People
Managing Director Ismay & Captain Smith
First Officer Murdock
J.P Morgan
Both wanted to beat the record and reach NY by Tuesday
Both did not discuss sailing route and speed
Both knew about iceberg warnings
Entered ownership
He was one of the worlds largest investment banks
Lack of knowledge
Failed to respond to iceberg warnings and ignored signals
Management
Organisational Factors
Job Design
Pressure
Legislation
Lack of communication
Behaviour guided by habit and company culture
Legislation was non-existent on a superannuation level
Legislation on the national level was retroactive
Titanic was pressured to become worlds largest ship
Titanic was pressured to be 'unsinkable'
Did not push for costly safety measures
Competition leading to to changes in structure and ownership
System Parts
Staff
Roles and Responsibilities
Training
Tasks
Cultue
The Titanic
The Iceberg
Organisational Systems/Management and Regulators
Passengers
Design Life Cycle
Concept & Design
Short planning phase
Design phase of 7 months
Construction
Took 3 years for the shell & decks to be constructed & then ship was launched in the water
Fitting out phase began lasting 11 months involving building inside the ship itself
Ship was then launched in water
ball room, cabins, furnishing & fitting steering systems and communication systems
Commissioning
Maintenance & Operation
Decommissioning
Sunk or sold as scrap metal
Quality Control
Materials
Manufacturing
Workers
Function
People
Usability of systems
Testing / Quality control
Testing
Ship was meant to be taken out for testing for 6-8 weeks
Transportation
Maintenance
Parts and Repairs
Services and legal requirements
Warranties & insurance
Availability of skills
Design usability
Numbers
Emergency procedures
Organisational Systems
Policies & Procedures
Accountability
Cost
Training
Workplaces
Work environment
Equipment design
7 iceberg warning signs received throughout the day from other ships
First voyage with passengers
pressure and rushed procedures
Last Design Phase error
downsizing number of life boats to 16
Architects assumed in case of collision the ship would remain afloat long enough for all to get transferred to a rescue ship
Workforce from titanic were transferred to get sister ship 'Olympic' back into service when it was damaged.
Shared resources being shifted to another project during an emergency
The Titanic was caused to be behind schedule
Focused on the costs over safety
Ship was only tested for half a day
The lookout workers did not have binoculars
Ice warnings were coming through onto the ship's radio but the wireless operators were overloaded by commercial traffic
Workers prioritised messages from passengers causing ice berg warnings to be ignored
Ismay pressured Captain Smith to increase speed despite iceberg risks
Leadership
When Ship hit the iceberg, damage was assumed to be minor
Captain Smith & Ismay assumed Titanic was safe to keep travelling
Lack of stakeholder management and leadership
Binoculars were left at Southampton
Captain Smith realised there was an iceberg too late and quickly steered the ship left causing the iceberg to damage the right side of the ships hull
Event Sequence
Passengers boarded the Titanic ship in Southampton and the ship set sail and began it's maiden voyage
Throughout the day 7 iceberg warnings were received but ignored due to using the radio for passenger messages instead of warnings from other ships
An iceberg was spotted too late and first officer William Murdoch ordered the ship to be steered left and engines reversed
The ships side scraped along the iceberg and 5 of the supposedly watertight compartments toward the bow were ruptured
As the hull filled with water the ship's bow dropped deeper into the ocean causing the compartments to spill over into each other and the ship sunk, killing 1500 people.
Binoculars were left at Southampton
Titanic sunk quicker than expected
Hollins (2008) discusses how important the design stage is to eliminate failure
Gries (2006) explains how design failure is identified through the problem solving of human failure.
Salonen (2008) identifies that cost is a step in preventing failure and can have an impact on the whole system when neglected.
Ob board facilities
Requirement to carry a large number of people
Lifeboats should have been thought out to accommodate all passengers
Hollins (2008) proves that the design stage is not only important for the design as a whole, but the costs to the organisation. Eliminating these errors early can prevent the failure occurring in the operation
Bassett (1998) explains how safety regulations were established from the Titanic disaster
Galley (2019) effectively explains how to eliminate errors, tasks need to be performed and staff need to follow accountability