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    Education

    Causality

    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.

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    • Spotify

    Latest Episodes:
    35: San Bruno Jul 27, 2020
    Show notes

    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)
    • Pup
    • API 5L X42 Steel Pipe Specification in PSL1, PSL2 and Sour Service

    Links of Potential Interest:

    • Pacific Gas and Electric Company
    • San Bruno Pipeline Explosion
    • Memorial for Anniversary of San Bruno Explosion
    • San Bruno Pipeline Explosion
    • Death Toll In San Bruno Climbs To 8
    • Five Years After Deadly San Bruno Explosion
    • PG&E Gets Maximum Sentence For San Bruno Crimes
    • Crestmoor Neighborhood
    • PG&E emerges from bankruptcy
    • PG&E Completes Natural Gas Pipeline Safety Report
    • PG&E Falsified Gas Pipeline Safety Records

    Legal Links:

    • Right Of Way
    • A Legal Introduction to Easements
    • California Law Study into Soverign Immunity (PDF)
    • Cost Allocation in Public Utility Relocation in California

    Support Causality on Patreon
    Episode Gold Producer: 'r'.
    Episode Silver Producers: Mitch Biegler, John Whitlow, Joseph Antonio, Kevin Koch, Oliver Steele and Shane O'Neill.
    With thanks to John for the topic suggestion.

    34: Aberfan May 08, 2020
    Show notes

    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 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

    Support Causality on Patreon
    Episode Gold Producer: 'r'.
    Episode Silver Producers: Mitch Biegler, John Whitlow, Joseph Antonio, Kevin Koch and Oliver Steele.

    33: 737 MAX Jan 31, 2020
    Show notes

    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 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 Gold Producer: 'r'.
    Episode Silver Producers: John Whitlow, Joseph Antonio, Kevin Koch and Shane O'Neill.

    32: Walkerton Dec 07, 2019
    Show notes

    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 Cache)
    • 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 Gold Producer: 'r'.
    Episode Silver Producers: Carsten Hansen, John Whitlow, Joseph Antonio and Kevin Koch.
    With thanks to Jon Paul for the topic suggestion.

    31: Black Energy Oct 04, 2019
    Show notes

    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]
    • 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 Gold Producer: 'r'.
    Episode Silver Producers: Carsten Hansen, John Whitlow, Joseph Antonio and Kevin Koch.

    30: Tim Maia Jul 05, 2019
    Show notes

    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

    Support Causality on Patreon
    Episode Gold Producer: 'r'.
    Episode Silver Producers: Carsten Hansen, John Whitlow and Joseph Antonio.

    29: Flight 1549 Jun 05, 2019
    Show notes

    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 Gold Producer: 'r'.
    Episode Silver Producers: Carsten Hansen, John Whitlow and Joseph Antonio.

    28: Hotel New World May 10, 2019
    Show notes

    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 Gold Producer: 'r'.
    Episode Silver Producers: Carsten Hansen, John Whitlow and Joseph Antonio.

    27: Gare De Lyon Apr 05, 2019
    Show notes

    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 Gold Producer: 'r'.
    Episode Silver Producers: Carsten Hansen and John Whitlow.

    26: Bhopal Feb 08, 2019
    Show notes

    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 Gold Producer: 'r'.
    Episode Silver Producers: Carsten Hansen and John Whitlow.

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