Every disaster requires seven things to go wrong. Six Cascade events leading to the 7th event, the disaster. At least one of the Cascade events involves human error. Thus most disasters can be avoided.
By studying past disasters we can learn to avoid future ones. Focusing on the Cascade Events and how they can be stopped is key! The Gift of Failure
“There is no danger that Titanic will sink. The boat is unsinkable and nothing but inconvenience will be suffered by the passengers.” Phillip Franklin, White Star Line vice-president, 1912
The Titanic sank in the early morning of 15 April 1912 after hitting an iceberg in the North Atlantic. The official death toll is 1,517 making it #5 on the all time fatality list for shipwrecks. What makes this sinking notable is that the Titanic was the largest ship afloat at the time of its maiden voyage and was declared ‘unsinkable’ by its builders.
Roughly 1,000 BC: Snow falls on Greenland, which will eventually become the iceberg the Titanic strikes.
31 July 1908: Plans for Number 400 (Olympic) are presented to the White Star Line and approved. Number 401 (Titanic) is also approved.
31 March 1909: Construction begins on Titanic.
1909: The fatal iceberg calves off a glacier on the west coast of Greenland.
31 May 1911: Number 401 slides on 22 tons of soap and tallow into the water. It is not christened or formally named, keeping with White Star tradition.
2 April 1912: First sea trials of Titanic. 10 April 1912: Titanic sets out on her first, and last, voyage. 14 April 1912; 11:40 pm: Titanic strikes an iceberg. 15 April 1912; 2:20 am: Titanic sinks.
THE CASCADE EVENTS:
Cascade One: An unusual weather pattern caused more icebergs than usual and forced them farther south than normal. The ice that struck the Titanic was formed three thousand years ago, via snowfall on the western coast of Greenland. Compressed into ice, then slowly pushed downward and outward as part of a glacier, the iceberg calved into the open ocean about the time the keel of the Titanic was laid in Ireland, thus setting two objects, thousands of miles apart, on an inexorable collision course. The iceberg made a rather difficult and unlikely journey, from Greenland, to Baffin Bay, to the Davis Strait, to the Labrador Sea and into the North Atlantic. Less than one percent of icebergs calved in a year make it that far. By the time it struck the Titanic it was 5,000 miles from its origin.
Lesson: Expect the unexpected. The icebergs were farther south, but it was also April, the worst iceberg month. It was well known as the season went on that it was a bad year for icebergs in the North Atlantic. Thus, while it was unusual, it wasn’t unexpected that the Titanic encountered one during this trip.
Cascade Two” Rivets were of inferior material, some put in by inexperienced welders, causing more damage during the collision than should have occurred. The iron rivets were class 3 (best) instead of 4 (best-best). While many believe the hole ripped into the Titanic by the iceberg was huge, there were actually six small gashes, totaling about one square meter. That is an incredibly small group of holes for such a large ship, totaling an area less than the size of your dining room table. But the six holes were stretched along the side of the ship pouring water into six of sixteen watertight compartments: if four flooded, the ship was doomed. Additionally, the ‘watertight’ compartments were only that in terms of bottom and horizontal. They were open on the top.
Lesson: Set realistic goals and don’t skimp on the cost of construction. Class 4 rivets should have been used at the very least, if not steel. Even more important was over-reaching in construction. Building the world’s three largest ships at the same time caused shortages of material and skilled labor. Yet, this did not deter the company from doing it. They set a goal, which exceeded safe capacity, and many paid the price for it.
Cascade Three: Lack of a sufficient number of lifeboats for the crew and passengers. Titanic carried lifeboats to accommodate 1,178 people; for a ship with a capacity three times that. British vessels over 10,000 tons were required to carry at least 16 lifeboats with capacity for 50% of passengers and crew. The Titanic actually exceeded this requirement by having a capacity for 52% of the people on board. Unfortunately, there wasn’t a focus on the 48% that weren’t provided for. The Titanic carried 20 lifeboats. 14 were wooden with a capacity of 65 each. 4 were collapsible boats (wooden bottom, canvas sides) with a capacity of 47 each.
Lesson: When building technology outstrips current safety requirements, one should not take the easy way and adhere to outdated laws. The reality of the new technology requires a new reality in safety requirements. After the Titanic, the lifeboat requirement was changed so that a ship was required to carry enough lifeboats for its capacity, a common sense requirement that should have been implemented by designers and builders as ships grew larger. Sadly, while the Titanic’s lifeboats had the capacity for 1,178 people, there were only 706 survivors.
Cascade Four: The two lookouts in the crows nest didn’t have binoculars because the key to the locker holding them had left the ship before sailing. The key was held by David Blair, an officer who was re-assigned just before the Titanic sailed. He failed to turn over the key to the box holding this equipment. One of the lookouts, Fred Fleet, survived and told the official enquiry he had no doubt that he would have spotted the iceberg earlier if he’d had binoculars. When asked how much earlier, he said that it would have been in “enough time to get out of the way.” Aside: Curiously, ninety-five years after the sinking, the key and a postcard from Blair indicating his disappointment at missing the sailing sold at auction for almost $200,000.
Lesson: Key equipment is just that: key. Pun inevitable. To realize an essential piece of gear isn’t available should raise a red flag, not a shrug. Just because the key wasn’t available, doesn’t mean they couldn’t have broken open the box and gotten to the binoculars. But institutional inertia was at work here: the lookouts didn’t want to complain up the chain of command and be labeled trouble-makers. An organization has to establish an environment of openness where potential problems can be raised before they become cascade events, particularly with regard to safety equipment.
Cascade Five: The ship was going too fast for the conditions. Captain Smith had a delusional mindset. Each day the ship encountered no problem, it went faster. On the first day, Titanic covered 386 miles. Day two: 519. Day 3: 546. The Titanic was warned several times of icebergs in the area. The ship was sailing full speed into an area with obstacles. With lookouts who didn’t have binoculars. A ship that massive is very slow to turn and even slower to stop. During sea trials, the Titanic required 850 yards to come to a halt from full speed. And 3,850 yards to turn around.
Lesson: Human error via speed. ‘Slow down’ is a mantra that works more often than ‘speed up’ does. Many human made catastrophes are the direct result of speed. And not just in a conveyance moving too fast. Speed is dangerous in inspections, production, and many other areas. Paradoxically, Captain Smith was slow in his decision to order the ship to be abandoned. It took 45 minutes from the time Smith was told the ship was going to sink for the first lifeboat to be launched; and it was only partly full. It took another hour and twenty minutes for the last lifeboat to be launched. When speed was critical, Smith and his crew didn’t deliver.
Cascade Six: Warnings were ignored and the wireless radio wasn’t used correctly. The radio on the Titanic was the most powerful in the world at the time. Its normal working range was guaranteed for 250 miles, but it could often reach 400 miles. Interestingly, the range was much greater at night, reaching out to 2,000 miles. This is bolstered by the fact that the two radio operators had watches that went from 8 pm to 2 am and 2 am to 8 am. They were not on duty during the day. The wireless was engaged in transmitting messages to New York City during the Night To Remember, as they had piled up all day long. In fact, passenger communication was such a priority that when the Californian tried to radio about encountering ice, the Titanic’s operator replied with “Shut Up!”
Lesson: Lack of standing operating procedures with regard to the radio caused its ability to warn to be ineffective, and its ability to secure rescue after the final event to be minimal. While the most powerful radio was built into the Titanic, it was viewed more as a passenger amenity rather than an integral part of the ship and key to its safe operation. When we prioritize amenity over safety, the results can be catastrophic.
Final Event: At 11:40 PM on the 14th of April 1912, the Titanic struck an iceberg, causing fatal damage to the ship. It sank at 2:20 am on the 15th of April.
Lesson: The United States inquiry concluded that all those involved had followed the standards of shipping as set at the time. The disaster was therefore an “act of God.” In essence, the British inquiry reached the same point, noting that Captain Smith had not done anything particularly unusual, following long-standing practices of the time, which had not previously been shown to be unsafe. After all, British ships had carried over 3.5 million passengers in the decade before the Titanic with only 10 fatalities. Ultimately, they were following delusion events, making a disaster like the Titanic inevitable.
This and 20 other great disasters are covered in detail in The Green Beret Guide to Great Disasters.