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TITANIC DISASTER RMS-Titanic (WHAT HAPPENED - Event Sequences (April 15,…

- - - - Event Where the hazard and the target met
- - - - Concept Failures: Lax safety standards and regulations, Design flaws, * Budget cutting - aesthetics taking priority,
      - Construction: built in the early nineteen hundreds by Harland and Wolff of Belfast, Ireland. Largest moving object ever built (Division,1997). Equipped with turn of the century design and technology (Gannon, 1995). What testing of the ships operations? Parts required. Budget. How long to manufacture. What training will be provided to operators.
      - Construction System Failures: the hull steel and the wrought iron rivets failed (Gannon, 1995), cost cutting. The use of low quality steel ( Gannon, 1995) cost cutting. Poor design of the watertight compartments (Hill, 1996). Inadequate testing at sea. No building standards (required safety features/testing). * Inadequate training of staff in operating (Garzke and others, 1994).
      - Commissioning: Safety standards. Manufactured for local waters or world sea travel. Budget considerations. Training
      - Commissioning System Failures: * Conflicts on who to market to. Financial and paperwork delays. Over spending on the budget. *
      - Operating: Training of operators. Passing required tests. Required operating instruments available and in working order. Considerations for the operators safety and working environment. Layout consideration for ease of use.
      - Operating System Failures: Operator not following correct use/guidelines. Damage due to incorrect use. Not following maintenance guidelines leading to damage. Lack of training for operators. Outdated safety systems (Savage, 2015).
      - Maintenance: Servicing and maintenance costs. Availability of parts. Costs to replace parts. Technicians trained in ship maintenance. Crew trained in maintenance. Manufacturer guidelines on maintenance.
      - Maintenance System Failures: Unavailable parts. Limited/no trained technicians to perform the repairs. Hold ups to the operating of the ship. High costs to repair.
      - Decommissioning: Sunk at sea.
      - Decommissioning System Failures: *Ship sank before its recommended lifespan.
- - - - Overall culture
  - - - Accountability
      - Procedures
- - - - Expectation - Captain wanted to continue full speed regardless of ice warnings. Time pressure to arrive early.
      - Attention - radio operator didn't prioritise ice viewing warnings, captain more concerned with arriving ahead of schedule and ignoring previous ice warnings. Other crew did not question navigation and speed.
      - Goals - arrive ahead of schedule
      - Fatigue - late into the evening - captain had gone to bed leaving other crew on deck to keep watch.
      - Stress - to sustain top speed as requested by the captain below deck coal shovelers worked hard and long hours. Iceberg watcher had to rely on own vision as didn't have binoculars
  - - - Fixed Plant Design - design flaws with sub standard materials used for the building of the hull. Design flaws with the water tight compartments.
      - Site Design
        
        North Atlantic Sea, Ice fields
    - - Feedback - Radio operator did not pass on the last iceberg message
      - Warning Systems - no main alarm system, bell was rung by the iceberg spotter.
      - Displays - no indicators to alarm of iceberg sightings
      - Controls -inadequate controls for a protection system
    - - Temperature - Freezing
      - Lighting - dark (night time)
      - Visibility - low visibility conditions (Labib and Read, 2013), slight haze.