Task / environmental conditions
What factors undermined the effectiveness of the defences and impacted on equipment and human performance?
Identify task / environmental conditions
Identify organisational factors (oft‟s)
• • DE Maritime regulations were based on nt of ship), not number of lifeboats (seats) per person on board. PR No formal procedure for operating ships in areas of iceberg activity OR There was no dedicated ice patrol or ice warning system in place in the North Atlantic shipping lanes during the months of iceberg activity
Iceberg
Iceberg
The Titanic Sinking
Absent or failed defences
What defences were in place that should have prevented the incident but failed or were absent? What defences were in place that should have mitigated the consequences of the the incident but failed or were absent?
Incident
Outcome: What happened that was unacceptable?
Incident
The RMS Titanic whilst on its maiden voyage struck an iceberg and sank 2 ½ hours later with the loss of 1502 lives.
Watertight door
Progressive flooding
Progressive flooding
Lifeboats launched
Individual / team actions
What actions were taken which directly lead to the incident occurrence?
• • • • • • • • • • • HW TR OR CO IG MC PR MM DE RM CM Hardware Training Organisation Communication Incompatible Goals Management of Change Procedures Maintenance Management Design Risk Management Contractor Management
• • • • • • • • The maiden voyage of the Titanic Worst iceberg season for 50 years The night was uncommonly clear and dark The sea was like glass and waves could not be seen breaking on icebergs Crew inexperienced in high speed manoeuvres. There was a rush to introduce the Titanic into service The MD of the shipping line was on board The ship was attempting a trans Atlantic crossing record
Identify the individual / team actions
• Radio operator gave priority to passenger telegrams over ice warning messages • The Officer of the Deck cut the engines and steered away from the iceberg, which was not the correct action for a ship of that size • Captain Smith was operating the ship at too high a speed for the local conditions
Identify absent or failed defences
• • • • • • • • 6 radio warnings of ice not acted upon Extra lookouts were not posted Lookouts did not have binoculars Lack of a formal procedure for collision avoidance Collison blankets were not used after impact to stem water ingress Watertight doors did not prevent flooding of compartments Insufficient lifeboat capacity for the ships compliment A full lifeboat drill was never carried out
Events leading to the accident
3
• At 0025 hours the Captain orders “women and children first to the lifeboats. • At 0045 hours the first lifeboat is launched • Lifeboats are launched with less than full capacity
The crow's nest is ordered to „keep a sharp lookout for ice‟ at 2100 hours.
•
Events leading to the accident
2
• The Californian radios to Titanic that it is surrounded by ice. Before its position could be relayed the R.O. on Titanic tells the Californian R.O to shut up and let him broadcast his important passenger personal telegrams. Californian R.O. gives up trying. • Lookout Frederick Fleet spots an iceberg and issues a warning to the bridge at 23.39 hours • Bridge orders “Stop”, “Full astern” and “Hard a starboard” • The Titanic struck an iceberg on Sunday, April 14, 1912 at 2340 hours and begins to flood. • F.O. closes watertight doors damage inspected and estimated that the ship will remain afloat for 2 hours • At 0001 hours on Monday, April 15 1912, Captain orders the crew to prepare lifeboats and send a distress signal
Organisational factors
What organisational factors allowed these environmental conditions (issues) to exist or remain unaddressed?
Organisational Factor Types
Identify organisational factors (oft‟s)
• • • • • • • OR Delegation / responsibilities for the safe running of the ship were not clearly defined IG Setting trans Atlantic crossing record took precedence over the safe operation of the ship TR No special training was provided for the ship's officers on the handling characteristics of a ship the size of the Titanic. TR There was no shakedown or practice cruise. DE Bulkheads, that were assumed to be watertight did not have transverse overheads (sealed tops or coverings). DE There was only one radio channel. PR Collision avoidance procedures incorrect.