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.
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, tri…
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, fo…
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 o…
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…
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 unusu…
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. Wi…
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 c…
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…
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 peop…
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-secur…
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 t…
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…
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 cri…
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 a…
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 indus…
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 w…
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…
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 stan…
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 sh…
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.
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00:31:39 |
Sun 29 Apr 2018
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