Disaster Autopsy (2024) s01e06 Episode Script
Sugar Factory, Lac Megantic Train, Suez Canal
1
[Narrator] In a high
rise building.
- There was no warning.
- At sea.
- Innocent people died.
- In a train.
- Everything was on fire.
Everything was burning.
[explosion]
- Disasters can begin
with the smallest things.
- Changing the opening
hours of a restaurant.
- The bad glue job.
- A paperwork error.
- Now, combining
the latest research
with every available
source of evidence,
experts will forensically
analyze three disasters
down to each tiny detail.
- You've really got to
think outside the box.
- You have to work
your way back
and understand each
link in the chain.
- State-of-the-art
graphics reveal
every critical detail at
every critical moment.
- This whole disaster
could have been averted.
- We can dissect
them, get inside,
or underneath,
freeze time,
and even reverse it.
To conduct a complete
disaster autopsy.
Canada, Lac-Mégantic.
A small town in rural
Quebec province.
- The population is only
about 6,000 people.
It's one of those
places where everyone
knows everybody else.
- July 6th, 2013.
- It is 1.15 in
the morning,
and it is a beautiful
summer's night.
There are still a
lot of people out
enjoying the nightlife.
[explosion]
[sirens wailing]
- A train carrying
crude oil derails.
The town is engulfed
by a series of
massive fireballs.
- Everything was on fire.
Everything was burning.
[Narrator] The fire rages
for a day and a half.
47 people are killed.
How could this happen?
Using all the
available evidence
and cutting edge
digital technology,
we will recreate the
events as they happened.
What causes the disaster
at Lac-Mégantic?
[train crashes]
♪
We know it begins with a
freight train derailment.
- This train is
so gigantic.
It's nearly a mile long.
It has to be hauled
by five locomotives.
and behind that
are 72 tanker cars
loaded with one
and a half million
gallons of crude oil.
The gigantic train is
heading to a refinery
in St. John, New
Brunswick, using
a track that runs right
through Lac-Mégantic.
-The rail track
in Lac-Mégantic
has a very tight curve.
It's flat as
opposed to banked,
and you have to slow
down quite a bit
to go through it.
The rail records suggest
that the speed limit
is about 10
miles per hour.
- A crucial piece
of evidence that
survives the inferno
is the locomotive
event recorder.
- This is the equivalent
of an aircraft black box.
It records all kinds
of data from speed,
time, distance,
throttle position.
- It holds critical
data about the
speed of the train at
the time of the disaster.
- The train was traveling
at 65 miles per hour,
six times the
speed limit.
- This excessive
speed causes 63
of the tank cars to
overturn on the bend
around Lac-Mégantic.
- In the end, it
all comes down to
just too much speed.
The train was
going way too fast
when it hit this
section of the tracks.
- The derailed tank
cars spill over
a million gallons of oil.
- The massive quantity
of burning oil
engulfs much of
the downtown.
The Muse Cafe, which
is full of patrons,
is completely destroyed.
Almost everyone
inside is killed.
- Why is the train
going so fast?
Why does no one stop it?
- There is a
very good reason
why this train was moving
at such a great speed.
It's quite simply
because no one was
driving the train.
♪
- How does the mile-long
train become a runaway?
We can use the
available evidence
to dissect the timeline
of this disaster.
At about 10.50 p.m.,
two hours and 20 minutes
before the accident, we
know the train arrives
at a town called Nantes,
a little over seven miles
west of Lac-Mégantic.
- This entire almost
mile-long train
has one crew member,
a locomotive engineer
called Thomas Harding.
- The plan is to leave
the train unattended
at Nantes overnight.
- And then the next
day, another engineer
would come along and
take the train on
its onward journey.
- The safest option
is to leave the train
on the siding at
Nantes, adjacent to
the main line.
- The siding is
specifically equipped
with a derail, a
device that is
designed to prevent
runaway trains
by derailing them
when they run over
it at low speeds.
[train riding over
tracks]
- But according to
Harding's testimony,
when he reaches Nantes,
the siding is in use.
So the agreed plan is
to leave the train
on the main tracks,
pointing straight down
towards Lac-Mégantic.
- The train is parked on
a descending gradient.
- Unlike the sidings,
the main track has
no derail system.
So the only thing
preventing a runaway
is the train's
braking system.
And there is evidence
that the train engineer
does check them.
- From official phone
records between Harding
and the rail traffic
control officer,
he's perfectly happy
with the braking system.
- He leaves the train,
goes to his hotel,
and everything
seems fine.
[Narrator] The train's
data recorder shows
that almost two hours
after this call,
the unoccupied
train begins to
roll down the track
towards Lac-Mégantic.
But according to the
audio recordings,
the brakes are on.
So how can that happen?
Each of the five
locomotives is equipped
with two different
braking systems.
The first uses
compressed air to
push the brake shoes
against the train wheels.
- That compressed
air is generated by
the engine running, and
essentially they're
used as parking brakes.
- There's also a separate
mechanical handbrake
in every locomotive
and rail car.
These have to be
applied individually.
In audio evidence from
the call between Harding
and the rail controller,
Richard Labrie,
they discuss
the handbrakes.
[Narrator] But according
to paperwork from the
rail company, MMA, seven
brakes is not enough.
- Harding has set the
handbrakes in seven cars,
but MMA guidelines
say that the minimum
brakes needed is
10% plus two, which
would be a total of
nine for this train.
[Narrator] These
regulations also require
that the air brakes
are released
to test that the
mechanical brakes alone
can hold the train.
- The handbrakes were
never tested on their own
because according to
Harding's testimony,
he never released
the air brakes
when he was testing
the mechanical brakes.
- But Harding's
testimony is also clear
that the combination of
handbrakes and air brakes
he applies does hold
the train securely.
- Around 11:30 p.m.,
Harding then leaves
for his hotel.
The engine is
running to keep
the air pressure
brake system going.
All seems well.
- Data from the
locomotive event recorder
shows that when
Harding leaves,
the pressure in
the braking system
is around 95 PSI,
enough to fully
apply the air brakes.
- But then
from about midnight,
it starts to drop by
one PSI a minute.
- The pressure
continues to fall
for the next hour.
- By 58 minutes
after midnight,
the pressure in the
brakes has dropped
to just 27 PSI and
it's no longer
enough to hold the
train stationary.
- But Harding leaves
the engine running
to maintain air
pressure in the brakes.
So why does the
pressure drop?
- The key question is,
what happens between
11:30 when Harding
leaves to around 1 a.m.
when the train
starts to roll?
- There is a piece
of critical evidence
for this time period,
but it doesn't come
from the rail company.
- According to the
Nantes Fire Department,
they receive a 911
call at around 11:40
saying that there is
a fire on board one
of the locomotives.
- Rail controller
Richard Labrie
lets Harding know
what has happened.
[Narrator] But they
are unaware of the
precise steps
the fire department
had taken to deal
with the incident.
- So the first thing they
do, which is protocol,
is to cut off the
diesel supply.
[fire burning]
- This removes the source
of fuel from the fire,
but it also stops
the engine running.
- According to
Harding's testimony,
the lead locomotive
had been left running
in order to provide
continual air pressure
to the system.
There are small leaks
throughout the system,
meaning that if it's not
continually topped up
by the compressor
from the lead engine,
it's going to
drop over time.
[Dr. Somara] The Nantes
Fire Department shut off
the diesel engine
at 23:58, which is
an interesting time
because that is when
the air pressure
starts to drop in
the braking system.
[Ada McVean] The
firefighters did
everything
according to protocol,
but they are
firefighters, not
train engineers.
And so in the end,
they didn't understand
the implications of
shutting down the
lead locomotive.
- By 12:58 a.m.,
the air pressure
has dropped so low
the brakes can no
longer hold the train.
- It's now got a
seven-mile run
downhill towards
Lac-Megantic
with no one on board
to control that train.
- The runaway train
is ultimately
the result of
an engine fire.
Why does it catch fire?
♪
[Narrator] The night
before the Lac-Megantic
disaster, audio evidence
of calls between
the train engineer and
the rail controller
reveals an issue
with the lead
locomotive, MMA 5017.
-Harding reports to the
rail traffic controller
that the locomotive is
smoking really badly,
but they agree that
he'll just leave
it for the night.
- What is wrong with the
locomotive's engine?
Following the disaster,
astonishing evidence
comes to light.
- When they disassemble
the engine,
they find the camshaft
bearing detached.
It had been glued
on with adhesive.
- In the lead-up
to the disaster,
this glued repair
clearly fails.
Vital evidence about the
resulting locomotive fire
comes from another
eyewitness.
- A local taxi
driver who takes
Tom Harding to his hotel
reports that there's
black smoke billowing
from the exhaust
of the engine, but
he also curiously
says that there
are oil droplets
that have collected
on the windshield
of his car.
- These oil droplets
are being blown out
through a hot exhaust.
- With the engine
running unattended,
the temperature
gradually rises,
and with oil being
sprayed out through
the exhaust, at
some point, the
mixture catches fire.
- This whole disaster
started essentially
with a bad glue
job, which happened
months before.
- We now know the
chain of events
that leads to
the disaster at
Lac Megantic
in July of 2013.
- The story goes back
to October 2012,
when the locomotive was
brought in for repair
using an adhesive that
wasn't up to the job.
- On the evening
of July 5th,
Tom Harding parks
up the train in
Nantes around 2250.
He never does a
proper handbrake test
to keep the train parked.
- Soon after Harding
leaves for the night,
a fire breaks out
caused by the failure
of the glued
engine repair.
At 11:40, the local fire
department get a call
that the locomotive
is on fire.
By 11:58, they have
turned off the fuel
supply and the fire is
extinguished.
But without power, the
train's airbrake system
starts to lose pressure.
- By 12:58 a.m., the
air pressure has
dropped so low, the
airbrakes fail.
The train begins to
roll towards the town,
picking up speed on
the downhill gradient.
Just over 15
minutes later,
the runaway train
hits the curve in
downtown Lac-Megantic
at 65 miles per
hour and derails.
A million gallons
of crude oil erupts
in a fireball,
engulfing the town.
47 people die.
In the aftermath
of the disaster,
engineer Tom Harding and
rail traffic controller
Richard Labrie
are charged
with criminal negligence
causing death.
Both are eventually
acquitted.
And new rules are
imposed to try
and ensure history
cannot repeat itself.
- The specific rail cars
that were involved
in the accident
have been banned.
The reason is that the
steel was too thin
and insufficiently
protected against
this kind of accident.
[Ada McVean] There are
plans to reroute the
tracks away from
Lac-Megantic,
but until that gets done,
the trains continue to
run through the town,
a constant reminder
of the devastation
that happened there.
- The tragedy at
Lac-Megantic results
from the obviously
flammable crude oil.
But something
apparently innocuous
can just as easily cause
a lethal explosion.
Port Wentworth, Georgia,
the Imperial Sugar
Refinery, 2008.
- At the time, the
factory produces
10% of all the processed
sugar consumed in
the United States,
and it's by far the
largest employer
in the town.
- On February 7th, the
refinery is rocked
by a huge explosion.
More follow.
- There are a series
of powerful blasts
and people are
scrambling to get
out of the buildings.
- In less than
half an hour,
most of the
facility is ablaze.
- The fire department
are on the scene
just minutes later,
and they're confronted
with dense smoke,
intense heat,
ruptured water mains,
and debris everywhere.
- Fires continue to
burn for over a week
until an industrial
firefighting crew
is able to put them out.
- 36 people are injured.
Some very seriously.
14 die.
Now, using surviving
evidence and key
eyewitness statements,
we will digitally
dissect the disaster
and piece together the
deadly chain of events.
What triggers catastrophe
at the sugar refinery?
[explosion]
[Narrator] To understand
the disaster at the
Georgia Sugar Refinery,
the first thing to do
is recreate the building
as it is before
the explosions.
- It's divided into
several sections.
There's the processing
area where the
sugar is processed
into the stuff we
can actually eat, a
storage area, and an
area where it's packed
up for transport,
it's known as the
palletiser building.
- What evidence
is there to draw
for the origin
of the blast?
- There's very little
video surveillance
within the
facility itself,
but cameras from
other businesses
around the facility are
able to catch the blasts.
- The Georgia Port
Authority have CCTV
just south of
the factory,
and it's on this
footage that we can see
the first explosion.
- This CCTV evidence
appears to show flames
coming from the
three 105-foot
tall storage silos
that dominate
the facility,
and what appear
to be explosions
in the packing and
palletising area.
Key witness
statements confirm
the explosive force
of these blasts.
- On the 7th of February,
2008, around 7:10 p.m.,
the new CEO is receiving
a tour of the factory.
As they're walking
around the facility,
they hear a huge
bang coming from
the packing area,
and they assume that
something has fallen
off of a forklift.
Of course, they're
very wrong.
- According to
their statements,
moments later,
they are knocked
backwards by the
force of an enormous
blast wave.
Debris explodes
through the packing
building doorway.
- Furniture and various
bits of machinery
were being flung
hither and yon
by the force of
the explosion,
and they couldn't get
out of the building
'cause you have this
superheated smoke
that's filling it.
- Photographic
evidence shows
just how powerful
this blast is.
The three-inch thick
concrete floors
in the packing
building are buckled.
The wooden roof of
the palletizer room
is shattered.
This evidence of damage
helps narrow down
the exact location where
the disaster begins.
[Professor Bisby] The
damage and the blast
patterns indicate that
the explosions have
come from a tunnel
which is located
underneath the silos.
This tunnel contains
a conveyor belt
which is used to
transport sugar from
silos one and two.
- The conveyor tunnel
is constructed
from a series of
metal panels.
After the accident, these
pinpoint the origin.
- You can see from
the images here
of the conveyor
the way in which
the housing had been
completely blown
apart by the explosion.
- All the panels
that are on the
east of the midpoint
have been blown east,
and those on the
west of the midpoint
have been blown
west, and this would
tend to indicate
that the explosion
has initiated
somewhere near
the midpoint
along the tunnel.
- The disaster begins
with an explosion
in the conveyor tunnel.
But why is there an
explosion at all?
[Ada McVean] The
difference between
something burning
and exploding is
essentially just the
speed of the reaction.
Once you get enough
gas expanding outward
with enough force,
it goes from
something burning to
something exploding.
- Just like any
fire, an explosion
requires oxygen, a
source of ignition,
and plenty of fuel.
And this particular
factory processes sugar.
- Sugar is an
amazing fuel.
- It is originally
produced from sunlight
by photosynthesis
in plants.
-In many ways, you
can think of it
as being sunbeams
captured into a molecule
for later release.
And therefore, you can
set fire to that fuel
and it will burn.
- But to create
an explosion,
the fuel must burn
incredibly fast.
So it needs to be
surrounded by a
source of oxygen.
- Within the
factory, the sugar
is being ground up.
There's dust being
thrown up into the air.
But it's so fine
that it actually
remains suspended.
There's almost something
like a sugar fog
within the factory.
And that means
that you've got
sugar, the fuel, and
air, the oxidizer,
intimately mixed.
And this is potentially
an accident
waiting to happen.
- Any flammable
dust in high enough
concentrations
is an explosive.
And in 2003, there
were three separate
such dust explosions
in vastly varying
factories with
different substances.
- The trick is to
keep the amount of
dust under control.
- In order to
ignite explosively,
it has to be in the
right concentration.
And this is called
the minimum explosive
concentration.
Provided we're below
that concentration,
an explosion
shouldn't occur.
- In the past 80
years of this
refinery's operation,
there have been minor
dust explosions before,
but never anything
on this scale.
So what changed?
[simulated explosion]
[simulated explosion]
[Narrator] The massive
explosions at the
Imperial Sugar
Refinery must result from
sugar dust reaching an
explosive concentration.
-If you look at the
schematics before 2007,
you see that the
conveyor belt is
exposed to the open air.
By 2008, it's been
enclosed completely.
- So the metal tunnel
covering the conveyor,
where the explosion
initiates, is new.
- They did this for
a very good reason,
which was fear that the
sugar being transported
would be contaminated.
- Before the
tunnel is fitted,
factory workers
occasionally saw sugar
get stuck in the
chutes above the belt.
Excess sugar spilled
over, releasing
dust into the air.
But because the conveyor
wasn't enclosed,
this sugar dust
quickly dispersed.
A similar blockage
occurs a few days
before the disaster.
- While workers
tried to fix the
blockage in silo one,
sugar from silo two
continued to fall
down onto the belt.
And it's easy to see how
that sugar falling down
could create a lot
of dust in the air.
- And because it is now
enclosed in a tunnel,
this explosive sugar dust
can no longer disperse.
- The unintended
consequence is that
the level of dust
begins to rise more
and more and more,
eventually reaching
the minimum explosive
concentration.
- The conveyor
tunnel has become
an unexploded bomb.
- Now, all that you
need inside the
conveyor housing is
a hotspot or other
source of ignition.
- What ignites the dust?
- Down in the tunnel, we
have a conveyor belt,
and this conveyor
belt has loads
of moving parts.
And if you have
moving parts,
then you have the
potential for friction.
And if you have
friction, then you
might have heat.
Now, several factory
workers had stated
that there had been
previous fires,
and often the culprit
in those situations
was an overheated
bearing.
So whilst we
can't be sure,
that's a potential
ignition source.
- This explains the
initial explosion
in the conveyor tunnel.
♪
But what causes the
subsequent blasts?
[explosion]
- Less than two months
before the accident,
an inspection revealed
that they were
regularly cleaning up
tons of spilled sugar
around the factory.
- This is backed up by
other key evidence.
- Workers had
previously mentioned
that sugar and sugar
dust often spilled
out of the processes,
and in some cases,
this would end up
being knee-deep within
the factory.
- And that isn't
really a big problem,
until, of course,
you get an explosion
in the center.
- Eyewitness testimony
of people being
blown off their feet
confirms that the
explosion produces
a shockwave.
- And that shockwave
is going to blow
all of the additional
sugar into the air.
- Each explosion creates
a fresh shockwave.
- This provides
more fuel for the
advancing fireball, and
this then pushes more
dust up into the
air, which causes
further explosions.
[explosion]
- Helpless workers
are trapped inside
a disaster of
increasing force.
- If you compress a
flammable substance,
that can increase the
force of the explosion.
- So every shockwave
effectively amplifies
the force of the
subsequent explosion.
- As the explosion goes
through the building,
it's pre-compressing
the sugary air,
and you actually wind
up with explosions
that are more powerful
as it moves along.
[explosion]
- We can now fit all
the evidence together
to explain the
disaster that
devastates the factory
and kills 14 people.
♪
[explosion]
After 80 years
of relatively
trouble-free operation,
this disaster begins
with an attempt to
reduce the risk
of contamination.
The factory encloses
a sugar conveyor
belt in steel panels.
A few days before
the explosion,
a chute above the
conveyor becomes blocked,
and this causes dust
to start accumulating
within the tunnel,
eventually exceeding
the minimum explosive
concentration.
- On February 7,
2008, at 7:15 p.m.,
the sugar dust
is ignited,
probably by an
overheating bearing.
It explodes.
- The initial blast
actually throws up
even more sugar
into the air,
and this provides more
fuel to the fire.
- The shock waves trigger
increasingly powerful
secondary explosions.
These destroy the
entire refinery.
- 14 people die. 36
more are injured,
some very
seriously, by burns.
Keep in mind, this
is burning sugar,
so when it falls on your
skin, it sticks there
and can really cause
horrible damage.
[explosion]
- As is the case
with many disasters,
we need to look at
the range of factors
that contributed
to the outcome.
And in this case, the
enclosing of the conveyor
is one factor we
need to look at.
Also, the fact that
sugar was piling up
within the conveyor.
And if either
of these things
had been thought
through carefully,
we might not have
ended up with this
disastrous outcome.
- It takes 16 months
of demolition
and reconstruction
before the Imperial
Sugar Refinery is
back in operation
in June 2009.
- This newly
rebuilt refinery
includes dust-handling
equipment
designed to prevent
the sugar accumulation
that led to this
horrible disaster.
- Imperial Sugar agreed
to pay $4 million
for safety
violations at its
Port Wentworth refinery.
But no criminal charges
were ever brought
against the company.
- The sugar refinery
disaster was devastating
for the families of
those who were lost
and for the
local community.
♪
But some disasters have
worldwide consequences.
The Gulf of Suez,
March 2021.
The giant container ship,
the Ever Given,
enters the Suez Canal.
- It's about a
quarter mile long.
It's as long as
the Empire State
Building is tall.
- Just 30 minutes
into the journey,
disaster strikes.
- They lose control of
this colossal ship,
and it ends up
wedged into both
banks of the canal,
blocking any
passage through.
- The consequences
are huge.
- It's like having
a skyscraper
blocking the canal, and
the losses are immense.
- It's impossible
to overestimate
the critical role that
the Suez Canal plays
in the entire
global economy.
Something like 30% of
the world's shipping
passes through
it every year.
- The Ever Given
accident ends that
instantaneously.
-It's stopping 50
ships a day
from passing through,
worth $10 billion
of trade daily.
- The ship has already
passed through the canal
20 times without
incident.
What is different
this time?
Now, using
eyewitness testimony
and every available
source of evidence,
we will digitally
dissect the disaster.
What goes wrong on
the Ever Given?
[Narrator] Because of
its vast size, the cargo
vessel Ever Given
completely blocks
the Suez Canal by
jamming itself
across both banks.
- It's what's known as
an ultra-large
container ship.
It displaces 200,000
tons and can carry up
to 20,000 shipping
containers at once.
It's loaded with a
billion dollars' worth
of consumer goods
furniture, electronics.
- Like all
vessels this big,
the ship carries an
AIS, or automatic
identification system.
This continuously
broadcasts the Ever
Given's position,
course, and speed.
It can be used to
create a timeline
of the accident.
- On the 23rd of March,
the ship arrives
at the southern entrance
to the Suez Canal.
- The Suez Canal
is 120 miles long,
but at its narrowest,
just 673 feet wide
barely more than
three times the width
of the Ever Given.
[Dr. Auerbach] When you
look at the width of the
canal compared
to the enormous
size of this ship,
this is not an easy
passage with a lot
of room for error.
It's more like
threading a needle.
- But thousands of huge
ships pass successfully
through the canal every
year without incident.
What is different
on the Ever Given?
[Narrator] The
ship enters the
canal at 7:11 a.m.
By 7:41, it has
run aground,
wedging itself diagonally
across the canal.
What happens in those
critical 30 minutes?
The AIS tracking
data shows
navigational anomalies
early in the
ship's passage.
- Usually when ships
cruise through canals,
they do so in the
middle of the canal
because that's where
the water is deepest.
If we look at the
data from the
reports, however,
relatively soon after the
ship enters the canal,
we can see that the
ship starts swerving
to the left-hand side
towards the bank.
- What could cause this
anomalous behavior?
The key evidence doesn't
come from the ship
or the canal authorities.
- A few days before the
Ever Given started going
through the Suez
Canal, the Egyptian
Meteorological Services
issued weather warnings.
Every spring in Egypt
and in North Africa
and the Arabian
Peninsula,
the Khamaseen winds go
through that region.
- The name "Khamaseen"
comes from the
Arabic word for "50,"
meaning the 50 days
a year over which
it tends to blow.
Weather data for
the 23rd of March
shows wind speeds in
the area reaching
46 miles per hour.
- On the day that
the Ever Given moves
through the canal,
the Khamaseen winds are
blowing from the south,
hitting the side
of the ship.
♪
- This could be
significant.
Loaded with
containers, the side
of the Ever Given
is a towering
wall of steel a
quarter mile long.
- This creates a massive
area for the wind
to be impacted upon.
You're looking
at 14-story-high
walls, essentially,
that act as a sail.
And actually, from
personal experience,
it can move the
vessel significantly.
- This theory is backed
up by critical evidence
from the Voyage Data
Recorder, or VDR,
the equivalent of an
aircraft's black box.
[Dr. Auerbach] VDR data
shows that immediately
after the ship
enters the canal,
the wind is blowing
on its right side,
which explains why
it's being pushed
towards the left
bank of the canal.
But sometime later,
the wind switches
and is now blowing
on its left side,
which pushes it
towards the right.
A little while later,
the wind changes again,
blowing again towards
the right side.
So the ship is being
kind of seesawed
back and forth
by this powerful
shifting wind as
it's trying to
navigate what, to it, is
a quite narrow canal.
- It is clear that
the Khamaseen winds
are pushing the massive
ship off course,
but the evidence suggests
that wind alone cannot
explain this disaster.
[Nadia El-Awady] When
ships travel through the
Suez Canal, they
go in convoys.
So right in front
of the Ever Given
was a ship called
the COSCO Galaxy,
which is pretty
much as large as
the Ever Given is.
Even though there were
gusty winds at the time,
the COSCO Galaxy
gets through,
but the Ever
Given doesn't.
There has to be a reason
for the Ever Given
not getting through
and getting wedged
that isn't just
about the winds.
♪
- What is so different
about the Ever Given?
[low rumbling and
screeching]
[Narrator] Why does the
Ever Given end up jammed
across the Suez Canal
when the ship right in
front makes it through
without incident?
- If we compare the
behavior of the two ships
and see if there are
any differences,
that might give us
a clue as to what,
in fact, happened.
- The tracking data
of the COSCO Galaxy
and the Ever Given
shows that shortly
after entering the
canal, the powerful
Khamaseen winds
push them towards
the left bank.
The data shows
that both ships
immediately
increase speed.
♪
This increases the
amount of water
flowing across the
rudder, increasing
maneuverability.
But after this point,
the behavior of the
two ships diverges.
- The data shows
that the COSCO Galaxy
slows down, but the Ever
Given does the opposite.
It increases speed
until it's traveling
between 12 and
13 1/2 knots,
which is a blistering
speed for the Suez Canal.
- The recommended
speed limit is
just 8 to 9 knots.
Going faster helps
with the steering,
but it comes
with problems.
- So when you
turn the rudder,
the back or the
rear of the ship
will start to swing,
and the faster you go,
the harder it will be
to control the swing.
♪
- This fits the Ever
Given's tracking data.
It begins swinging
from side to side,
repeatedly coming very
close to the banks.
Immediately before
the accident,
the back of the
ship moves towards
the left bank with
increasing speed.
What causes this anomaly?
[Dr. Somara] When
a vessel is moving
through water,
the water rushing
past its sides
quickly replaces
the void that it's
creating at the back.
That's fine on
open waters,
but when you're in a
restricted waterway
like the Suez, that
effect can be dramatic.
- The problems occur
when the ship is closer
to one bank
than the other.
- A narrowing
of the waterway
on one side of the
container ship
means that the water
is having to move
much faster than
the other side.
- This produces a
force known in physics
as the Bernoulli effect.
- And wherever you've
got fast-moving fluid,
in this case water,
you've got very
low pressure, and
low pressure is what
causes a suction effect.
So the higher pressure
on the other side
pushes the ship over.
- This phenomenon is
called the bank effect.
The faster the
ship is going,
the more powerful it is.
And at the time
of the disaster,
AIS data records
the Ever Given
traveling well above the
recommended speed limit.
- So as the stern
of the Ever Given
gets close to
the left-hand
side of the bank, it
gets sucked in due
to the bank effect.
- This causes both ends
of the massive ship
to pivot in opposite
directions.
[Nadia El-Awady] The
front of the ship,
the bow, starts rotating
clockwise.
And what that
does is that
in this narrow
section of the canal,
the ship ends up
getting wedged in
between the two banks.
- A combination
of high winds
and the bank effect
strand the ship.
But this only
happens because she
is traveling fast and
steering erratically.
What is going on
aboard the Ever Given?
The captain of the ship,
Krishnan Kanthavel,
is a highly
experienced mariner.
But Suez is so
tricky and narrow
that every ship
must be guided by
specialist canal
pilots from the
Suez Canal Authority.
- Asking who's
really in charge
of this whole
moving carnival
is a complicated
question.
The Suez is a very tricky
bit of navigation.
So while the
captain is always
an overall command
of the ship,
it's really the pilots
who are supposed
to be telling the
crew what to do.
But technically, they're
just consulting.
They're not
really in charge.
So even if it's the
pilot's instructions
that cause a calamity,
it's still the captain's
responsibility.
It's his ship.
- The voyage data
recorder provides
valuable audio
recordings of what
is actually happening on
the Ever Given's bridge.
[Nadia El-Awady] What
happened on the day is
that as the conditions
got worse,
the two pilots we
have a senior pilot
and a junior pilot
they start arguing with
each other in Arabic.
- No one else on the
bridge speaks Arabic.
- The rest of the
crew aren't sure
what they're
talking about
because of the
language barrier.
But apparently,
the junior pilot
is not happy with
the decisions
that are being made
by the senior pilot.
- 20 minutes before
the accident,
the Ever Given
increases speed,
and we know this is a
contributing factor.
[Dr. Auerbach We know it
was the senior pilot
who initially ordered
the increase in speed,
but what happens
after that is more
of a gray area.
Did the pilot assume
that the captain
would give the command
to lower speed,
or did the captain
assume that the pilot
would give instructions
about when the speed
needed to be lowered?
- Whatever happens,
the ship continues
along the Suez Canal
at high speed,
swinging from one
bank to the other.
So why doesn't the
captain step in?
- According to the
captain's statement,
he twice ordered the
rudder to be centered
to avoid the ship
from swinging,
but in the confusion
of who was
giving the orders,
apparently that
did not happen.
- This disaster is
the result of
multiple factors
physical, natural,
and human.
We can now explain how
it all comes together.
March 23, 2021.
The Ever Given enters
the Suez Canal.
Almost immediately, the
strong Khamaseen winds
push it towards
the left bank.
The pilots order an
increase in speed
to assist with
steering in the
unstable conditions.
- You have this
situation where the
wind is increasing
and also changing
the quarter where
it's coming from,
so the senior
pilot is giving
instructions to the crew
to either move hard
right rudder or
hard left rudder,
depending upon the
direction that the
wind is coming from,
and this is all an
effort to try to stop
these wild oscillations.
- The giant ship
gets too close
to the left side
of the canal.
The bank effect kicks
in, sucking the
stern of the ship
into the side
of the canal and
rotating the entire
vessel clockwise.
The Ever Given grounds
itself simultaneously
on both banks,
wedged diagonally
across the canal.
Despite frantic efforts,
it takes six days to
free the Ever Given.
[Dr. Auerbach] And by
then, you had 429
vessels waiting passage.
-It isn't until the
afternoon of March 29
that she is finally
re-floated.
[ship horn blaring]
[workers cheering]
[Narrator] It's been
estimated that
the Ever Given
disaster costs
$60 billion in
global trade.
That is $400 million for
every hour she is stuck.
- It might seem at
first glance that as
naval accidents go,
this one's pretty mild,
but the cost of all
this, the damage done,
goes far beyond the
financial loss.
I mean, these are real
people with small
businesses and jobs
that go under if
they don't get the
supplies that they need
because this vital
supply chain was broken
by a single ship.
- Since the Ever
Given disaster,
the Egyptian government
has announced
that it will be
spending $10 billion
on widening the canal
and also deepening it.
-The aim of all this work
is to prevent a repeat
of the disaster
that cost so much.
Since then, the Ever
Given has managed
to pass successfully
through the canal
without getting stuck.
[Narrator] In a high
rise building.
- There was no warning.
- At sea.
- Innocent people died.
- In a train.
- Everything was on fire.
Everything was burning.
[explosion]
- Disasters can begin
with the smallest things.
- Changing the opening
hours of a restaurant.
- The bad glue job.
- A paperwork error.
- Now, combining
the latest research
with every available
source of evidence,
experts will forensically
analyze three disasters
down to each tiny detail.
- You've really got to
think outside the box.
- You have to work
your way back
and understand each
link in the chain.
- State-of-the-art
graphics reveal
every critical detail at
every critical moment.
- This whole disaster
could have been averted.
- We can dissect
them, get inside,
or underneath,
freeze time,
and even reverse it.
To conduct a complete
disaster autopsy.
Canada, Lac-Mégantic.
A small town in rural
Quebec province.
- The population is only
about 6,000 people.
It's one of those
places where everyone
knows everybody else.
- July 6th, 2013.
- It is 1.15 in
the morning,
and it is a beautiful
summer's night.
There are still a
lot of people out
enjoying the nightlife.
[explosion]
[sirens wailing]
- A train carrying
crude oil derails.
The town is engulfed
by a series of
massive fireballs.
- Everything was on fire.
Everything was burning.
[Narrator] The fire rages
for a day and a half.
47 people are killed.
How could this happen?
Using all the
available evidence
and cutting edge
digital technology,
we will recreate the
events as they happened.
What causes the disaster
at Lac-Mégantic?
[train crashes]
♪
We know it begins with a
freight train derailment.
- This train is
so gigantic.
It's nearly a mile long.
It has to be hauled
by five locomotives.
and behind that
are 72 tanker cars
loaded with one
and a half million
gallons of crude oil.
The gigantic train is
heading to a refinery
in St. John, New
Brunswick, using
a track that runs right
through Lac-Mégantic.
-The rail track
in Lac-Mégantic
has a very tight curve.
It's flat as
opposed to banked,
and you have to slow
down quite a bit
to go through it.
The rail records suggest
that the speed limit
is about 10
miles per hour.
- A crucial piece
of evidence that
survives the inferno
is the locomotive
event recorder.
- This is the equivalent
of an aircraft black box.
It records all kinds
of data from speed,
time, distance,
throttle position.
- It holds critical
data about the
speed of the train at
the time of the disaster.
- The train was traveling
at 65 miles per hour,
six times the
speed limit.
- This excessive
speed causes 63
of the tank cars to
overturn on the bend
around Lac-Mégantic.
- In the end, it
all comes down to
just too much speed.
The train was
going way too fast
when it hit this
section of the tracks.
- The derailed tank
cars spill over
a million gallons of oil.
- The massive quantity
of burning oil
engulfs much of
the downtown.
The Muse Cafe, which
is full of patrons,
is completely destroyed.
Almost everyone
inside is killed.
- Why is the train
going so fast?
Why does no one stop it?
- There is a
very good reason
why this train was moving
at such a great speed.
It's quite simply
because no one was
driving the train.
♪
- How does the mile-long
train become a runaway?
We can use the
available evidence
to dissect the timeline
of this disaster.
At about 10.50 p.m.,
two hours and 20 minutes
before the accident, we
know the train arrives
at a town called Nantes,
a little over seven miles
west of Lac-Mégantic.
- This entire almost
mile-long train
has one crew member,
a locomotive engineer
called Thomas Harding.
- The plan is to leave
the train unattended
at Nantes overnight.
- And then the next
day, another engineer
would come along and
take the train on
its onward journey.
- The safest option
is to leave the train
on the siding at
Nantes, adjacent to
the main line.
- The siding is
specifically equipped
with a derail, a
device that is
designed to prevent
runaway trains
by derailing them
when they run over
it at low speeds.
[train riding over
tracks]
- But according to
Harding's testimony,
when he reaches Nantes,
the siding is in use.
So the agreed plan is
to leave the train
on the main tracks,
pointing straight down
towards Lac-Mégantic.
- The train is parked on
a descending gradient.
- Unlike the sidings,
the main track has
no derail system.
So the only thing
preventing a runaway
is the train's
braking system.
And there is evidence
that the train engineer
does check them.
- From official phone
records between Harding
and the rail traffic
control officer,
he's perfectly happy
with the braking system.
- He leaves the train,
goes to his hotel,
and everything
seems fine.
[Narrator] The train's
data recorder shows
that almost two hours
after this call,
the unoccupied
train begins to
roll down the track
towards Lac-Mégantic.
But according to the
audio recordings,
the brakes are on.
So how can that happen?
Each of the five
locomotives is equipped
with two different
braking systems.
The first uses
compressed air to
push the brake shoes
against the train wheels.
- That compressed
air is generated by
the engine running, and
essentially they're
used as parking brakes.
- There's also a separate
mechanical handbrake
in every locomotive
and rail car.
These have to be
applied individually.
In audio evidence from
the call between Harding
and the rail controller,
Richard Labrie,
they discuss
the handbrakes.
[Narrator] But according
to paperwork from the
rail company, MMA, seven
brakes is not enough.
- Harding has set the
handbrakes in seven cars,
but MMA guidelines
say that the minimum
brakes needed is
10% plus two, which
would be a total of
nine for this train.
[Narrator] These
regulations also require
that the air brakes
are released
to test that the
mechanical brakes alone
can hold the train.
- The handbrakes were
never tested on their own
because according to
Harding's testimony,
he never released
the air brakes
when he was testing
the mechanical brakes.
- But Harding's
testimony is also clear
that the combination of
handbrakes and air brakes
he applies does hold
the train securely.
- Around 11:30 p.m.,
Harding then leaves
for his hotel.
The engine is
running to keep
the air pressure
brake system going.
All seems well.
- Data from the
locomotive event recorder
shows that when
Harding leaves,
the pressure in
the braking system
is around 95 PSI,
enough to fully
apply the air brakes.
- But then
from about midnight,
it starts to drop by
one PSI a minute.
- The pressure
continues to fall
for the next hour.
- By 58 minutes
after midnight,
the pressure in the
brakes has dropped
to just 27 PSI and
it's no longer
enough to hold the
train stationary.
- But Harding leaves
the engine running
to maintain air
pressure in the brakes.
So why does the
pressure drop?
- The key question is,
what happens between
11:30 when Harding
leaves to around 1 a.m.
when the train
starts to roll?
- There is a piece
of critical evidence
for this time period,
but it doesn't come
from the rail company.
- According to the
Nantes Fire Department,
they receive a 911
call at around 11:40
saying that there is
a fire on board one
of the locomotives.
- Rail controller
Richard Labrie
lets Harding know
what has happened.
[Narrator] But they
are unaware of the
precise steps
the fire department
had taken to deal
with the incident.
- So the first thing they
do, which is protocol,
is to cut off the
diesel supply.
[fire burning]
- This removes the source
of fuel from the fire,
but it also stops
the engine running.
- According to
Harding's testimony,
the lead locomotive
had been left running
in order to provide
continual air pressure
to the system.
There are small leaks
throughout the system,
meaning that if it's not
continually topped up
by the compressor
from the lead engine,
it's going to
drop over time.
[Dr. Somara] The Nantes
Fire Department shut off
the diesel engine
at 23:58, which is
an interesting time
because that is when
the air pressure
starts to drop in
the braking system.
[Ada McVean] The
firefighters did
everything
according to protocol,
but they are
firefighters, not
train engineers.
And so in the end,
they didn't understand
the implications of
shutting down the
lead locomotive.
- By 12:58 a.m.,
the air pressure
has dropped so low
the brakes can no
longer hold the train.
- It's now got a
seven-mile run
downhill towards
Lac-Megantic
with no one on board
to control that train.
- The runaway train
is ultimately
the result of
an engine fire.
Why does it catch fire?
♪
[Narrator] The night
before the Lac-Megantic
disaster, audio evidence
of calls between
the train engineer and
the rail controller
reveals an issue
with the lead
locomotive, MMA 5017.
-Harding reports to the
rail traffic controller
that the locomotive is
smoking really badly,
but they agree that
he'll just leave
it for the night.
- What is wrong with the
locomotive's engine?
Following the disaster,
astonishing evidence
comes to light.
- When they disassemble
the engine,
they find the camshaft
bearing detached.
It had been glued
on with adhesive.
- In the lead-up
to the disaster,
this glued repair
clearly fails.
Vital evidence about the
resulting locomotive fire
comes from another
eyewitness.
- A local taxi
driver who takes
Tom Harding to his hotel
reports that there's
black smoke billowing
from the exhaust
of the engine, but
he also curiously
says that there
are oil droplets
that have collected
on the windshield
of his car.
- These oil droplets
are being blown out
through a hot exhaust.
- With the engine
running unattended,
the temperature
gradually rises,
and with oil being
sprayed out through
the exhaust, at
some point, the
mixture catches fire.
- This whole disaster
started essentially
with a bad glue
job, which happened
months before.
- We now know the
chain of events
that leads to
the disaster at
Lac Megantic
in July of 2013.
- The story goes back
to October 2012,
when the locomotive was
brought in for repair
using an adhesive that
wasn't up to the job.
- On the evening
of July 5th,
Tom Harding parks
up the train in
Nantes around 2250.
He never does a
proper handbrake test
to keep the train parked.
- Soon after Harding
leaves for the night,
a fire breaks out
caused by the failure
of the glued
engine repair.
At 11:40, the local fire
department get a call
that the locomotive
is on fire.
By 11:58, they have
turned off the fuel
supply and the fire is
extinguished.
But without power, the
train's airbrake system
starts to lose pressure.
- By 12:58 a.m., the
air pressure has
dropped so low, the
airbrakes fail.
The train begins to
roll towards the town,
picking up speed on
the downhill gradient.
Just over 15
minutes later,
the runaway train
hits the curve in
downtown Lac-Megantic
at 65 miles per
hour and derails.
A million gallons
of crude oil erupts
in a fireball,
engulfing the town.
47 people die.
In the aftermath
of the disaster,
engineer Tom Harding and
rail traffic controller
Richard Labrie
are charged
with criminal negligence
causing death.
Both are eventually
acquitted.
And new rules are
imposed to try
and ensure history
cannot repeat itself.
- The specific rail cars
that were involved
in the accident
have been banned.
The reason is that the
steel was too thin
and insufficiently
protected against
this kind of accident.
[Ada McVean] There are
plans to reroute the
tracks away from
Lac-Megantic,
but until that gets done,
the trains continue to
run through the town,
a constant reminder
of the devastation
that happened there.
- The tragedy at
Lac-Megantic results
from the obviously
flammable crude oil.
But something
apparently innocuous
can just as easily cause
a lethal explosion.
Port Wentworth, Georgia,
the Imperial Sugar
Refinery, 2008.
- At the time, the
factory produces
10% of all the processed
sugar consumed in
the United States,
and it's by far the
largest employer
in the town.
- On February 7th, the
refinery is rocked
by a huge explosion.
More follow.
- There are a series
of powerful blasts
and people are
scrambling to get
out of the buildings.
- In less than
half an hour,
most of the
facility is ablaze.
- The fire department
are on the scene
just minutes later,
and they're confronted
with dense smoke,
intense heat,
ruptured water mains,
and debris everywhere.
- Fires continue to
burn for over a week
until an industrial
firefighting crew
is able to put them out.
- 36 people are injured.
Some very seriously.
14 die.
Now, using surviving
evidence and key
eyewitness statements,
we will digitally
dissect the disaster
and piece together the
deadly chain of events.
What triggers catastrophe
at the sugar refinery?
[explosion]
[Narrator] To understand
the disaster at the
Georgia Sugar Refinery,
the first thing to do
is recreate the building
as it is before
the explosions.
- It's divided into
several sections.
There's the processing
area where the
sugar is processed
into the stuff we
can actually eat, a
storage area, and an
area where it's packed
up for transport,
it's known as the
palletiser building.
- What evidence
is there to draw
for the origin
of the blast?
- There's very little
video surveillance
within the
facility itself,
but cameras from
other businesses
around the facility are
able to catch the blasts.
- The Georgia Port
Authority have CCTV
just south of
the factory,
and it's on this
footage that we can see
the first explosion.
- This CCTV evidence
appears to show flames
coming from the
three 105-foot
tall storage silos
that dominate
the facility,
and what appear
to be explosions
in the packing and
palletising area.
Key witness
statements confirm
the explosive force
of these blasts.
- On the 7th of February,
2008, around 7:10 p.m.,
the new CEO is receiving
a tour of the factory.
As they're walking
around the facility,
they hear a huge
bang coming from
the packing area,
and they assume that
something has fallen
off of a forklift.
Of course, they're
very wrong.
- According to
their statements,
moments later,
they are knocked
backwards by the
force of an enormous
blast wave.
Debris explodes
through the packing
building doorway.
- Furniture and various
bits of machinery
were being flung
hither and yon
by the force of
the explosion,
and they couldn't get
out of the building
'cause you have this
superheated smoke
that's filling it.
- Photographic
evidence shows
just how powerful
this blast is.
The three-inch thick
concrete floors
in the packing
building are buckled.
The wooden roof of
the palletizer room
is shattered.
This evidence of damage
helps narrow down
the exact location where
the disaster begins.
[Professor Bisby] The
damage and the blast
patterns indicate that
the explosions have
come from a tunnel
which is located
underneath the silos.
This tunnel contains
a conveyor belt
which is used to
transport sugar from
silos one and two.
- The conveyor tunnel
is constructed
from a series of
metal panels.
After the accident, these
pinpoint the origin.
- You can see from
the images here
of the conveyor
the way in which
the housing had been
completely blown
apart by the explosion.
- All the panels
that are on the
east of the midpoint
have been blown east,
and those on the
west of the midpoint
have been blown
west, and this would
tend to indicate
that the explosion
has initiated
somewhere near
the midpoint
along the tunnel.
- The disaster begins
with an explosion
in the conveyor tunnel.
But why is there an
explosion at all?
[Ada McVean] The
difference between
something burning
and exploding is
essentially just the
speed of the reaction.
Once you get enough
gas expanding outward
with enough force,
it goes from
something burning to
something exploding.
- Just like any
fire, an explosion
requires oxygen, a
source of ignition,
and plenty of fuel.
And this particular
factory processes sugar.
- Sugar is an
amazing fuel.
- It is originally
produced from sunlight
by photosynthesis
in plants.
-In many ways, you
can think of it
as being sunbeams
captured into a molecule
for later release.
And therefore, you can
set fire to that fuel
and it will burn.
- But to create
an explosion,
the fuel must burn
incredibly fast.
So it needs to be
surrounded by a
source of oxygen.
- Within the
factory, the sugar
is being ground up.
There's dust being
thrown up into the air.
But it's so fine
that it actually
remains suspended.
There's almost something
like a sugar fog
within the factory.
And that means
that you've got
sugar, the fuel, and
air, the oxidizer,
intimately mixed.
And this is potentially
an accident
waiting to happen.
- Any flammable
dust in high enough
concentrations
is an explosive.
And in 2003, there
were three separate
such dust explosions
in vastly varying
factories with
different substances.
- The trick is to
keep the amount of
dust under control.
- In order to
ignite explosively,
it has to be in the
right concentration.
And this is called
the minimum explosive
concentration.
Provided we're below
that concentration,
an explosion
shouldn't occur.
- In the past 80
years of this
refinery's operation,
there have been minor
dust explosions before,
but never anything
on this scale.
So what changed?
[simulated explosion]
[simulated explosion]
[Narrator] The massive
explosions at the
Imperial Sugar
Refinery must result from
sugar dust reaching an
explosive concentration.
-If you look at the
schematics before 2007,
you see that the
conveyor belt is
exposed to the open air.
By 2008, it's been
enclosed completely.
- So the metal tunnel
covering the conveyor,
where the explosion
initiates, is new.
- They did this for
a very good reason,
which was fear that the
sugar being transported
would be contaminated.
- Before the
tunnel is fitted,
factory workers
occasionally saw sugar
get stuck in the
chutes above the belt.
Excess sugar spilled
over, releasing
dust into the air.
But because the conveyor
wasn't enclosed,
this sugar dust
quickly dispersed.
A similar blockage
occurs a few days
before the disaster.
- While workers
tried to fix the
blockage in silo one,
sugar from silo two
continued to fall
down onto the belt.
And it's easy to see how
that sugar falling down
could create a lot
of dust in the air.
- And because it is now
enclosed in a tunnel,
this explosive sugar dust
can no longer disperse.
- The unintended
consequence is that
the level of dust
begins to rise more
and more and more,
eventually reaching
the minimum explosive
concentration.
- The conveyor
tunnel has become
an unexploded bomb.
- Now, all that you
need inside the
conveyor housing is
a hotspot or other
source of ignition.
- What ignites the dust?
- Down in the tunnel, we
have a conveyor belt,
and this conveyor
belt has loads
of moving parts.
And if you have
moving parts,
then you have the
potential for friction.
And if you have
friction, then you
might have heat.
Now, several factory
workers had stated
that there had been
previous fires,
and often the culprit
in those situations
was an overheated
bearing.
So whilst we
can't be sure,
that's a potential
ignition source.
- This explains the
initial explosion
in the conveyor tunnel.
♪
But what causes the
subsequent blasts?
[explosion]
- Less than two months
before the accident,
an inspection revealed
that they were
regularly cleaning up
tons of spilled sugar
around the factory.
- This is backed up by
other key evidence.
- Workers had
previously mentioned
that sugar and sugar
dust often spilled
out of the processes,
and in some cases,
this would end up
being knee-deep within
the factory.
- And that isn't
really a big problem,
until, of course,
you get an explosion
in the center.
- Eyewitness testimony
of people being
blown off their feet
confirms that the
explosion produces
a shockwave.
- And that shockwave
is going to blow
all of the additional
sugar into the air.
- Each explosion creates
a fresh shockwave.
- This provides
more fuel for the
advancing fireball, and
this then pushes more
dust up into the
air, which causes
further explosions.
[explosion]
- Helpless workers
are trapped inside
a disaster of
increasing force.
- If you compress a
flammable substance,
that can increase the
force of the explosion.
- So every shockwave
effectively amplifies
the force of the
subsequent explosion.
- As the explosion goes
through the building,
it's pre-compressing
the sugary air,
and you actually wind
up with explosions
that are more powerful
as it moves along.
[explosion]
- We can now fit all
the evidence together
to explain the
disaster that
devastates the factory
and kills 14 people.
♪
[explosion]
After 80 years
of relatively
trouble-free operation,
this disaster begins
with an attempt to
reduce the risk
of contamination.
The factory encloses
a sugar conveyor
belt in steel panels.
A few days before
the explosion,
a chute above the
conveyor becomes blocked,
and this causes dust
to start accumulating
within the tunnel,
eventually exceeding
the minimum explosive
concentration.
- On February 7,
2008, at 7:15 p.m.,
the sugar dust
is ignited,
probably by an
overheating bearing.
It explodes.
- The initial blast
actually throws up
even more sugar
into the air,
and this provides more
fuel to the fire.
- The shock waves trigger
increasingly powerful
secondary explosions.
These destroy the
entire refinery.
- 14 people die. 36
more are injured,
some very
seriously, by burns.
Keep in mind, this
is burning sugar,
so when it falls on your
skin, it sticks there
and can really cause
horrible damage.
[explosion]
- As is the case
with many disasters,
we need to look at
the range of factors
that contributed
to the outcome.
And in this case, the
enclosing of the conveyor
is one factor we
need to look at.
Also, the fact that
sugar was piling up
within the conveyor.
And if either
of these things
had been thought
through carefully,
we might not have
ended up with this
disastrous outcome.
- It takes 16 months
of demolition
and reconstruction
before the Imperial
Sugar Refinery is
back in operation
in June 2009.
- This newly
rebuilt refinery
includes dust-handling
equipment
designed to prevent
the sugar accumulation
that led to this
horrible disaster.
- Imperial Sugar agreed
to pay $4 million
for safety
violations at its
Port Wentworth refinery.
But no criminal charges
were ever brought
against the company.
- The sugar refinery
disaster was devastating
for the families of
those who were lost
and for the
local community.
♪
But some disasters have
worldwide consequences.
The Gulf of Suez,
March 2021.
The giant container ship,
the Ever Given,
enters the Suez Canal.
- It's about a
quarter mile long.
It's as long as
the Empire State
Building is tall.
- Just 30 minutes
into the journey,
disaster strikes.
- They lose control of
this colossal ship,
and it ends up
wedged into both
banks of the canal,
blocking any
passage through.
- The consequences
are huge.
- It's like having
a skyscraper
blocking the canal, and
the losses are immense.
- It's impossible
to overestimate
the critical role that
the Suez Canal plays
in the entire
global economy.
Something like 30% of
the world's shipping
passes through
it every year.
- The Ever Given
accident ends that
instantaneously.
-It's stopping 50
ships a day
from passing through,
worth $10 billion
of trade daily.
- The ship has already
passed through the canal
20 times without
incident.
What is different
this time?
Now, using
eyewitness testimony
and every available
source of evidence,
we will digitally
dissect the disaster.
What goes wrong on
the Ever Given?
[Narrator] Because of
its vast size, the cargo
vessel Ever Given
completely blocks
the Suez Canal by
jamming itself
across both banks.
- It's what's known as
an ultra-large
container ship.
It displaces 200,000
tons and can carry up
to 20,000 shipping
containers at once.
It's loaded with a
billion dollars' worth
of consumer goods
furniture, electronics.
- Like all
vessels this big,
the ship carries an
AIS, or automatic
identification system.
This continuously
broadcasts the Ever
Given's position,
course, and speed.
It can be used to
create a timeline
of the accident.
- On the 23rd of March,
the ship arrives
at the southern entrance
to the Suez Canal.
- The Suez Canal
is 120 miles long,
but at its narrowest,
just 673 feet wide
barely more than
three times the width
of the Ever Given.
[Dr. Auerbach] When you
look at the width of the
canal compared
to the enormous
size of this ship,
this is not an easy
passage with a lot
of room for error.
It's more like
threading a needle.
- But thousands of huge
ships pass successfully
through the canal every
year without incident.
What is different
on the Ever Given?
[Narrator] The
ship enters the
canal at 7:11 a.m.
By 7:41, it has
run aground,
wedging itself diagonally
across the canal.
What happens in those
critical 30 minutes?
The AIS tracking
data shows
navigational anomalies
early in the
ship's passage.
- Usually when ships
cruise through canals,
they do so in the
middle of the canal
because that's where
the water is deepest.
If we look at the
data from the
reports, however,
relatively soon after the
ship enters the canal,
we can see that the
ship starts swerving
to the left-hand side
towards the bank.
- What could cause this
anomalous behavior?
The key evidence doesn't
come from the ship
or the canal authorities.
- A few days before the
Ever Given started going
through the Suez
Canal, the Egyptian
Meteorological Services
issued weather warnings.
Every spring in Egypt
and in North Africa
and the Arabian
Peninsula,
the Khamaseen winds go
through that region.
- The name "Khamaseen"
comes from the
Arabic word for "50,"
meaning the 50 days
a year over which
it tends to blow.
Weather data for
the 23rd of March
shows wind speeds in
the area reaching
46 miles per hour.
- On the day that
the Ever Given moves
through the canal,
the Khamaseen winds are
blowing from the south,
hitting the side
of the ship.
♪
- This could be
significant.
Loaded with
containers, the side
of the Ever Given
is a towering
wall of steel a
quarter mile long.
- This creates a massive
area for the wind
to be impacted upon.
You're looking
at 14-story-high
walls, essentially,
that act as a sail.
And actually, from
personal experience,
it can move the
vessel significantly.
- This theory is backed
up by critical evidence
from the Voyage Data
Recorder, or VDR,
the equivalent of an
aircraft's black box.
[Dr. Auerbach] VDR data
shows that immediately
after the ship
enters the canal,
the wind is blowing
on its right side,
which explains why
it's being pushed
towards the left
bank of the canal.
But sometime later,
the wind switches
and is now blowing
on its left side,
which pushes it
towards the right.
A little while later,
the wind changes again,
blowing again towards
the right side.
So the ship is being
kind of seesawed
back and forth
by this powerful
shifting wind as
it's trying to
navigate what, to it, is
a quite narrow canal.
- It is clear that
the Khamaseen winds
are pushing the massive
ship off course,
but the evidence suggests
that wind alone cannot
explain this disaster.
[Nadia El-Awady] When
ships travel through the
Suez Canal, they
go in convoys.
So right in front
of the Ever Given
was a ship called
the COSCO Galaxy,
which is pretty
much as large as
the Ever Given is.
Even though there were
gusty winds at the time,
the COSCO Galaxy
gets through,
but the Ever
Given doesn't.
There has to be a reason
for the Ever Given
not getting through
and getting wedged
that isn't just
about the winds.
♪
- What is so different
about the Ever Given?
[low rumbling and
screeching]
[Narrator] Why does the
Ever Given end up jammed
across the Suez Canal
when the ship right in
front makes it through
without incident?
- If we compare the
behavior of the two ships
and see if there are
any differences,
that might give us
a clue as to what,
in fact, happened.
- The tracking data
of the COSCO Galaxy
and the Ever Given
shows that shortly
after entering the
canal, the powerful
Khamaseen winds
push them towards
the left bank.
The data shows
that both ships
immediately
increase speed.
♪
This increases the
amount of water
flowing across the
rudder, increasing
maneuverability.
But after this point,
the behavior of the
two ships diverges.
- The data shows
that the COSCO Galaxy
slows down, but the Ever
Given does the opposite.
It increases speed
until it's traveling
between 12 and
13 1/2 knots,
which is a blistering
speed for the Suez Canal.
- The recommended
speed limit is
just 8 to 9 knots.
Going faster helps
with the steering,
but it comes
with problems.
- So when you
turn the rudder,
the back or the
rear of the ship
will start to swing,
and the faster you go,
the harder it will be
to control the swing.
♪
- This fits the Ever
Given's tracking data.
It begins swinging
from side to side,
repeatedly coming very
close to the banks.
Immediately before
the accident,
the back of the
ship moves towards
the left bank with
increasing speed.
What causes this anomaly?
[Dr. Somara] When
a vessel is moving
through water,
the water rushing
past its sides
quickly replaces
the void that it's
creating at the back.
That's fine on
open waters,
but when you're in a
restricted waterway
like the Suez, that
effect can be dramatic.
- The problems occur
when the ship is closer
to one bank
than the other.
- A narrowing
of the waterway
on one side of the
container ship
means that the water
is having to move
much faster than
the other side.
- This produces a
force known in physics
as the Bernoulli effect.
- And wherever you've
got fast-moving fluid,
in this case water,
you've got very
low pressure, and
low pressure is what
causes a suction effect.
So the higher pressure
on the other side
pushes the ship over.
- This phenomenon is
called the bank effect.
The faster the
ship is going,
the more powerful it is.
And at the time
of the disaster,
AIS data records
the Ever Given
traveling well above the
recommended speed limit.
- So as the stern
of the Ever Given
gets close to
the left-hand
side of the bank, it
gets sucked in due
to the bank effect.
- This causes both ends
of the massive ship
to pivot in opposite
directions.
[Nadia El-Awady] The
front of the ship,
the bow, starts rotating
clockwise.
And what that
does is that
in this narrow
section of the canal,
the ship ends up
getting wedged in
between the two banks.
- A combination
of high winds
and the bank effect
strand the ship.
But this only
happens because she
is traveling fast and
steering erratically.
What is going on
aboard the Ever Given?
The captain of the ship,
Krishnan Kanthavel,
is a highly
experienced mariner.
But Suez is so
tricky and narrow
that every ship
must be guided by
specialist canal
pilots from the
Suez Canal Authority.
- Asking who's
really in charge
of this whole
moving carnival
is a complicated
question.
The Suez is a very tricky
bit of navigation.
So while the
captain is always
an overall command
of the ship,
it's really the pilots
who are supposed
to be telling the
crew what to do.
But technically, they're
just consulting.
They're not
really in charge.
So even if it's the
pilot's instructions
that cause a calamity,
it's still the captain's
responsibility.
It's his ship.
- The voyage data
recorder provides
valuable audio
recordings of what
is actually happening on
the Ever Given's bridge.
[Nadia El-Awady] What
happened on the day is
that as the conditions
got worse,
the two pilots we
have a senior pilot
and a junior pilot
they start arguing with
each other in Arabic.
- No one else on the
bridge speaks Arabic.
- The rest of the
crew aren't sure
what they're
talking about
because of the
language barrier.
But apparently,
the junior pilot
is not happy with
the decisions
that are being made
by the senior pilot.
- 20 minutes before
the accident,
the Ever Given
increases speed,
and we know this is a
contributing factor.
[Dr. Auerbach We know it
was the senior pilot
who initially ordered
the increase in speed,
but what happens
after that is more
of a gray area.
Did the pilot assume
that the captain
would give the command
to lower speed,
or did the captain
assume that the pilot
would give instructions
about when the speed
needed to be lowered?
- Whatever happens,
the ship continues
along the Suez Canal
at high speed,
swinging from one
bank to the other.
So why doesn't the
captain step in?
- According to the
captain's statement,
he twice ordered the
rudder to be centered
to avoid the ship
from swinging,
but in the confusion
of who was
giving the orders,
apparently that
did not happen.
- This disaster is
the result of
multiple factors
physical, natural,
and human.
We can now explain how
it all comes together.
March 23, 2021.
The Ever Given enters
the Suez Canal.
Almost immediately, the
strong Khamaseen winds
push it towards
the left bank.
The pilots order an
increase in speed
to assist with
steering in the
unstable conditions.
- You have this
situation where the
wind is increasing
and also changing
the quarter where
it's coming from,
so the senior
pilot is giving
instructions to the crew
to either move hard
right rudder or
hard left rudder,
depending upon the
direction that the
wind is coming from,
and this is all an
effort to try to stop
these wild oscillations.
- The giant ship
gets too close
to the left side
of the canal.
The bank effect kicks
in, sucking the
stern of the ship
into the side
of the canal and
rotating the entire
vessel clockwise.
The Ever Given grounds
itself simultaneously
on both banks,
wedged diagonally
across the canal.
Despite frantic efforts,
it takes six days to
free the Ever Given.
[Dr. Auerbach] And by
then, you had 429
vessels waiting passage.
-It isn't until the
afternoon of March 29
that she is finally
re-floated.
[ship horn blaring]
[workers cheering]
[Narrator] It's been
estimated that
the Ever Given
disaster costs
$60 billion in
global trade.
That is $400 million for
every hour she is stuck.
- It might seem at
first glance that as
naval accidents go,
this one's pretty mild,
but the cost of all
this, the damage done,
goes far beyond the
financial loss.
I mean, these are real
people with small
businesses and jobs
that go under if
they don't get the
supplies that they need
because this vital
supply chain was broken
by a single ship.
- Since the Ever
Given disaster,
the Egyptian government
has announced
that it will be
spending $10 billion
on widening the canal
and also deepening it.
-The aim of all this work
is to prevent a repeat
of the disaster
that cost so much.
Since then, the Ever
Given has managed
to pass successfully
through the canal
without getting stuck.