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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.

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.

Location:

Australia

Description:

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.

Language:

English


Episodes

47: Hyatt Regency Kansas City

7/15/2022
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...

Duration:00:41:29

46: Mindbender

5/16/2022
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: MindbenderGeoffrey KulakMindbender (Galaxyland)Triple...

Duration:00:29:28

45: Granville

4/2/2022
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 disasterThe Day of...

Duration:00:25:51

44: Beirut Warehouse 12

2/10/2022
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 ExplosionCondensation CloudPrillANFOAmmonium NitrateHow an unscheduled port visit led to...

Duration:00:36:26

43: Triangle Shirtwaist Factory

11/9/2021
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 FireBrown BuildingShirtwaistCourt Transcript of the Criminal...

Duration:00:31:55

42: Royal Canberra Hospital

9/16/2021
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 - YouTubeRoyal...

Duration:00:21:38

41: Florida International University

7/8/2021
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...

Duration:00:43:07

40: Ocean Ranger

5/24/2021
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 RangerHydrodynamic Model Studies of the Ocean Ranger Marine DisasterThe Loss of the Ocean...

Duration:00:19:59

39: Therac-25

3/22/2021
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 Accidents‎Medical...

Duration:00:59:55

38: Thunder River Rapids

1/24/2021
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...

Duration:00:40:49

37: Variola Birmingham

11/26/2020
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...

Duration:00:41:34

36: Big Dig

9/15/2020
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...

Duration:00:31:47

35: San Bruno

7/26/2020
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...

Duration:00:49:32

34: Aberfan

5/7/2020
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...

Duration:00:16:50

33: 737 MAX

1/30/2020
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:...

Duration:00:30:48

32: Walkerton

12/6/2019
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...

Duration:00:37:52

31: Black Energy

10/3/2019
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...

Duration:00:26:13

30: Tim Maia

7/4/2019
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...

Duration:00:10:47

29: Flight 1549

6/4/2019
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...

Duration:00:11:10

28: Hotel New World

5/9/2019
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...

Duration:00:28:26