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Worksafe BC - The Sinking of the Titanic (Management (Organisational…
Worksafe BC - The Sinking of the Titanic
Management
Job Design
Job requirements
Wireless Operator to pass on wireless messages
did not pass on all messages
did nto understand the improtance or the language being used
training should have been provided and a clear understanding of job function
Wireless radio was not manned 24 hours
The Carpathian wireless operator had turned off radio and gone to bed not long before the incident
Supervision
Wireless operator was not supervised by White Star Liners
Wireless Operator Phillips did not pass on vital iceberg warnings
he was focused on getting out 1st class passenger messages
There was no clear process on pass this information
He did not understand the messages or importance
Competence training - to ensure the wireless operator
Task Analysis
Information Flow Chart could be used to assess the relationship required between the Bridge/Captain and the wireless operator in transmitting the information
Organisational Factors
Leadership
Captain continued at excessive speed given the ice warnings
Captain ignored ice warnings
not all ice warnings were delivered
Procedures
Shakedown so staff were familiaried with the ship was not conducted
Ship Lookout did not know where to find binoculars
Sea Readiness testing for maneuverability etc was only 6 hours
Emergency training as per regulations was not carried
Crew were not properly trained on how to deploy
lifeboat drill on the 14th of April was cancelled for passengers and crew to attend mass
No procedure on managing personal communications transmissions when communications go out, resulting in backlog
Resourcing
Wireless Operations outsourced
Thomas Andrew - nephew of William Pirrie (the Chairman of Harland and Wolff) was hired as the Chief designer
Management decisions
20 Lifeboats on board
32 required to accommodate all
British Board of Trade of 1894 had requirements by tonnage not numbers of people
40 years since the last serious loss of life at sea, when 562 people died on the Atlantic in 1873
Titanic was a newer class of ship and the biggest of it's kind
Last time reviewed the largest ship only weight 10,000 tonnes, while Titanic weighed 46,328 tonnes
Would take up space on promenade deck
Luxury placed over safety
Poor safety understanding/culture
Too expensive
Lack of understanding of Safety
Relied on regulator instead of conducting their own Risk Assessment
Enough for 52% of the passengers and crew
Purchase of White Star Lines by a Financing company
Did not have knowledge or experience in passenger ferrying
Followed a track that was accepted since 1899
This was outward bound route for mail steamers
Was this still appropriate?
Route chose based on weather conditions generally for that time of year
It was not expected to see icebergs that time of year on that route
Exclusive contract with Harland and Wolff in Belfast - shipbuilding company.
Personal relationship for profit meant that there was no due diligence when choosing a ship builder
Socio-political issues at the time had issues between the catholic and protestant Irish.
The ship builder exclusively hired protestant Irish which poses a problem as there is the likelihood that the best person or people for the job were not employed
J. Bruce Ismay had final say on design
he did not have the experience
Lights on 2nd and 3rd class were put out to encourage passengers to head to bed
Less people were awake or above deck when Titanic struck
This would have lead to disorientation from passengers not knowing what had happened or the danger they were in
Culture
State of the art technology ie, wireless,
false sense of security, complacency
perception
No proper shakedown
No emergency evacuation or preparation training conducted
Sea readiness cruise less than 12 hours
Information Transfer
Written Communication
Wireless communications were not given to the Captain/bridge
CQD-MGY distress signal to SOS
Instructions
No instructions on the wireless operations.
Managing sending personal messages and receiving vital wireless transmissions.
Training
No training for emergency procedures
Inadequate training for lifeboat deployment (this training on the 14th of April was cancelled)
Training on iceberg conditions - this would be felt by most. The Captain, the ship lookout, First officer Murdoch
Handovers
No handover between wireless operators
No distress flares for visual communication - White flares kept on board, not red for distress
People
Individual Factors
Captain Smith
Competency
Seasoned Captain, highly skilled and trained
Knowledge
Age
This was his last voyage before retirement
His risk perception
Stress
Final voyage as a captain
To get to New York ahead of schedule
Finish off career on a high
Goals
To make the fastest Atlantic crossing/break record
Because it was his final voyage before retirement
Pressure from Bruce Ismay
He was present on the ship
Continued at speed even with ice warnings
Attitude
uneventful career
high self confidence and complacency
belief that he was invincible
Continued into waters at full speed with iceberg warnings
Event Network Analysis
Competency assessment
Training
First Officer Murdoch
Knowledge
Murdoch called for Titanic to be put into reverse and turn hard to starboard
this was the procedure of the time
J. Bruce Ismay
Knowledge
J. Bruce Ismay had no knowledge of navigating ships
Goals
To make the fastest Atlantic crossing/break record
Presumed increased profit and marketability
Stress
To make the fastest Atlantic crossing/break record
competition from other passenger ferries
Culture
J. Bruce Ismay was wealthy and the Managing Director of the ship.
Wireless Officer Phillips
Knowledge
He did not understand some of the messages importance and therefore did not forward on
lack of procedure
Stress
could not keep up with first class passengers communication needs
failed to pass on crucial messages about the ice bergs
Changed from CQD-MGY distress signal to SOS
Expectation
To clear the backlog of personal communication messages from/for 1st class passengers.
Fred Fleet - Ship Lookout
Competency
Knowledge
Did not know where to find the binoculars
Deck officers
Launched life boats partially empty
There was no Regulation safety drill conducted
Lack of communication about severity
Workplace
Workplace Factors
Site design
16 watertight compartments were designed. the ship could still stay afloat if 2 middle or 4 front compartments flooded.
No transverse bulkhead (did not have a lid)
5 were damaged
water then tipped from one compartment to the next as they gradually filled
Access
Access between 2nd and 3rd glass had locked gates to keep separated
No emergency planning in place for passenger safety
Equipment Design
Pumps could only cope with 2000 tonnes of water per hour
Work Environment
Visibility
Uncharacteristically clear/calm night
This made the iceberg harder to see at night as waves did not break on it
Were ships look out trained in spotting icebergs? Did they have the appropriate equipment?
Event network analysis (Kristiansen and Eide,
1994)
Task Analysis on ship look out for competence and equipment required to perform task
Captain continued to sail in this, but other ships stopped, such as the Caluifornian.
Did Captain have knowledge of sailing in iceberg conditions at night?
Why did one ship stop and not the other? Was this a company wide procedure or a Regulatory requirement?
No moon meant there was no reflection or visibility of the iceberg in the darkness
Temperature
The temperature of the water made the steel abnormally brittle and less impact resistant