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TITANICa Human Performance Case Study
Picture by. Charley Ayers
What was the name of the three giant vessels built by Harland
and Wolff?
• Olympic• Titanic
• Gigantic
Which one of the three ships had its name changed?
• Gigantic
• It would be changed to the Brittanic
The Titanic was also known as the RMS TITANIC what
does RMS stand for?
• Royal Mailing Steamer
TITANIC FACTS
• March 31, 1909 construction begins by Harland and Wolff for WHITE STAR LINE in Belfast Ireland.
• The ship cost 7.5 million dollars to build. Today’s cost 400 million dollars.
• Skilled shipyard workers earned $10.00 per week.
• One First Class ticket would cost 4 to 8 months wages.
TITANIC was one of the largest movable objects ever built.
• The ship was 883 feet long, 92 feet wide.
• Weighed 46,328 tons.
• Was 104 feet high from keel to bridge.
• Powered by 3 engines (2 reciprocating, 1 turbine), which equaled 46,000 total hp.
• Total capacity 3547 people, 2,227 were on board.
TITANIC a floating city!!Brief description of food supplies on board:
• 75,000 lbs. fresh meat
• 11,000 lbs. fresh fish
• 40,000 fresh eggs
• 200 barrels of flour
• 2.75 tons of tomatoes
• 40 tons of potatoes
• 1,500 gals. fresh milk
• 20,000 bottles of beer and stout
• 1,500 bottles of wine
The Titanic’s Hull
• Protected by double bottoms.
• Separated by 15 “watertight” bulkheads which extended half way up the hull.
• Bulkheads could be sealed by activating watertight hatches which would compartmentalize the hull into 16 different sections.
• As a result the ship was considered UNSINKABLE.
Trivia Facts
• Ship cost 7.5 million dollars.
• Titanic movie cost 250 million dollars.
• Titanic sank in approximately 2 hrs. 40 min.
• The film Titanic runs 3 hrs. 14 min.
• It took 3 years to build the Titanic.
• It took approximately 3 years to make the film.
FIVE PRINCIPLES OF HUMAN PERFORMANCE
1) People are fallible and even the best make mistakes.
• Neither manager nor worker is immune. It is human nature to be imprecise, to err. Consequently, error is inevitable.
FIVE PRINCIPLES OF HUMAN PERFORMANCE
2) Error-likely situations are predictable, manageable, and preventable.
• Just as we can predict that a person writing a personal check at the beginning of new year stands a good chance of writing the previous year on the check, the same can be done in the context of work at the job site. Recognizing the likelihood of such an error permits us to manage the situation proactively and prevent its occurrence.
FIVE PRINCIPLES OF HUMAN PERFORMANCE
3)Individual behavior is influenced by organizational processes and values.
• Traditionally management of human performance has focused on the “individual error-prone or apathetic worker.” However, all work is done within the context of the organizational processes, culture, and management control system which contribute the lions share of the causes of human performance problems and resulting plant events.
FIVE PRINCIPLES OF HUMAN PERFORMANCE
4) People achieve high levels of performance based largely on the encouragement and reinforcement received from leaders, peers, and subordinates.
• The level of safety and reliability of the plant is directly dependent on the behavior of people. Human performance is a function for behavior and the results of that behavior. Behavior is mostly influenced by the consequences experienced by a person when that behavior occurs. Consequently, what happens to workers when they exhibit certain behaviors is an important factor in improving human performance.
FIVE PRINCIPLES OF HUMAN PERFORMANCE
5) Events can be avoided by an understanding of the reasons mistakes occur and application of the lessons learned from past events.
• Events can be avoided reactively and proactively. Learning from our mistakes and the mistakes of others is reactive; it’s after the fact. Anticipating how the next event or error can happen by applying the fundamentals of human performance to plant work is proactive.
5 Principles / 6 Tools1) People are fallible and even the
best make mistakes.
2) Error-likely situations are predictable, manageable, and preventable.
3) Individual behavior is influenced by organizational processes and values.
4) People achieve high levels of performance based largely on the encouragement and reinforcement received from leaders, peers, and subordinates.
5) Events can be avoided by an understanding of the reasons mistakes occur and application of the lessons learned from past events.
PersonalSafety
Assessment
Self-Check(STAR)
Questioning Attitude(QV&V)
P r o c e d u r e U s e & A d h e r e n c eC l e a r C o m m u n i c a t i o n T e c h n i q u e s
STOP When Unsure
Work PreparationTask Assignment
Clear AccountabilityPre-Job Brief / Post-Job Brief
F i e l d I n v o l v e m e n t / J o b O b s e r v a t i o n
Communication & Information
Common MissionGoals, ExpectationsClear Priorities, Roles& ResponsibilitiesHigh StandardsKnowledge & Skill
Maintain FocusManage ChangePerformance MonitoringObservation FeedbackEffective Problem SolvingConservative Decision Making
EVENTFREEHUMANPERFORMANCE
OBJECTIVES Identify the sequence of events that led to
the fatal shipwreck of the Titanic. Determine the contributing factors of the
event. Identify the practices that should have
prevented the event. Identify Human Error Prevention
Techniques and practices used to prevent similar events (MNS Specific).
Organizational Behaviors
• Managers foster a culture that values prevention of events.
• Managers strengthen the integrity of defenses to prevent or mitigate the consequences of error.
• Managers preclude the development of error-likely situations.
• Managers create a learning environment that promotes continuous improvement.
Harland and Wolff build two mammoth passenger
liners!• Titanic and the Olympic were built at the
Harland and Wolff shipyard in Belfast Ireland, for the White Star line.
• Titanic slipped from her Belfast dry dock on May 31, 1911 and was towed to her fitting out basin for completion.
• The Titanic was fitted out in a little over ten months and left Belfast on April 2, 1912 for sea trials.
Titanic was declared sea worthy after a little over eight hours of sea trials.
• Sea Trials are designed to prove capabilities of equipment, crew, and procedures during both normal and abnormal conditions.
• Only one life boat drill was conducted and several members of her crew of nearly 900 would not report on board until the day of departure.
Titanic’s Maiden Voyage
• Titanic left Southampton, April 10 1912, first stop Cherbourg, France, final, destination New York.
• Scheduled 7 day voyage.
• Titanic was commanded by Captain Edward J Smith.
• Ironically, he expected this to be his last voyage and crowning achievement.
Five years prior to the Titanic, Captain Smith commented on the technology in the shipping industry.
• “I will say that I cannot imagine any condition that would cause a ship to founder … Modern shipbuilding has gone beyond that.”
Titanic witnessed close call while leaving port!
• Suction created by her passing caused the New York to break loose from pier and swing dangerously near her path.
• Seven months prior, her sister ship, the Olympic passed the HMS Hawke, drawing it into its side causing damage to both vessels.
Titanic alters course!
• The arctic winter was unusually warm and ice had been reported at lower latitudes than normal.
• Titanic would proceed on a more southerly route.
• Other than this minor change, the first days at sea were uneventful.
Sunday night April 12thTitanic was steaming into an area of reported ice!
• Titanic speed was over twenty-two knots.
• Air temperature was dropping and below freezing.
• Marconi operators received ice warnings from four different vessels.
• Warnings were passed on to Captain Smith.
• Only one warning was posted in the chart room for officers’ information .
Iceberg Detection
• Radar and Sonar were unknown of in 1912.
• Icebergs could only be detected by vigilant observation by the crew.
• Light reflected by the surface or waves splashing against the base of the berg were the only signs of ice in the water.
• With no moon and a dead calm sea, these indicators were absent.
Leaders exhibit the following Behaviors
• Facilitate open communications.
• Promote teamwork to eliminate error-likely situations and strengthen defenses.
• Search for and eliminate organizational weaknesses that create the conditions for error.
• Reinforce desired jobsite behaviors.
• Value the prevention of errors.
Change of command on bridge!
• At 9:20 P.M., Captain Smith left Second Officer Charles H. Lightoller in command.
• Smith’s instructions were, “If in the slightest degree doubtful, let me know”.
• 9:30 Marconi operator received a wireless message from the Mesabe warning of pack ice and large icebergs in the Titanic’s path.
• The message was not forwarded to Captain Smith or the bridge.
Leaders verify that organizational processes and values are aligned with desired individualbehaviors and desired results.
10:00 P.M. Second Change of Command takes place
on the bridge.
• Second Officer Lightoller turned command over to First Officer William Murdoch.
• Murdoch was advised that they would come into the reported ice at about 11:00 P.M.
• Watch relief in the crow’s nest also occurred at this time.
Californian sends wireless message to Titanic!!
• Californian stated “Say old man we are stopped and surrounded by ice”.
• Titanic replied “Shut up! Shut up! I am working Cape Race.” Titanic was trying to beat the record set earlier by sister ship Olympic.
• The Californians report was never forwarded.
11:35 Huge Ice Berg was discovered!
• Immediately the crow’s nest rang the bell and reported huge ice berg ahead.
• At nearly the same time First Officer Murdoch saw the berg and ordered “Hard a’starboard!” and “Full speed astern!”
• These orders were intended to slow the vessel and steer to the left of the ice.
• At 11:40 Murdoch then ordered “Hard a’port!” in an attempt to swing the stern clear.
“Knight’s Seamanship”The Ruling Seamanship
Manual• States that striking head-on with the bow
was far more desirable then an oblique strike, should a collision be unavoidable.
A Seaman’s Worst Nightmare!!
• At 11:40 the vessel grazed the ice, hull plates ripped open along a 250 to 300 foot section.
• This opened the the forward six compartments of the ship to the sea.
• Perhaps no more than twelve square feet of hull surface was opened, but the damage would begin dragging the Titanic down by the bow.
Ship’s Chief Architect, Thomas Andrews inspects
damage!• Andrews after learning of flooding in six
compartments, reported to Captain Smith that the ship had only a short time to live.
• 12:10 AM on April 15, Captain Smith ordered Marconi operator to send out a “CQD”, Calling Distress.
• Many on board including some officers were not aware that the ship had struck an ice berg.
Carpathia answers distress signal!
• From approximately 60 miles away the Carpathia responded to distress signal.
• The Californian, who was possibly 5 to 18 miles away failed to answer.
• She had shutdown for the night in heavy ice and the Marconi operator was no longer at his station.
Individual Behaviors
• Individuals communicate to create shared understanding.
• Individuals anticipate error-likely situations.
• Individuals confirm the integrity of defenses.
• Individuals improve personal capabilities.
Lifeboat operation progressed slowly and
with significant confusion.
• Only 16 regular lifeboats and 4 collapsible boats were on the Titanic.
• This was only half the lifeboats that was needed for the passengers and crew.
• Titanic had capacity for sixty lifeboats.
• British Board of Trade regulations did not require vessels to carry enough lifeboats for all on board.
Lifeboats
• Passengers did not realize the danger and were slow to get to the lifeboat stations.
• Ships officers were unfamiliar with lifeboat davits and their capacities.
• Most lifeboats were half full when they were lowered into the water.
• Crew members were unfamiliar with small boat handling and had to be taught how to row by passengers.
Mystery Ship Spotted!!
• Shortly after midnight, Fourth Officer Boxhall sighted the mast light of another vessel, apparently a steamer.
• His Morse signals would go unanswered.
• At 12:45 A.M. Quartermaster Rowe began firing distress rockets at five minute intervals.
Could it be the Californian?
• Even though distress rockets had been sighted by the Californian and reported to her captain, Stanley Lord, they went unanswered.
• Captain Lord, upon hearing of the signals, ordered the Morse lamp manned.
• With no response Captain Lord did not investigate the rockets nor did he re-station his Marconi operator who had secured at 11:35 P.M.
Even today it is unknown whether the mast lights sighted were those of the Californian or
another ship in the area - possibly the Norwegian Samson,
operating illegally in the area for seals.
The Titanic Sinks
• The bow sank and the stern rose into the air.
• The ship broke in half with the stern settling back into a horizontal position for a few moments.
• The bow drifted to the bottom, two and one half miles below, followed by the stern.
• Passengers still on board either jumped or were thrown into the 33 degree water.
By 3:30 A.M. the Carpathia arrives at the scene!
• The Carpathia began picking up lifeboats.
• At 8:50 A.M. she headed for the New York harbor.
• The Californian, after learning of the accident, had arrived at the scene and remained in the area searching for survivors.
• No others were found.
Carpathia arrived in New York, Thursday evening
April 18, 1912.
• Of the 2,227 enthusiastic passengers, only 705 would survive.
Case Study
• Divide into groups of five.
• Event documentary will be provided.
• Using the Five Principles of Human Performance determine factors that led up to the event and document this information on a flipchart.
• Select a speaker and report your findings.
Evaluation
• Facilitate a group discussion identifying problem areas in your group.
• Utilize the six tools of human performance as prevention techniques to prevent identified problems from becoming events.
