The first catastrophe I study in Shit Doesn’t Just Happen: The Gift of Failure is the Titanic.
Phillip Franklin, White Star Line vice-president, 1912
Titanic is a classic example of systematic cascade events, many unrelated to each other, any of which if corrected, would have averted the final event.
The Facts: 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.
Hubris is the father of tragedy and catastrophe.
Roughly 1,000 BC: Snow falls on Greenland, which will become the iceberg the 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.
I cover the six cascade events leading to the final event, the sinking. Cascade #3 is:
CASCADE THREE: Lack of a sufficient number of lifeboats for the crew and passengers.
Titanic carried enough lifeboats to accommodate 1,178 people; for a ship with a capacity three times that. It must be understood that at the time, the theory was that lifeboats weren’t exactly that. They were transfer boats, as it was believed that if needed, there would be time to radio for help, and then transfer all passengers and crew to the responding vessels. In fact, the lifeboat capacity for Titanic exceeded that which was legally required at the time: 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.
Plus, the Titanic displaced 52,000 tons, more than five times that maximum. By constructing the largest vessel at the time, the builder was outstripping maritime law. As we push the limits of technology and construction, constantly going for bigger and faster, there is a need to be self-regulating in terms of safety.
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. There were also two emergency cutters with a capacity of 40 each.
Interestingly, the Titanic had 16 sets of davits, each of which was capable of handling 4 lifeboats. Doing the math, this gives the ship the capacity to carry 62 wooden boats (62 boats x 65 capacity equals 4,030 people). The original design for the Titanic called for 48 lifeboats, which would have held 3,120 people. But that number was reduced to 16 for various reasons (including esthetics as some of those additional lifeboats would have blocked the view from the deck).
Lesson: When building technology that 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 sinking, naturally, 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 organically 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.
To rely on simply obeying the law when dealing with safety issues, one leaves things open to a final event that will require the law to be changed after the fact.
It should not require death to update safety requirements.
For a good portion of my life, I was a warrior. I block that out a lot these days, although the pain from various parts of my body remind me otherwise at times. From when I was 17 years old I was trained as a warrior and spent a large portion of my years living that life, delving deeper and deeper into it, volunteering for more and more. In a way the pure warrior is a defense against the pain of life although it brings other pains; physical, emotional and spiritual.
But I see now there are much more important and difficult battles in life.
Sometimes we feel like we’re all alone. And sometimes we think everyone else is doing just fine. But everyone is carrying around a burden we can’t see and fighting a battle we often can’t imagine, never mind understand. They might be sick. They might be depressed. They might be in pain, physical or emotional, or both. They might have experienced trauma or tragedy in their life recently. Or old pains resurface. They might be suffering because someone they love is suffering or suffered or has died. There are some pains people outside of the ones who suffer it can’t even begin to comprehend.
But we can’t see it. Because we all put on our best to go out there in the world to face it and do what we have to do. To fulfill our responsibilities.
Lately, I’ve focused more and more on the fact that I don’t know shit about other people. And because of that, I have to be kinder. To let go of my preconceived notions, my selfishness, and my impatience.
To be a kinder person, because everyone I meet is fighting a hard battle I cannot see.
As a Green Beret, I was focused on two main reasons for catastrophe planning and preparation. As a writer, I learned about a third, more subtle benefit of catastrophe planning, in order to have a successful career in a field where 99% of those entering eventually fail.
You Catastrophe Plan for 3 reasons:
- To avoid the catastrophe. Since at least one of the six cascade events is human error, if we plan and prepare adequately, we can delete the human error cascade event from the situation, thus avoiding the final event.
- To have a plan, equipment, training etc. in place in case the catastrophe strikes. If we project out possible final events, we can prepare for their eventuality. I am adamant that preparation is critical, even more so than actual actions during the final event. It is too late when we reach a final event to prepare for it. Even the best-trained individual will be overwhelmed by a final event if they have not prepared for it. In the last catastrophe we cover in this book, you’ll see how the fact someone planned for possible catastrophes helped avert a terrible final event.
- To give you peace of mind in day-to-day living so you don’t constantly have to worry about potential catastrophes because you are prepared for them. This allows you to experience a higher quality of life. You’ve done your best to avoid the catastrophe, making the likelihood that much less. And you’ve done your best to prepare for the catastrophe, so you can focus on other things. Too many people worry about potential catastrophes without preparing; this is a fundamental failure and fuels fear. Fear feeds on itself and is debilitating. Often, extreme fear can bring about an event that would have never occurred otherwise. Confident people are prepared people.
Excerpt from Shit Doesn’t Just Happen: The Gift of Failure
Why be concerned about catastrophes?
- False Assumptions
What is a catastrophe?
- The final event of the dramatic action, especially of a tragedy
- An event causing great and often sudden damage or suffering; a disaster
- Utter failure
We are usually surprised when a catastrophe strikes. There is a tendency to believe that a catastrophe is something that is unexpected, always happens suddenly, and is caused by a single thing going wrong.
These are false assumptions. The vast majority of catastrophes can easily be predicted with some attention and focus. If predicted, they can often be planned for and averted. If unavoidable, they can be planned for and their results blunted and minimized. Catastrophes occur suddenly only in terms of the final event, the catastrophe itself; however, the buildup, via a series of what we will term cascade events, can be very long in the unfolding. And at least one of these cascade events involves human error. Thus most catastrophes can be avoided.
In this book I walk through seven well-known catastrophes, showing the six cascade events leading to the seventh and final event. I list the events, pointing out how each could either be noted (knowledge often can prevent the cascade of events that lead to #7, the final event) or corrected. The key for us to focus on is what was learned and changed because of each, saving the lives of countless others afterward.
- A catastrophe is closer than you think.
While you might not have personally been in a catastrophe or a tragedy, I can assure you that we have all come close more often than we realize. Many times we’ve been to a #4, #5 or #6 cascade event and not gone into the final event; therein lies one of the key deceptions that lulls us into complacency.
As we will see in the seven examples, there are many places along the cascade of events where a single person saying or doing something, could have stopped the cascade and prevented the catastrophe or, at the very least, minimized the effect of the final event. Thus it’s very important for us to understand how seemingly innocuous events can play a tragic role if left unchecked. This book is also about the gift of failure: how we can learn from past catastrophes in order to avoid ones in the future. The aviation industry works off the gift of failure in that practically every safety innovation introduced is invented in response to a plane crash.
Ultimately, it’s about gaining the proper catastrophe mindset, which goes against our natural instincts because . . .
- Delusion events fool us.
We often look at narrow escapes or near misses as ‘fortunate’ events where disaster was averted; indeed, we get to the point where we normalize near misses. Instead, we need to look at these ‘fortunate’ events as cascade events where we came close to catastrophe and were simply fortunate that we didn’t hit the final event. Relying on luck is a very dangerous mindset yet we immerse ourselves in it on a daily basis. We often call it ‘dodging the bullet’ forgetting that when a bullet hits, the results are catastrophic to the target.
We need to focus on cascade events, see their negative potential, and reduce their occurrence. A cascade event that doesn’t lead to a final event we will label a delusion event. A cascade event and delusion event are exactly the same: the only difference is that a delusion event doesn’t result in a final event.
Delusion events lead us into delusional thinking: that we will continue to dodge the bullet by doing nothing. In fact, a delusion event, where something goes wrong, but doesn’t lead to the final event, reinforces our complacency to do nothing about correcting a delusion event and increases our risk of a final event, a catastrophe. We take it as the status quo, not an aberration. Delusion events lead to the normalization of unacceptable risk. For a very simple example, the further you drive with the check engine light on in your car, the more you think it’s normal for that light to be on. This is called normalization by Diane Vaughan in her book The Challenger Launch Decision.(1) We’ll discuss this catastrophe as one of our seven in the second book in this series, focusing on organizational thinking about delusion events.
How many times have you been in a hotel or restaurant or store and the fire alarm goes off? How many times did you hurry to the exit? Rather, didn’t you, and everyone around you, with no smoke or fire, stand around, and wait for someone to actually announce what’s going on? We’ve been desensitized by false alarms to the point where the alarm serves little purpose any more.
The Harvard Business Review did a study in 2011 (2) and found that delusion events (multiple near misses) preceded every disaster and business crisis they studied over a seven-year period. Besides delusional thinking leading to normalization, the other problem is outcome bias. If you flip a coin six times and it come up heads six times, even though statistically rare (1 chance in 64 attempts), you will tend to start focusing on the result, believing all coin tosses end up heads. While we know this isn’t true, we tend to base our probabilities of future occurrences not on the statistics of reality but on our experiences.
This is called heuristics and is at the root of many disasters. Hueristics is experience-based techniques for learning and problem solving that give a solution which isn’t necessarily optimal. We generalize based on the things we value most: our own experience and information related to us from sources we trust. Think how many ‘truths’ you have heard that turn out to be nothing more than an urban legend or a superstition. Yet we base many of our daily and emergency actions around these.
A small example from The Green Beret Survival Guide: every so often there is a news article about someone in a desperate survival situation who claims drinking their urine helped them make it through. That’s absolutely the wrong thing to do. But it’s one of those stories that gets repeated enough, we believe it to be true. Because we only hear from survivors, who did so despite doing the wrong thing.
It is human nature that we focus on successful outcomes much more than negative ones. It’s irrational, but that’s part of being human. In the same way, managers and leaders are taught to plan for success, not failure, since it’s believed planning for failure is negative thinking. In fact, I would submit that many people are part of a cult of positive thinking that often excludes reality.
The good news is we tend to be predictably irrational and understanding our tendency to make a cascade event a delusion event, is the first step in correcting this problem.