The following is the final installment of a four-part series on the legacies of the Titanic disaster:
Lessons Learned: Causation: The “Error Chain” and investigating how and why it happened
The history of maritime investigations, since TITANIC, has been one of slow, and sometime frustrating, development. It has been 60 years since the legal obligation of maritime administrations to conduct investigations into any casualty to ships flying their flag was first adopted. The relevant provision of the 1948 International Convention for the Safety of Life at Sea was retained in the SOLAS Conventions of 1960 and 1974 and included in the 1966 Load Lines Convention. In addition, the IMO adopted no fewer than eight resolutions pertaining to different aspects of accident investigation between 1968 and 2005. The latest specifically addresses the fair treatment of seafarers, reflecting concern about criminal investigations that serve no other purpose than to feed the social climate of today. Most recently, in 2006, the International Labour Organization adopted a new provision on marine casualty investigation as part of its new consolidated convention on maritime labour standards and working conditions for seafarers. It is to the credit of the IMO that it has increased the pressure on laggard flag states by developing an enhanced accident investigation regime to supersede its existing Code for the Investigation of Marine Casualties and Incidents. Fundamental to this is the already agreed proposal to introduce a range of express mandatory requirements concerning the investigation of very serious casualties — involving death, total loss of the ship or severe environmental damage. This drafting task was brought to a successful conclusion, with the IMO flag state implementation subcommittee, which created International Standards and Recommended Practices for a Safety Investigation into a Marine Casualty or Marine Incident. The input of those flag administrations that take their responsibilities seriously was helpful. There are “good” flags that have a proved record of diligent accident investigation serving distinct safety purposes and take the trouble to produce detailed reports and disseminate their findings widely. The challenge for the IMO is to take onboard legitimate coastal state interests without unnecessarily fragmenting the process of investigation and analysis which, by necessity, requires a systematic and comprehensive approach as well as a high level of detailed work. However, it has been necessary for the IMO to ensure the affected flag and coastal states are properly addressed in accordance with the United Nations Convention on the Law of the Sea. UNCLOS gives to governments the inherent right to investigate casualties and incidents affecting or threatening their inland waters or territorial sea, regardless of the ship’s flag. The IMO has foreseen the need for mandatory notification requirements, for both flag and coastal states. It has, however, stopped short of barring states from conducting parallel investigations. Experience shows these can make life extremely difficult for witnesses and jeopardize access to evidence. The current standards and recommendations contain a number of useful provisions on such new developments as the increased use of data from shipborne voyage data recorders and on the protection of seafarers’ basic rights.
Recent experiences in the evacuation of passengers have been varied: in the case of the PRINSENDAM in 1980, in the Gulf of Alaska, there was a happy ending: no fatalities. However, in the case of COSTA CONCORDIA, there was loss of life, which continues to surprise some observers, in view of that ship’s proximity to land at the time of its partial capsizing.
Investigators try to go further: identifying how the unsafe condition(s) went unnoticed and why the human, technical and procedural defenses aimed at preventing disaster did not work. It has been said that the “chain of error” is broken when these defenses do work, and a mistake does not turn into a disaster. In the case of TITANIC, once it entered an unsafe ice field, and the many diverse factors — human and systemic — aligned on that fateful April night, the chain of causation reached its climax. However, it can now be seen that mistakes that led to the tragedy began at a much earlier time.
In 1907, the great Cunard liners MAURETANIA and LUSITANIA were launched with steam turbine propulsion systems, both faster then previous ships and innovative for this period of shipbuilding. This amounted to a revolution in maritime affairs during the 1890s — ships had typically been both smaller and slower. White Star responded that same year with the Olympic-class ships, designed to carry more than 3,400 passengers and crew, but with design speed of “just” 21.5 knots, 3 knots less than LUSITANIA.
It can now be seen that the loss of TITANIC, and of many ships since (as well as less disastrous accidents) do not result from a single proximate cause, but came about as a result of an “error chain” that can originate many years in advance, in a series of unsafe conditions that set the stage for disaster. On that fateful night, many diverse factors lined up to contribute to catastrophe.
Mariners and operating companies were still adapting to this revolution in maritime affairs in 1912. By one informed estimate, drawing on Lloyds Register data in 1914, two years after TITANIC was launched, only 35 percent of the British merchant fleet was capable of making speeds of more than 12 knots.
TITANIC, being the largest ship afloat, was considered to be likely to survive the sea conditions of the North Atlantic better than a lifeboat, or a person in a life jacket. Also, it, being a very large ship, would be more easily found by rescuers than a small lifeboat, or persons floating in a semi-submerged state. In 1912, mariners and naval architects were well aware of the consequences of low-speed collisions aboard smaller ships, particularly those with steel hulls.
With TITANIC, however, moving through the seas at 21 knots, a new situation existed, that was not fully understood by those experts who were more familiar with collisions at slower speeds. For example, the previous year, RMS OLYMPIC, TITANIC’s sister ship, collided with HMS HAWKE, a Royal Navy cruiser. OLYMPIC was under the command of Captain Edward J. Smith, who was to be in command of TITANIC the following year. An inspection of OLYMPIC’s hull after the incident showed a combination of buckling and brittle fractures of the sideshell hull plating, along with the failure of hundreds of wrought-iron rivets. This revelation should have been a warning, although it is difficult to see what could have been done to alter the process of hull design and construction, given the metallurgy and technology of 1912. Metallurgy was still an emerging discipline when TITANIC was built; recent studies indicate that the use of cast iron rivets, with slag inclusions, may have made the rivets brittle and likely to shatter under heavy stress. It has been suggested that these brittle rivets may have undermined TITANIC’s key defense against a collision: the ability of a vessel’s hull to deform without allowing disastrous flooding. It is believed that modern steel hulls would not react in this way.
Common practice in 1912, for navigating through fog, was to actually pick up speed. Arriving at lunch aboard TITANIC on April 14, 1912, J. Bruce Ismay of White Star Lines was asked by a passenger if the ship would slow down as it crossed the ice field. He replied “Oh no. On the contrary, we are going to let her run faster and get out of it.” This reflected a common practice at the time. However, the 1912 edition of Modern Seamanship took a different view: “A common reason given for advocating high speed in a fog is that, the fog bank being definite width, the danger of collision will be reduced by getting across as quickly as possible. This is like saying that it one if called on a dark night to cross a public square in which people are moving about in all directions, it will be safer to run across at full speed than to walk across slowly.”
Déjà Vu, All Over Again?
It is still widely believed that TITANIC had an insufficient number of lifeboats, due to a desire to keep her “lines” aesthetically pleasing. This was not the case. In reality, the tragic deficiency in the number of lifeboats was the consequence of a huge regulatory failure on the part of the British Board of Trade. TITANIC was not only fully compliant, but actually exceeded BOT requirements by four boats! Plans had been prepared for more lifeboats, in the event that requirements were changed for the White Star Line’s new and much larger class of ship. These were dispensed with, when the Board or Trade — the regulator — informed the design team that they would not be necessary. The thinking at that time — and, needless to say, the kind of thinking that sometimes can be found today — was that the Board of Trade’s decision should not be questioned.
It should be said of the regulators of 100 years ago that lifeboats were considered to be simply a way to ferry passengers to nearby rescue ships, and that a lower number could easily make several trips to accommodate all passengers and crew!
You may recall a famous line from the movies: “What we have here is a failure to communicate.” What we had, in the case of TITANIC, was a failure to anticipate.
What if the disaster that overtook TITANIC had itself been predicted, and timely countermeasures taken? What if we could foretell, as we often no doubt have, the problems that might lead to future trouble or disaster? We always try to do so. For example, early next year, the United States Coast Guard will conduct a comprehensive exercise aimed at measuring its ability to carry out a mass rescue operation at sea. “Exercise Black Swan” will be conducted on April 1-5, 2013, in and around Miami, Fla. The name of the exercise is significant. In his book, The Black Swan, Dr. Nassim Taleb reviews major historical events that, while rare, like “black swans”, can change the course of history. The possibility of a major disaster involving large numbers of passengers is not discounted. It still exists. Therefore, “contingency planning” can be defined as an attempt to anticipate what might go wrong. All major disasters at sea, as on land, have their origins, in a failure to anticipate what might go wrong. And, of course, to counteract, or compensate, or prevent it. We are aware that many modern cruise ships are enormous, some with a capacity of over 6,000 passengers and crew. From TITANIC, 1,514 lost their lives. The problem of how to evacuate large numbers of passengers from the large, modern “floating wedding cake” multi-deck cruise ships is one that many experts are aware of, and that gives rise to concern today. The recent grounding of COSTA CONCORDIA is simply a not-so-gentle reminder that things can still go wrong at sea.
Great improvements have been made in the design, navigation and structure of passenger vessels since 1912. Modern-day lifesaving equipment standards are very different, and are the products of many incidents that have occurred, and taught us the hard way, since that April night a century ago. But…
In our experience over the past century, there remains the uncomfortable feeling that what’s missing is an antidote to complacency. The fact is that since 1912 many “unsinkable” ships, not all of them passenger vessels, have gone down at sea.
Moreover, there seems to be a “General Rule of Disaster Causation” that simply stated can be defined by the phrase: “we didn’t plan for that.” Every major tragedy at sea, except those caused in wartime by enemy action, seems to share this characteristic. The unexpected simply could not happen.
Another characteristic, well-known to engineers, and one that has no doubt prevented a great many disasters, has to do with its corollary; “ALWAYS EXPECT THE UNEXPECTED.” Engineers often call this “Bazalgette’s Rule.” Sir Joseph Bazalgette was a great engineer of the mid-19th century, responsible for the construction of bridges, tunnels, and, notably, the drainage and water system of Victorian London. When Parliament commissioned him to undertake this tremendous project in the 1850s, he came back with plans for enormous cast-iron pipes, intended to carry runoff into the River Thames. The parliamentary committee, flabbergasted, responded by giving him the sack. However, Bazalgette stood his ground. He defended himself by pointing out that any good engineer will design with numerous redundant features, in anticipation of unpredictable, or at least unanticipated, consequences. At some point, Parliament did reconsider his plans, including the enormous cost of producing cast-iron pipes of unprecedented diameters, and rehired him. Somehow, those enormous sewer mains were fabricated, and work on the greater London system, under the renewed supervision of Sir (he was later knighted) Joseph did go forward.
Of course, there remained many critics, as would be (and is) the case for similar undertakings today.
In 1940, 90 years after Bazalgette’s plans were first put forward, enemy action breached London’s reservoir walls and water mains on a massive, unanticipated scale. His plans were at last put to the test. Huge quantities of water were safely carried off by the colossal pipes designed by him into the Thames, avoiding the disastrous flooding of many areas of London, including the underground.
Can it be said that the Bazalgette system is being applied to design and testing of the passenger vessels of today? SOLAS has been revised and updated many times since 1914, and covers the required lifeboat and life raft capacity of a passenger vessel, with a capability of launch in less than 30 minutes from the time of the order to abandon ship. To meet this standard, modern ship designers must consider the layout of the ship, the locations of muster and embarkation stations, escape routes, and requirement that each lifeboat be attached to its own set of davits. Lifeboats today are stowed ready for launching, and are not required to be launched individually.
Current marine evacuation systems are also much more efficient than they were in 1914. Some systems are approved for capacities in excess of 400 persons in 30 minutes. These resemble those in use for commercial airliners. They may be in the form of an inflatable slide, similar to an aircraft evacuation slide, and provide fast access to an open inflatable platform at the waterline, from which multiple rafts may be quickly boarded.
As I have discussed, TITANIC carried lifeboats that met British Board of Trade specifications, but which were totally inadequate for a ship carrying more than 2,000 passengers and crew. The Board of Trade had simply never bothered to increase lifeboat requirements to meet the growth in size of oceanliners in the first decade of the 20th century. Our problem today is that, somewhat like the TITANIC, OLYMPIC and LUSITANIA of pre-World War I days, the size and capacity of passenger ships has rapidly grown in recent years. Not only are there far more passengers (and crew), but the modern “wedding cake,” multi-deck design of these vessels makes for important new problems in evacuation.
Which brings us back to Operation Black Swan, and the importance of contingency planning. It is important to take a leaf from the Bazalgette rulebook. We should consider all the possibilities, and examine, and test, design options for dealing with them. Lifesaving equipment is one area that needs a careful examination. Experience also teaches us that no matter how fireproof a ship may seem to be, fire and explosion can occur, collisions at sea are not impossible, and the greatest threat of all, human error, needs to be taken into account. The great majority of accidents at sea today are still the result of human error, which played so large a part of the loss of TITANIC.
There is, however, one other aspect of safety that began to appear with the adoption of the Plimsoll reforms early in the 19th century. Shipping interests, like those on dry land, will on occasion cut corners in the interest of saving money. The present economic recession, which promises to be the longest and deepest to hit the shipping industry in many years, is a warning to us that the development as well as the enforcement of adequate safety requirements is of vital importance.
Above all, there is the need to avoid complacency. Particularly in the area of passenger or cruise ship design, the regulators, inspectors and overseers — including coast guards, classification societies, flag states and port states — should not stand still. TITANIC was in full compliance with existing regulations; her crew was the best available at that time; she carried the most modern technology, and was a product of the most advanced shipbuilding techniques. It is of course clear to us that none of this was enough to even mitigate the accident that befell her. TITANIC, her passengers and crew were victims ultimately of a kind of thinking to which we are all — whether we admit it or not — often prone.
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Clay Maitland is a maritime industry leader who is Managing Partner of International Registries Inc. and Founding Chairman of the North America Marine Environment Protection Association. He can be reached at claymaitland@yahoo.com or through his website/blog at www.claymaitland.com.
