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Lessons Learned: Historic Wisdom: TH ST ND RD

The Titanic sank in 1912, killing over 1,300 people, which remains one of the worst maritime disasters. Several critical safety issues contributed to the sinking, including reducing lifeboats to increase passenger capacity without analyzing the impact. Other issues were using spare parts from another ship without proper review, inadequate testing and operator training, and prioritizing speed over safety by cutting corners on sea trials and inspections. The lessons learned are that changes late in design require impact analysis, stakeholder input is important, and operational safety should not be compromised for business or design goals.

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Tracey Morin
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39 views2 pages

Lessons Learned: Historic Wisdom: TH ST ND RD

The Titanic sank in 1912, killing over 1,300 people, which remains one of the worst maritime disasters. Several critical safety issues contributed to the sinking, including reducing lifeboats to increase passenger capacity without analyzing the impact. Other issues were using spare parts from another ship without proper review, inadequate testing and operator training, and prioritizing speed over safety by cutting corners on sea trials and inspections. The lessons learned are that changes late in design require impact analysis, stakeholder input is important, and operational safety should not be compromised for business or design goals.

Uploaded by

Tracey Morin
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Lessons Learned: Historic Wisdom

1. Unsinkable Titanic sank with a loss of 1328 lives and property worth
millions of pounds-greatest 20th century maritime disaster
2. 3 ships proposed. Profit from 1st and 2nd to be used for 3rd
3. Blunders:
a. Compromising safety for viewing pleasure and appearance
i. Life boats reduced from 48 to 16
ii. Life boat capacity not matching with ships capacity as they
assumed the presence of rescue ship, and damaged
Titanic to remain afloat for long enough until transfer to a
rescue ship in multiple trips
b. Revenue from 1st ship olympics first class was very high, a quick
change and added 100 more 1st class capacity without doing an
impact analysis
c. To accommodate a large dining room for this added capacity,
compromised on bulkheads(facilitate sealing), expanded into other
decks-resulted in flooding and sinking in 2 hrs
d. Instead of original objective of luxury, they added speed
without analysis
e. Spares for Olympics supplied by cannibalizing Titanic which already
had a schedule constraint
f. Design was not done for ease of maintenance
g. Project on Cost overrun as repairs of Olympic stopped the cash
inflow and increased the expenditure
h. Financial difficulty forced lot of comprises and launched
i. Third shift was added to the already haphazard working
j. Testing Compromise: Sea trials were cut off from 8 weeks to day
k. In experienced Crew recruited 3 days before the maiden voyage
reflects a less than cautious approach-aim of which was to beat best
times of Olympic
l. Inspectors tested only 1 life boat lowering and gave clearance
certificate for one year
m. Plan was to run at high speed until iceberg alley, slow down and
then pick up
n. Critical feedback check while speeding to be done were: look-outs,
water temperature check, study warning messages
o. Binoculars unavailable(spotted icebergs only 37 sec before
hitting)
p. Rope length insufficient to scoop water and messaged
unheeded
q. Inexperienced Crew had not used capacity of 1st 8 boats and
landed 2 upside down
Lessons Learned
Design, Safety and Testing Compromises
Elevation of expectation of end deliverable allowed business pressures to
override operational pressured (cut losses speeden to get more ROI)
Lack of stakeholder management
Lack of respect for feedback mechanism at critical points
Summary
Making changes after design is frozen without impact analysis (CCB)

Inadequate testing, Inadequate training of operators, Unsubstantiated


terminology oriented approach (unsinkable Titanic)

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