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THE CHALLENGER: ORGANIZATIONAL FAILURE
“My God, Thiokol. When do you want me to launch? Next April?” Senior NASA official on a conference call to the manufacturer of the solid boosters, when they recommended on the morning of the launch that it be postponed.
THE SINKING OF THE KURSK
“It’s dark here to write, but I’ll try by touch. It seems like there are no chances, 10%-20%. Let’s hope that at least someone will read this. Hello to everyone. There is no need to despair.” Captain Lieutenant Dmitri Kolesnikov, commander 7th Compartment (turbine room) Russian submarine Kursk.
THE SULTANA EXPLOSION
“If we arrive safe at Cairo it would be the greatest trip ever made on the western waters, as there were more people on board than were ever carried on one boat on the Mississippi River!” William J, Gambrel, first clerk & part owner of the steamship Sultana.
“Should hostilities once break out between Japan and the United States, it would not be enough that we take Guam and the Philippines, nor even Hawaii and San Francisco. To make victory certain, we would have to march into Washington and dictate the terms of peace in the White House. I wonder if our politicians (who speak so lightly of a Japanese-American war) have confidence as to the final outcome and are prepared to make the necessary sacrifices.” Admiral Yamamoto, Commander Japanese Navy. (Note that this quote was used extensively for propaganda purposed by the United States by leaving out the last sentence)
Mulholland & The St. Francis Dam
During the Los Angeles Coroner’s Inquest, William Mulholland said, “this inquest is a very painful for me to have to attend but it is the occasion of that is painful. The only ones I envy about this whole thing are the ones who are dead.” In later testimony, after responding to a question, he added, “Whether it is good or bad, don’t blame anyone else, you just fasten it on me. If there was an error in human judgment, I was the human, I won’t try to fasten it on anyone else.” William Mulholland, chief engineer, Water Department Los Angeles
THE LAST CZAR
“I am not prepared to be a tsar. I never wanted to become one. I know nothing of the business of ruling.” Nicholas II, last Czar of Russia.
“It was repugnant. Through the eyes of our civilized society it was a disgusting decision. My dignity was on the floor having to grab a piece of my dead friend and eat it in order to survive. ‘But then I thought of my mother and wanted to do my best to get back to see her. I swallowed a piece and it was a huge step – after which nothing happened.” Dr. Robert Canessa
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.