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
• of-multiple-generators-and-lines-in-qld-and-associated-under-frequency-load-shedding.pdf">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.html">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:

• V5I6489.pdf">Super-Critical Boiler Technology (PDF)
• Supercritical Fluids
• Supercritical Coal Plants

Electrical Engineering References:

• Hydrogen-cooled Turbo Generator
• help.schneider-electric.com/ED/MTZ/Micrologic_X_User_Guide/EDMS/DOCA0102EN/DOCA0102xx/ProtectionFunctions/ProtectionFunctions-18.htm">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 PatreonEpisode 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:

• 117hhrg45085.htm">Hearing Before the Committee on Homeland Security House of Representatives Transcript
• 117shrg46569.pdf">Threats to Critical Infrastructure: Examining the Colonial Pipeline Cyber-Attack (PDF)
• 117-HM00-Wstate-CarmakalC-20210609.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 PatreonEpisode 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.

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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 PatreonEpisode 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
• 0071.en.pdf">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
• Angle-of-Attack-AOA-Systems.pdf">Collins AOA Systems (PDF)
• Auto-Throttle and Auto-Thrust
• autothrottle-at-normal-and-non-normal-operations.html">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
• passes-bill-to-reform-plane-certification-process-after-two-boeing-737-max-crashes.html">House passes bill to reform plane certification process after two Boeing 737 Max crashes
• of-canada-introduces-additional-requirements-to-allow-for-the-return-to-service-of-the-boeing-737-max.html">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)
• NM-035fr.pdf">Airworthiness Directive 2020-24-02 (PDF)
• FAA: Boeing 737 MAX Reading Room
• Transport Canada: Boeing 737-MAX-8

Litigation:

• fines-boeing-over-2point5-billion-charges-it-with-fraud-conspiracy-over-737-max-crashes.html">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
• slammed-in-house-report-over-737-max-failures-as-company-tries-to-return-the-plane-to-service.html">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 PatreonEpisode 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)
• durable.gouv.fr/wp-content/files_mf/A22018_ips22018_002.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:

• fireworks-incident-report-has-global-implications.aspx">Carmel fireworks incident report has global implications
• fireworks-factory-explodes-20020306-gdu0yb.html">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 PatreonEpisode 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.

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Official Report:

• pub.iaea.org/MTCD/publications/PDF/Pub815_web.pdf">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)
• 325612711062370.html">Notes on nuclear energy. What lawyers should know about nuclear technology (Spanish)
• brazil-1987.html">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…
• saude-go-gov-br.translate.goog/cesio137goiania/percepcao-dos-envolvidos?_x_tr_sl=pt&_x_tr_tl=en&_x_tr_hl=en&_x_tr_pto=sc">The Perception of Individuals Involved in the Accident With Caesium-137
• Two Radiation Victims Die
• magazine.com/july18/the-goina-incident/">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 PatreonEpisode 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.

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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
• Flange-Beam-Dimensions-Chart.aspx">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:

• online.com/News/PR2011_3rd/Jul11_KansasCityHyatt.html">The Kansas City Hyatt Disaster 30 Years Later
• Collapse Did Not Involve Safety Violations
• hotel-disaster-walkway-swayed-to-the-rhythm-of-dancers.html">Walkway Swayed To The Rhythm Of Dancers
• killed-in-Hyatt-collapse-as-tea-dance-turns-to-terror.html">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
• are-held-at-fault-in-81-hotel-disaster.html">Engineers Are Held At Fault In 1981 Hotel Disaster

Support Causality on PatreonEpisode 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.

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:

• Mindbender
• Geoffrey Kulak (Archive.org)
• Mindbender (Galaxyland)
• Triple Five Group
• Roller coaster wheel assembly
• Bogie
• m-wikipedia-org.translate.goog/wiki/Schwarzkopf_GmbH?_x_tr_sl=de&_x_tr_tl=en&_x_tr_hl=en&_x_tr_pto=sc">Schwarzkopf GmbH
• 6 Reasons Why Bolts Fail & How To Prevent It
• Testing for Amusement Rides and Theme Parks TÜV SÜD

Videos:

• Tragedy on the Mindbender (Video)
• Mindbender Accident Inquiry - Film & Video Stock (Video)

News Articles:

• Coaster Ride’s Mastermind Fired
• Roller-coaster goes at full tilt
• Mindbender 25 Years Later (Archive.org)
• Roller-coaster Derailment Kills Three
• Survivor of 1986 mall coaster crash wants memorial
• xpm-1986-06-16-mn-10861-story.html">3 Hurled to Death in Canada as Roller Coaster Derails in Mall
• Authorities today investigated a weekend triple-loop ‘Mindbender’ roller coaster
• sentinel.com/news/fl-xpm-1986-06-16-8602050101-story.html">3 Killed in RollerCoaster Crash
• [Mall Owner Blames Manufacturer’s Defect for Roller Coaster Deaths (Dead Link)](LINK DEFUNCT “Original Link: https://apnews.com/8be3b0f7291c22472aa8c00790de1358")

Rollercoaster Articles:

• 31 years ago today, the Mindbender rollercoaster at WEM crashed
• deadliest-roller-coaster-accidents.htm#pt8">10 Deadliest Roller Coaster Accidents
• List of incidents at independent amusement parks
• Amusement Ride Accidents
• The Mindbender Fantasy Roller Coaster Accident in Canada
• Worst Coaster Crash?
• Mindbender - Galaxyland - Roller Coasters
• Mindbender - Galaxyland Amusement Park
• American Dreier Looping
• coaster.net/ESmindbender-edmontonGF.htm" title="Original Link: https://www.schwarzkopf-coaster.net/ESmindbender-edmontonGF.htm">Mindbender Edmonton (Archive.org)
• coaster.net/unternehmenGF.htm" title="Original Link: https://www.schwarzkopf-coaster.net/unternehmenGF.htm">Schwarzkopf (Archive.org)
• Mindbender - Park Vault
• Anton Schwarzkopf
• academic.com/dic.nsf/enwiki/963649">Mindbender (Galaxyland)

Legislature Assembly Minutes:

• 21st Legislature First Session Minutes (PDF)

Support Causality on PatreonEpisode Gold Producers: 'r' and Steven Bridle.Episode Silver Producers: Mitch Biegler, Kevin Koch, Shane O'Neill, Lesley Law Chan, Hafthor, Jared, Bill, Joel Maher and Katharina Will.With thanks to Quinton Zaborski for the topic suggestion.

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 disaster
• The Day of the Roses
• Public Transport Commission of NSW
• t3776.htm" title="Original Link: https://www.railpage.com.au/f-t3776.htm">Granville Train Disaster (Archive.org)
• 30129611.aspx">Turnouts
• CityRail
• Australia’s worst rail disaster
• The Granville Train Disaster Association
• Revisiting the Granville Train Disaster of 1977: Barry Gobbe
• Remembering the Day of the Roses
• Wheel was covered up (Archive.org)
• 45 years since Granville Train Disaster
• Granville Train Disaster Memorial Garden
• The rail disaster that changed Australia
• Mixed response as NSW Government apologises for Australia’s worst train disaster
• Granville Railway Disaster
• Granville train disaster: victims speak out

Formal Investigation Extracts:

• Formal Investigation State Records Authority
• Report on the formal investigation
• Formal Investigation extract: Research Data
• Research Data Australia Search

Informal Investigations:

• Permanent Way Institution Granville Search
• Granville: The Untold Story
• rail-disasters-granville.html">The Granville Train Disaster
• The Granville Disaster

Video:

• Granville Train Disaster Documentary (Video)

Support Causality on PatreonEpisode Gold Producers: 'r' and Steven Bridle.Episode Silver Producers: Mitch Biegler, John Whitlow, Kevin Koch, Shane O'Neill, Oliver Steele, Lesley Law Chan, Hafthor, Jared, Bill, Joel Maher and Katharina Will.

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 Explosion
• Condensation Cloud
• Prill
• ANFO
• Ammonium Nitrate
• How an unscheduled port visit led to disaster
• Beirut Ammonium Nitrate Blast
• Government Amends Ammonium Nitrate Rules
• FBI probe shows amount of chemicals in Beirut blast was a fraction of original shipment
• Beirut Whistleblower Returns to Work
• Ideal Gas Law
• Gases, Liquids and Solids (PDF)

Reports into the incident:

• Human Rights Watch (PDF)
• architecture.org/investigation/beirut-port-explosion">The Beirut Port Explosion, Forensic Architecture

Video and Images:

• Video of Explosion 1 (Twitter)
• Video of Explosion 2 (Twitter)
• Video of Wilsons Cloud Ring (Twitter)

Documentary:

• Beirut Blast: The Story Of Warehouse 12 (2021)
• Beirut Blast: The Story of Warehouse 12 (2021) - IMDb

Ammonium Nitrate Information:

• Storage requirements for security sensitive ammonium nitrate (SSAN) | Resources Safety & Health Queensland
• Orica Mining Services, Report for Kooragang Island Uprate PHA MOD1 Report (PDF)
• Ammonium Nitrate Advisory USEPA (PDF)
• en-mtr-UGHS-000022013201.pdf">Orica ANFO MSDS (PDF)

Support Causality on PatreonEpisode Gold Producers: 'r' and Steven Bridle.Episode Silver Producers: Mitch Biegler, John Whitlow, Kevin Koch, Shane O'Neill, Oliver Steele, Lesley Law Chan, Hafthor, Jared, Bill, Joel Maher and Katharina Will.