56: BP Husky Toledo

In 1983 a newly introduced 767 ran out of fuel mid-flight and the pilots were able to land completely dead-stick. Whilst 0.8kg/L and 1.77lbs/L represent the same density, when the wrong one was used in a refuelling calculation they came up well short. Why they were forced to manually calculate their fuel at all, was not nearly as controversial as the pilots decision to fly. We look at what went wrong and what went right in the incident of the Gimli Glider.With John Chidgey.Investigation Report: Final Report of the Board on Inquiry (PDF) Commentary Articles: The Gimli Glider by Damn Interesting The Gimli Glider by AOPA AC143 Airplane Crash General Information: Gimli Glider Jet Fuel Boeing 767 Forward vs Side Slips Civil aircraft fleet. Data by Country Metric vs Imperial Support Causality on PatreonEpisode Gold Producers: 'r', Steven Bridle, Kellen Frodelius-Fujimoto and Steve Branam.Episode Silver Producers: Mitch Biegler, Shane O'Neill, Jared Roman, Katharina Will, Chad Juehring, Ian Gallagher and Jamie Russell.

Spurred on to build the tallest and fastest Waterslide in the world by a Travel Channel show about Waterparks, the owners of the Kansas City Schlitterbahn Waterpark designed and built the Verrückt Waterslide in record time. A net enclosed the ride and on its third Summer Season a 10 Year Old boy died on impact with that netting mid-ride. We look at how design decisions, subsequent modifications and assumptions made this incident inevitable...but also how it could have easily been prevented.With John Chidgey.News Articles: Water slide that decapitated 10-year-old boy Kansas water slide death: 10yo son of Scott Schwab killed Women with boy in ill-fated waterslide raft speak out Trial of Schlitterbahn maintenance workers opens | Kansas City Star World’s tallest waterslide Court Grants Permission To Destroy World’s Tallest Waterslide Designer of Schlitterbahn slide that decapitated boy arrested at DFW Kansas lawmakers approve amusement ride law following child’s death Kansas water slides remain closed after new law Verrückt water slide timeline of events Charges laid over tragic death of Caleb Schwab on world’s tallest waterslide Commentary Articles: Verruckt Waterslide Death Result Of Poor Weight Distribution? The making of Schlitterbahn’s Verruckt water slide: Too much, too fast? Schlitterbahn’s Tragic Slide (ORIGINAL) Schlitterbahn’s Tragic Slide (ARCHIVED) Legal Articles: Sisters Represented by SJB Reach Verruckt Settlement $20M Settlement Reached In Verrückt Water Slide Tragedy - Legal Reader Murder charges dismissed over decapitation of Caleb Schwab on ‘world’s tallest waterslide’ - ABC News ‘Good old boys’ acquitted over 10-year-old boy’s death on ‘world’s tallest’ waterslide - ABC News Videos of the Ride: World’s Tallest Water Slide Now Open to Public Verrückt Water Slide at Schlitterbahn Kansas City ASTM: ASTM International ASTM International Safety Standards for Amusement Rides & Devices published by Committee F24 F2291 (2006 Edition) (PDF) General Information: Schlitterbahn Kansas City Schlitterbahn ProSlide - Hydro Magnetic Support Causality on PatreonEpisode Gold Producers: 'r', Steven Bridle, Kellen Frodelius-Fujimoto and Steve Branam.Episode Silver Producers: Mitch Biegler, Shane O'Neill, Jared Roman, Katharina Will, Chad Juehring, Ian Gallagher and Jamie Russell.With thanks to Rosie Symes for the topic suggestion.

With demand for Asbestos in building products in the 1940s, a discovery in Western Australia's remote Pilbara region of Blue Asbestos led to the creation of a mining town called Wittenoom. Despite the growing list of illnesses and deaths of workers from the mine and milling operation, the company pressed on until it closed for 'financial' reasons. We look at the dangers of dust inhalation and try to determine if we have collectively learned anything from the disaster at Wittenoom.With John Chidgey.News Articles: Memories of Wittenoom Exposure to Asbestos Takes Its Toll CSR Still Fighting Closure of Wittenoom Wittenoom Riddled with Asbestos About Asbestos: Asbestos The Colours of Asbestos What Is Asbestos and Where Does it Come From? About Engineered Stone: Engineered Stone Fact Sheet Engineered Stone Ban General Information: Closure of Wittenoom Asbestos fiber length as related to potential pathogenicity Consequences of Wittenoom Silicosis and Black Lung Cases Rising Wittenoom Australian Blue Asbestos Selling the Wittenoom Dream Wittenoom Health Disaster Lang Hancock Support Causality on PatreonEpisode Gold Producers: 'r', Steven Bridle, Kellen Frodelius-Fujimoto and Steve Branam.Episode Silver Producers: Mitch Biegler, Shane O'Neill, Jared Roman, Katharina Will, Chad Juehring, Ian Gallagher and Jamie Russell.With thanks to Christian French for the topic suggestion.

A young company pushing to re-invent deep sea exploration with an initial focus on opening up tourism to the wreck of the Titanic, OceanGate garnered the fascination of many around the world. With a different approach to their hull design they forged ahead despite many warnings from experts in the field, concerned about their design decisions and materials choices. When the submersible imploded killing all five aboard including the company CEO, the experts were only surprised about how OceanGate had got as far as they had...before it all went horribly wrong.With John Chidgey.Formal Reports: NTSB Final Report (PDF) US Coast Guard Marine Board of Investigation Final Report (PDF) General Information: OceanGate Titan Submersible Implosion Antipodes Oceangate Cyclops 1 (PDF) OceanGate founder looks beyond Titanic to new deep-sea frontiers The Titan Tragedy: A Deep Dive Into Carbon Fiber Support Causality on PatreonEpisode Gold Producers: 'r', Steven Bridle, Kellen Frodelius-Fujimoto and Steve Branam.Episode Silver Producers: Mitch Biegler, Shane O'Neill, Jared Roman, Katharina Will, Chad Juehring, Ian Gallagher and Jamie Russell.

Planned for nearly a century, when the time came to build a permanent link across the Lower Yarra River, a relatively new style of bridge, the box-girder, was chosen. Using new computer technology assisting the engineers to design a bridge that was too complex to calculate by hand, and using a unique lifting strategy promised time and cost savings. Ultimately though when the pieces didn't fit together in the air, their attempts to make them fit, didn't work. We dive into what went wrong on Australia's largest ever industrial disaster.With John Chidgey.Formal Report: Victorian Royal Commission Report (PDF) Milford Haven Incident: Cleddau Bridge disaster General Information: Kentledge West Gate Tunnel Slide rule Box girder bridge Cleddau Bridge Widening the West Gate Freeway Melbourne October 15 Weather The West Gate Bridge Memorial Robbo Bennett’s Tribute How the West Gate Bridge collapse changed Melbourne 1970 West Gate Bridge Disaster West Gate Bridge Image Gallery The West Gate Bridge Collapse West Gate Bridge Under Construction, 1969 Support Causality on PatreonEpisode Gold Producers: 'r', Steven Bridle, Kellen Frodelius-Fujimoto and Steve Branam.Episode Silver Producers: Mitch Biegler, Shane O'Neill, Jared Roman, Katharina Will, Chad Juehring, Ian Gallagher and Jamie Russell.

A leaking flexible pipe started a fire in the Engine Room aboard the Carnival Triumph during its return journey from Mexico in early 2013. The fire caused minor damage in one, very important section of the Engine Room leading to a total loss of Mains Power. With only intermittent Emergency Power and over 4,000 people on board the ship drifted with the currents before it was tugged finally to safety. The Netflix Documentary 'Poop Cruise' looked at the human consequences...we dive into the engineering design that was inherently flawed from Day One.With John Chidgey.Formal Report: BMA Investigation Report (PDF) News Releases and Articles: Carnival Cruises issues statement Carnival Triumph set sail with problems Stricken cruise ship docks How Poop Cruise Crisis Reshaped Cruising General Information: Trainwreck Poop Cruise (Netflix) Failure Domain Cruise Lines International Association Understanding Cruise Passenger Rights Support Causality on PatreonEpisode Gold Producers: 'r', Steven Bridle, Kellen Frodelius-Fujimoto and Steve Branam.Episode Silver Producers: Mitch Biegler, Shane O'Neill, Jared Roman, Katharina Will, Chad Juehring, Ian Gallagher and Jamie Russell.

After an extended outage of the Methomyl Unit at the Bayer facility in Institute, West Virginia, the decision was made to commence a restart of the Unit even though the DCS upgrade was still incomplete and the newly replaced Residue Treater hadn't been fully recommissioned. An incident whose root cause was years in the making would ultimately cost two people their lives.With John Chidgey.Related Episodes: Causality Episode 26: Bhopal Formal Reports: Bayer CropScience Pesticide Waste Tank Explosion CSB Final Report (PDF) CSB Final Report News Release CSB Hearing Testimony (PDF) Public Meeting Transcript News Releases and Articles: Lawsuit links student’s death to ‘08 Bayer explosion Bayer Settles 2008 Fatal Plant Explosion Lawsuit Bayer cited, fined in fatal explosion at plant in August General Information: Bayer Insecticide Ovicide Organising for Safety: How Structure Creates Culture Support Causality on PatreonEpisode Gold Producers: 'r', Steven Bridle and Kellen Frodelius-Fujimoto.Episode Silver Producers: Mitch Biegler, Shane O'Neill, Jared Roman, Katharina Will, Chad Juehring, Ian Gallagher and Jamie Russell.

In the early hours of the evening on the 17th of April, 2013 in the small city of West, Texas...smoke was seen emanating from the West Fertilizer Company building. In 20 minutes there was a massive explosion that levelled the facility and its surroundings, killing 15 people and injuring hundreds more. How this came to be, represented a failure of regulations, planning and grandfathering on every level.With John Chidgey.Related Episodes: Causality Episode 44: Warehouse 12 Formal Reports: Preliminary Findings Chemical Safety Board (PDF) Final Chemical Safety Board Report (PDF) West Fertilizer Explosion and Fire CSB releases final report on West, TX blast News Releases and Articles: Fire that led to Texas fertilizer-plant explosion was deliberately set West Texas Plant Explosion Regulations: Code of Practice: Safe storage of Solid Ammonium Nitrate (PDF) General Information: West Fertilizer Company Explosion West, Texas Polyolefin Asphalt Shingle Ammonium nitrate | H3N.HNO3 | CID 22985 - PubChem This Month in Fire History: April 2024 City of West to Receive $10.4 Million in Lawsuit Settlement Support Causality on PatreonEpisode Gold Producers: 'r', Steven Bridle and Kellen Frodelius-Fujimoto.Episode Silver Producers: Mitch Biegler, Shane O'Neill, Jared Roman, Katharina Will, Chad Juehring, Ian Gallagher and Jamie Russell.

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 PatreonEpisode 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 PatreonEpisode 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.