On Valentines Day in 1981 in the North of Dublin, Ireland a fire broke out in a nightclub just following a Disco Dancing competition. We look at how measures taken to prevent illegal entry and poor building material choices cost 48 young people their lives.
With John Chidgey.

Related Episodes:

• Causality Episode 43: Triangle Shirtwaist Factory

Formal Reports:

• Report of the Stardust Victims’ Compensation Tribunal (PDF)
• Report of the Tribunal of Inquiry on the fire at the Stardust

News Releases and Articles:

• Stardust: A timeline of the Tribunals, reports and inquests that led to this week’s verdict
• Stardust: Apology call after nightclub fire deaths verdict
• Stardust fire inquest of ‘paramount importance’
• A grim uncertainty that haunts Stardust families
• Stardust: Apology call after nightclub fire deaths verdict
• How Did The Stardust Fire Start?
• Stardust 30 Years On
• Stardust Verdict
• How tragedy unfolded at a Valentine’s disco
• Irish government makes official apology
• The night that started like any other
• Law Society of Ireland Gazette
• Stardust nightclub was pretty horrendous fire risk

Regulations:

• Fire Services Act, 1981, Section 37
• The Public Dance Halls Act, 1935 on JSTOR

General Information:

• Dublin Corporation
• Stardust Fire
• A History of the Fire Service in Ireland

Support Causality on Patreon

Episode Gold Producers: 'r', Steven Bridle and Kellen Frodelius-Fujimoto.
Episode Silver Producers: Mitch Biegler, Shane O'Neill, Jared Roman, Katharina Will, Chad Juehring and Ian Gallagher.

With thanks to Aileen Brennan for the topic suggestion.

On the 20th of September, 2022 at the BP Husky Toledo refinery in Ohio, a level transmitter change out from a month prior triggered a chain of events that would cost two operators their lives. We look at how poor Management of Change, high alarm rates and a resistance to stopping the job, let a plant upset turn into a disaster.
With John Chidgey.

Formal Report:

• U.S. Chemical Safety Board Issues Final Report into Fatal 2022 Fire at BP-Husky Refinery
• Fatal Naphtha Release and Fire at BP-Husky Toledo Refinery (PDF)
• CSB June 2023 Investigation Update (PDF)
• CSB Comments on the OSHA September 20, 2022, Federal Register Notice (PDF)

News Releases and Articles:

• BP Faces $156K OSHA Fine in Refinery Explosion
• BP accused of serious violations after fatal blast at US refinery

General Information:

• Naphtha
• What You Need to Know About California’s PSM Regulation for Refinery Safety
• OSHA Penalties

Support Causality on Patreon

Episode Gold Producers: 'r', Steven Bridle and Kellen Frodelius-Fujimoto.
Episode Silver Producers: Mitch Biegler, Shane O'Neill, Jared Roman, Katharina Will, Chad Juehring and Ian Gallagher.

On Friday the 19th of July, 2024 millions of CrowdStrike Falcon Agents the world over would lead to a Windows system crash on business machines throwing parts of the world into chaos. We look into exactly what caused it and how complacency and a lack of understanding amplified the effect of this wholly preventable incident.
With John Chidgey.

About Causality (TV):

• Introducing Causality TV
• Causality TV Episode 1: CrowdStrike (Video Release)

Formal Report:

• Falcon Content Update Preliminary Post Incident Report
• Channel File 291 Incident Root Cause Analysis (PDF)

News Releases and Articles:

• CrowdStrike releases root cause analysis of the global Microsoft breakdown
• CrowdStrike Senior Executive Adam Meyers faces CyberSecurity Committee
• CrowdStrike exec apologises before US Congress for software glitch behind July global outage | Reuters
• 1 In 10 Orgs Dumping Their Security Vendors After CrowdStrike Outage

General Information:

• CrowdStrike
• 2024 CrowdStrike incident
• What is CrowdStrike?
• Falcon Content Update Remediation and Guidance Hub
• Antivirus XML Configuration File for CrowdStrike Falcon Sensor
• Named Pipes
• Pipes (Interprocess Communications)
• Wildcard character

Support Causality on Patreon

Episode Gold Producers: 'r', Steven Bridle and Kellen Frodelius-Fujimoto.
Episode Silver Producers: Mitch Biegler, Shane O'Neill, Jared Roman, Katharina Will, Chad Juehring and Ian Gallagher.

In 2017 during an Odoriser decontamination procedure in West Virginia, two people were killed when it unexpectedly exploded. Barely a month later, a similar procedure at the same site led to a second explosion, killing someone else. We examine how poor hazard analysis and legal interference led to yet another fatality...right in front of the eyes of the investigators on site.
With John Chidgey.

Formal Report:

• Midland Resource Recovery Explosion
• Midland Resource Recovery Factual Update (PDF)
• Improving Reaction Hazard Management (PDF)

News Releases and Articles:

• Chemical Tank Explosion in Barbour County Kills Two Employees Plus One Severely Injured
• One Dead After Another Explosion at Midland Resource Recovery
• Midland Resources Recovery Explosion Kills 2, Injures 1
• McDonald Volunteer Fire Chief Laid To Rest After W.Va. Explosion
• Widow Blames Natural Gas Odorization Company for Husband’s Death
• CSB releases final report on explosions at Midland Resource Recovery Facility
• Midland Resource Recovery Explosion 2017
• Second Fatal Explosion at Midland Resources Recovery

General Information:

• About Midland Resource Recovery
• The Growing Importance of Mercaptans
• Sodium Hypochlorite (PDF)
• Principles of Natural Gas Odorization (PDF)
• Attorney-Work Product Privilege

Support Causality on Patreon

Episode Gold Producers: 'r', Steven Bridle and Kellen Frodelius-Fujimoto.
Episode Silver Producers: Mitch Biegler, Shane O'Neill, Lesley, Jared Roman, Katharina Will, Chad Juehring and Ian Gallagher.

In 2021 the Callide C Power Station experienced a unit failure that tore the turbine-generator apart, resulted in hundreds of thousands of premises losing power, and cost hundreds of millions to repair. We look at how design errors and ultimately a lack of information led to the incident escalating out of control, when it could have been recovered.
With John Chidgey.

Formal Reports:

• Callide Unit C4 Turbine Generator Failure 25 May 2021 (PDF)
• Animation of the Callide Unit C4 incident
• Trip of multiple generators and lines in Central Queensland and associated under-frequency load shedding on 25 May 2021 (PDF)

News Releases and Articles:

• CS Energy releases report into 2021 Callide C4 Unit Failure
• CS Energy releases technical report into 2021 Unit C4 incident
• Dr Sean Brady to lead independent investigation into Callide incident
• Battery failure led to power plant mass outage
• Both units trip at Callide C on Wednesday 13th January 2021
• Statement regarding IG Power
• Intergen voluntary administration
• Report says Callide C4 incident “could not have been anticipated”
• Callide explosion blamed on battery charger failure
• Callide Power Trading taken to court over system failure
• CS Energy says insurers won’t agree to $300m claim over power station
• Jim Soorley stands down from CS Energy
• CS Energy Post about Incident on LinkedIn

Super-Critical Boilers:

• Super-Critical Boiler Technology (PDF)
• Supercritical Fluids
• Supercritical Coal Plants

Electrical Engineering References:

• Hydrogen-cooled Turbo Generator
• Reverse Active Power Protection (ANSI 32P)

Court Action:

• Alleged failure to obtain regulatory approval to operate a generating system
• Notice of Filing: Australian Energy Regulator v Callide Power Trading Pty Ltd (PDF)
• Coal generator to face court over blackouts caused by catastrophic explosion

General Information:

• Callide Power Station
• Stanwell Power Station
• Tarong Power Station
• Callide Power Station
• CS Energy: Water Management

NOTE: Minor Corrections in audio updated: 31st March, 2024

Support Causality on Patreon

Episode Gold Producers: 'r' and Steven Bridle.
Episode Silver Producers: Mitch Biegler, Shane O'Neill, Lesley, Jared Roman, Joel Maher, Katharina Will, Chad Juehring, Kellen Frodelius-Fujimoto and Ian Gallagher.

In 2021 many of Colonial Pipelines IT systems were locked by malware and out of caution they shutdown the fuel pipelines feeding nearly half of the Eastern US leading to chaos at the gas pump and a state of emergency being declared. We look at how poor off-boarding hygiene led to an easily preventable cyber-attack.
With John Chidgey.

Hearing:

• Hearing Before the Committee on Homeland Security House of Representatives Transcript
• Threats to Critical Infrastructure: Examining the Colonial Pipeline Cyber-Attack (PDF)
• Charles Carmakal Statement from Hearing (PDF)

General Information:

• Colonial Pipeline
• Colonial Pipeline Ransomware Attack
• How Three Major Cyber Attacks Could Have Been Prevented
• What IT security teams can learn from the Colonial Pipeline
• Evolution of the Chief Information Security Officer
• US Fuel Pipeline Hackers Statement
• DarkSide
• DarkSide Leaks Press Center (X)
• DarkSide Ransomware Gang Behind Pipeline Hack Quits
• TSA Renews Cyber-Security Guidelines for Pipelines
• DHS Announces New Cybersecurity Requirements for Critical Pipeline Owners and Operators
• Federal Motor Carrier Safety Administration
• Emergency Declaration for 17 States

Support Causality on Patreon

Episode Gold Producers: 'r' and Steven Bridle.
Episode Silver Producers: Mitch Biegler, Shane O'Neill, Lesley, Jared Roman, Joel Maher, Katharina Will, Chad Juehring, Dave Jones, Kellen Frodelius-Fujimoto and Ian Gallagher.

The I35W bridge over the Mississippi River carried 140,000 cars every day. Inspections in 1999 and 2003 showed damage to support plates that was dismissed as unimportant at the time. We look into how poor design checking and assumptions led to the bridge collapsing in 2007, costing the lives of 13 people.
With John Chidgey.

This show is Podcasting 2.0 Enhanced

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Reports:

• Collapse of I-35W Highway Bridge Minneapolis, Minnesota August 1, 2007 (PDF)

General Information:

• I-35W Mississippi River bridge
• URS Corporation
• Sverdrup & Parcel
• Gusset Plate

Articles:

• Design errors factor in 2007 bridge collapse
• NTSB releases final report
• Despite final NTSB report, some still have questions

Videos:

• Inside a Catastrophic Minneapolis Bridge Collapse (YouTube)

Litigation:

• NTSB is wrong about cause of bridge collapse
• Last Minneapolis Bridge Collapse Lawsuit Settled For $52.4 Million

Support Causality on Patreon

Episode Gold Producers: 'r' and Steven Bridle.
Episode Silver Producers: Mitch Biegler, Shane O'Neill, Lesley, Jared Roman, Joel Maher, Katharina Will, Chad Juehring, Dave Jones and Kellen Frodelius-Fujimoto.

With thanks to Joe Stariha for the topic suggestion.

Five months after Lion Air 610 crashed, another 737-MAX went down with a similar cause. However the official report was at odds with two other internationally respected investigative organisations. We dig into the detail of how the AOA Sensor was claimed to have failed, and review checklist discrepancies to extract fact from opinion as to what most likely triggered this horrible chain of events.
With John Chidgey.

This show is Podcasting 2.0 Enhanced

Celebrating Causality’s 50th Episode!!

Previous Episode:

• Causality Episode 33: 737 MAX

Reports:

• EAIB: Aircraft Accident Investigation Report B737- MAX 8, ET-AVJ December 2022 (PDF)
• US Comments: ET302 Report March 2022 (PDF)
• US Comments: Response to EAIB Final Report (PDF)
• BEA: Accident du Boeing 737 immatriculé ET-AVJ et exploité par Ethiopian Airlines survenu le 10/03/2019 près de Bishoftu
• BEA: Incidents to the Boeing 737 - 800 registered F-GZHO operated by Transavia France on 07/02/2018 at Norwich (United Kingdom) and 08/02/2018 at Paris-Orly
• BEA: Incidents to the Boeing 737 - 800 registered F-GZHO operated by Transavia France (PDF)
• ICAO Annex 13: Aircraft Accident and Incident Investigation (PDF)

General Information:

• Ethiopian Airlines Flight 302
• Addis Ababa Bole International Airport
• Jomo Kenyatta International Airport
• Rotation (Aeronautics)
• Ground Proximity Warning System
• Boeing 737 MAX Groundings
• Federal Aviation Administration
• Impact of the COVID-19 Pandemic on Aviation
• Financial Impact of the Boeing 737 MAX Groundings
• ICAO
• N1 and N2
• March 10, 2019 Historical Weather at Addis Ababa Bole International Airport, Ethiopia
• ET-AVJ Flight Tracking and History
• Collins AOA Systems (PDF)
• Auto-Throttle and Auto-Thrust
• B737 Autothrottle (A/T) Normal and Non-Normal Operations
• Airworthiness Directives

Articles:

• The BEA Weighs In: Ethiopian Airlines Flight 302
• Controversy Surrounds Final Report on Ethiopian Air Flight 302
• More Omissions In Ethiopian 737 MAX Report
• US NTSB Criticises Ethiopian MAX Report
• House passes bill to reform plane certification process after two Boeing 737 Max crashes
• Government of Canada introduces additional requirements to allow for the return to service of the Boeing 737 MAX  - Canada.ca
• EASA Decision Not to Adopt FAA AD 2020-24-02 (PDF)

Regulations:

• Aircraft Certification Reform and Accountability Act
• FAA Proposes New Policy that Would Fulfill One of the Key Requirements of the Aircraft Certification, Safety, and Accountability Act | Federal Aviation Administration
• Post MCAS Law Changes
• Boeing 737 Airworthiness Directives
• Airworthiness Directive 2018-23-51 (PDF)
• Airworthiness Directive 2020-24-02 (PDF)
• FAA: Boeing 737 MAX Reading Room
• Transport Canada: Boeing 737-MAX-8

Litigation:

• Boeing to pay more than $2.5 billion to settle criminal conspiracy charge over 737 Max
• Boeing Charged with 737 Max Fraud Conspiracy and Agrees to Pay over $2.5 Billion
• Boeing Directors Settle Shareholder Lawsuit Over 737 MAX Crashes For $237.5 Million
• Boeing: Directors to face investor lawsuit over fatal crashes
• Boeing, FAA slammed in House report over deadly 737 Max failures
• Boeing agrees deal with families of Ethiopia crash victims
• Boeing to compensate victims in Ethiopian Airlines 737 MAX crash

Support Causality on Patreon

Episode Gold Producers: 'r' and Steven Bridle.
Episode Silver Producers: Mitch Biegler, Shane O'Neill, Lesley, Jared Roman, Joel Maher, Katharina Will, Chad Juehring, Dave Jones and Kellen Frodelius-Fujimoto.

A fireworks company in Western Australia that had been in business for nearly a century, were preparing for a fireworks display in their packing shed when one ignited and set off a fire and an explosion. Onlookers were shocked when there was a subsequent explosion that was so big it was heard 30 kilometers away leaving the facility in ruins.
With John Chidgey.

This show is Podcasting 2.0 Enhanced

Celebrating Causality’s 50th Episode!!

Reports:

• Report of the investigation into the fireworks accident at Carmel, Western Australia (PDF)
• Fire and Explosions at a Fireworks Storage Depot (PDF)

Links of Interest:

• Department of Mines, Industry Regulation and Safety
• Explosives Magazine Storage and Use
• Net Explosive Quantity
• Class 1 Dangerous Goods Explosive Substances and Articles
• Cardile Fireworks

News Articles:

• Carmel fireworks incident report has global implications
• Perth fireworks factory explodes
• A Fireworks Factory Exploded In Perth’s Hills (VIDEO)

About Pyrotechnics:

• The Illustrated Dictionary of Pyrotechnics (PDF)
• List of Pyro Chemicals and Terms
• Display Fireworks Glossary
• Pyrostar Glossary
• Fireworks Stars and Shells Garnitures
• All you wanted to know about fireworks fuses

Support Causality on Patreon

Episode Gold Producers: 'r' and Steven Bridle.
Episode Silver Producers: Mitch Biegler, Kevin Koch, Shane O'Neill, Lesley, Jared, Joel Maher, Katharina Will, Dave Jones and Kellen Frodelius-Fujimoto.

With thanks to Heather Shaw for the topic suggestion.

When a radiation therapy machine was left behind during a move between buildings in central Brazil, it set in motion a series of events that would lead to one of the worst radiological incidents in history. We look into how bureaucracy and misdiagnosis cost four people their lives and how the actions of a concerned mother with no medical experience, saved the lives of countless more.
With John Chidgey.

This show is Podcasting 2.0 Enhanced

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Official Report:

• The Radiological Accident in Goiânia (PDF)

Links of Interest:

• Goiânia Accident
• IGR - Instituto Goiano de Radiologia
• Teletherapy Capsule
• Becquerel
• The Goiânia Incident
• Caesium
• Gray

Other Reports and Articles:

• The most rambling and insane nuclear accident in history (Italian)
• Doctors and the radioactive accident (Portugese)
• Notes on nuclear energy. What lawyers should know about nuclear technology (Spanish)
• Goiânia Brazil 1987 - Rick On Theater
• Caesium Radiation Goiania Brazil - 1102
• The blue powder entranced…then it killed…
• The Response to Technological Accidents: The Case of Radioactive Accident in Goiania (PDF) (Portugese)

News Articles:

• Victims of Radiation Ostracised in Brazil
• A Brazilian burglar stole a capsule…
• The Perception of Individuals Involved in the Accident With Caesium-137
• Two Radiation Victims Die
• The Goiâna Incident - NCT Magazine

Related Incidents:

• List of orphan source incidents
• Samut Prakan radiation accident
• Origin of Cobalt-60 traced to Delhi University
• 1962 Mexico City radiation accident

Support Causality on Patreon

Episode Gold Producers: 'r' and Steven Bridle.
Episode Silver Producers: Mitch Biegler, Kevin Koch, Shane O'Neill, Lesley, Jared, Joel Maher, Katharina Will, Dave Jones and Kellen Frodelius-Fujimoto.

With thanks to Shane O'Neill for the topic suggestion.

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 Credited Soundbite

Links of Interest:

• Tea dance
• Fast-track construction
• Sheraton Kansas City Hotel at Crown Center
• Hyatt Regency Walkway Collapse
• Strength Requirements by Grades
• All Thread Rod
• Wide Flange Beam Dimensions Chart
• Obituary for Jack D. Gillum
• Hotel Horror from Kansas City History
• The Engineer of Record and Design Responsibility

Engineering Analysis:

• Investigation of the Kansas City Hyatt Regency Walkways Collapse (Link to PDF)
• Understanding the Tragic Hyatt Regency Walkway Collapse
• Hyatt Regency Walkway Collapse 1981
• Hyatt Regency Walkway Collapse
• The Hyatt Regency Disaster Revisited
• Hyatt Regency Walkway Collapse
• Ethics in Engineering Practice and Research by Caroline Whitbeck
• Chronology And Context Of The Hyatt Regency Collapse by Gregory P. Luth (PDF)

News Articles:

• The Kansas City Hyatt Disaster 30 Years Later
• Collapse Did Not Involve Safety Violations
• Walkway Swayed To The Rhythm Of Dancers
• 18th July 1981 Hyatt collapse
• Hyatt Regency Skywalk Collapse Memorial Dedicated In 2015
• 1981 Hyatt Regency Walkway Collapse
• Hyatt Regency Collapse Remains Among The Deadliest In USA History
• Engineers Are Held At Fault In 1981 Hotel Disaster

Support Causality on Patreon

Episode Gold Producers: 'r' and Steven Bridle.
Episode Silver Producers: Mitch Biegler, Kevin Koch, Shane O'Neill, Lesley, Hafthor, Jared, Bill, Joel Maher, Katharina Will and Dave Jones.