Education Podcasts

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.

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.




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.




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: River Rapids RideThunder River Rapids RideDreamworld operator Ardent Leisure Fined $3.6M for...


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: SmallPoxHistory of SmallpoxBiosafety Level 4A Bioweapon Expert Explains Four Ways A Pathogen Can Escape From A...


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 Report (PDF) Technical Links: EpoxyTunnel Links of Potential Interest: Big Dig ceiling...


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 FatigueGIS (Geographic Information System)PupAPI 5L X42 Steel Pipe Specification in PSL1, PSL2 and Sour Service Links of Potential...


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 GiveawayCausality Episode 20: Stava Dam Investigation and Reports: Coal MiningAberfan DisasterAberfanThirty-year...


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 CometCausality Episode 14: Concorde Investigation and Reports: FAA Finds New Safety Risk in Boeing 737 MaxKNKT JT610 Final ReportNTSB ASR-19-01 Safety Recommendation ReportJATR Report:...


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 OntarioToronto OntarioWalkerton E. coli OutbreakDeath On Tap: The Poisoning Of WalkertonThe Walkerton Inquiry ReportHeavy Rainfall and Waterborne Disease Outbreaks: The Walkerton ExampleFactors That Led To The...


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-attackAnalysis of the Cyber Attack on the Ukrainian Power GridUkraine Report: When The Lights Went OutInside the Cunning, Unprecedented Hack of Ukraine’s Power...


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 HostAnger Grows Over Rio Bike Path Failure - WSJQuestions...


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 1549The Miracle On The HudsonNTSB Official Report (PDF)49 CFR 830.2 DefinitionsCFM International CFM56Chesley SullenbergerJeff SkilesWhat...


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: MaccabiahCausality Episode 15: Sampoong Department Store Links of potential interest: Hotel New World CollapseCollapse of Hotel New WorldStructural LoadReport of the...


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 AccidentSNCFSNCF Class Z 5300Gare de LyonParis Gare de...


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: BhopalCarbarylMethyl isocyanateBhopal ChronologyLABOR REPORT ON BHOPAL CITES PLANT MODIFICATIONEight convicted over India gas...


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 DrillingSemi-submersible PlatformMacondo ProspectMacondo Prospect Gulf of MexicoDeepwater Horizon MC252 Data...


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 ColumbiaSpace Shuttle Columbia DisasterSTS-107When The Space Shuttle Didn’t Come HomeColumbia Space Shuttle Disaster ExplainedList of Space Shuttle MissionsA New Vision for...


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 WatchKipton Train Wreck AnniversaryThe Great Kipton Train WreckKipton Train CrashKipton Train CollisionRailway Post Office Support Causality on Patreon Episode Silver Producers:...


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: FukushimaCausality Episode 17: Three Mile Island Technical References: Iodine-135Periodic TableList of Chemical ElementsXenon Poisoning in ReactorsNuclear...


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 HavenMilford Haven HSE Accident ReportAlarm ManagementAbnormal Situation Management Support Causality on Patreon Episode sponsor: Makers4Good: Makers4Good are an innovative company based in Palo Alto,...


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 failureWater Management Considerations for Conventional StorageConventional Impoundment Storage - The current techniquesThe Stava Mudflow of 19 July 1985LiquefactionThe Val di Stava Dam CollapseMine Tailings Safety Stava...


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 TowersThe SmilerHow Alton Towers Smiler Crash UnfoldedAlton Towers Smiler Crash Footage ReleasedAlton Towers Smiler Ride Reopens Support Causality on Patreon Episode...