systems and an extensible REST API to integrate anything else you might need.
Visit clubhouse.io/TENto learn more.
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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
Bhopal Chronology [PDF]
LABOR REPORT ON BHOPAL CITES PLANT MODIFICATION
Eight convicted over India gas disaster
Support Causality on Patreon Episode sponsor: Clubhouse:
Looking for an easy to use software development project management solution that everyone in an organisation can use? Clubhouse was built with Agile Development in mind with an intense focus on intuitiveness and responsiveness, supporting seamless integrations with standard version control and messaging systems and an extensible REST API to integrate anything else you might need.
Visit clubhouse.io/TENto learn more.
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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-submersible Platform
Macondo Prospect
Macondo Prospect Gulf of Mexico
Deepwater Horizon MC252 Data ERMA
Tool Pusher
Blowout (well drilling)
Deepwater Horizon Explosion
BP Oil Spill Report As It Happened
How Prepared Are We For the Next Major Oil Spill
Oil Spill Day 100 The 11 Men Who Died On The Deepwater Horizon
Deepwater Horizon Oil Spill
Letter To BP CEO Tony Hayward
BP Manager Ignored Warnings Before Deepwater Horizon Blew
BP And The Deepwater Horizon Disaster Of 2010
DeepWater Horizon Explosion Was No Surprise
Minerals Management Service
Muster And Evacuation Regulation
GPO Oil Commission
BP Guilty Verdict
BP Deepwater Horizon Costs Balloon To $65B USD
Support Causality on Patreon Episode sponsor: Many Tricks:
If you’re looking for some Mac software that can do Many Tricks remember to specifically visit the URL below for more information about their amazingly useful apps.
Visit manytricks.com/pragmatic and use the Coupon Code (listen to the episode to get the code) for 25% off the total price of your order. Hurry it's only for a limited time!
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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 Home
Columbia Space Shuttle Disaster Explained
List of Space Shuttle Missions
A New Vision for NASA
STS-27
Legendary Commander Tells Story Of Shuttle’s Close Call
This Is Why The Space Shuttle’s External Fuel Tank Stopped Being Painted White
NASA - Report of Columbia Accident Investigation Board, Volume I
Soyuz
Project Gemini
Support Causality on Patreon Episode sponsor: Many Tricks:
If you’re looking for some Mac software that can do Many Tricks remember to specifically visit the URL below for more information about their amazingly useful apps.
Visit manytricks.com/pragmatic and use the Coupon Code (listen to the episode to get the code) for 25% off the total price of your order. Hurry it's only for a limited time!
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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
Kipton Train Collision
Railway Post Office
Support Causality on Patreon
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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 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
Support Causality on Patreon Episode sponsor: Makers4Good:
Makers4Good are an innovative company based in Palo Alto, California and they’ve recently released the HELIO: A Solar Light, Torch and Powerbank that’s perfect for camping, hiking, emergencies, gazebos, use as a night light or wherever your adventures might happen to take you. All profits from the sale of the HELIO go to providing light and power for those in need.
Visit makers4good.com/engineered and use the Coupon Code ENGINEERED for 20% off the total price of your order.
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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 Causality on Patreon Episode sponsor: Makers4Good:
Makers4Good are an innovative company based in Palo Alto, California and they’ve recently released the HELIO: A Solar Light, Torch and Powerbank that’s perfect for camping, hiking, emergencies, gazebos, use as a night light or wherever your adventures might happen to take you. All profits from the sale of the HELIO go to providing light and power for those in need.
Visit makers4good.com/engineered and use the Coupon Code ENGINEERED for 20% off the total price of your order.
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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 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]
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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 Footage Released
Alton Towers Smiler Ride Reopens
Support Causality on Patreon
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