TITANIC a Human Performance Case Study

TITANIC a Human Performance Case Study

What was the name of the three giant vessels built by Harland and Wolff? Olympic Titanic Gigantic

Which one of the three ships had its name changed? Gigantic It would be changed to the Brittanic Brittanic

The Titanic was also known as the RMS TITANIC what does RMS stand for? Royal Mailing Steamer

TITANIC FACTS March 31, 1909 construction begins by Harland and Wolff for WHITE STAR LINE in Belfast Ireland. The ship cost 7.5 million dollars to build. Today s cost 400 million dollars. Skilled shipyard workers earned $10.00 per week. One First Class ticket would cost 4 to 8 months wages.

TITANIC was one of the largest movable objects ever built. The ship was 883 feet long, 92 feet wide. Weighed 46,328 tons. Was 104 feet high from keel to bridge. Powered by 3 engines (2 reciprocating, 1 turbine), which equaled 46,000 total hp. Total capacity 3547 people, 2,227 were on board.

TITANIC a floating city!! Brief description of food supplies on board: 75,000 lbs. fresh meat 11,000 lbs. fresh fish 40,000 fresh eggs 200 barrels of flour 2.75 tons of tomatoes 40 tons of potatoes 1,500 gals. fresh milk 20,000 bottles of beer and stout 1,500 bottles of wine

The Titanic s Hull Protected by double bottoms. Separated by 15 watertight bulkheads which extended half way up the hull. Bulkheads could be sealed by activating watertight hatches which would compartmentalize the hull into 16 different sections. As a result the ship was considered UNSINKABLE.

Trivia Facts Ship cost 7.5 million dollars. Titanic movie cost 250 million dollars. Titanic sank in approximately 2 hrs. 40 min. The film Titanic runs 3 hrs. 14 min. It took 3 years to build the Titanic. It took approximately 3 years to make the film.

FIVE PRINCIPLES OF HUMAN PERFORMANCE 1) People are fallible and even the best make mistakes.

FIVE PRINCIPLES OF HUMAN PERFORMANCE 2) Error-likely situations are predictable, manageable, and preventable.

FIVE PRINCIPLES OF HUMAN PERFORMANCE 3)Individual behavior is influenced by organizational processes and values.

FIVE PRINCIPLES OF HUMAN PERFORMANCE 4) People achieve high levels of performance based largely on the encouragement and reinforcement received from leaders, peers, and subordinates.

FIVE PRINCIPLES OF HUMAN PERFORMANCE 5) Events can be avoided by an understanding of the reasons mistakes occur and application of the lessons learned from past events.

5 Principles / 6 Techniques 1) People are fallible and even the best make mistakes. 2) Error-likely situations are predictable, manageable, and preventable. 3) Individual behavior is influenced by organizational processes and values. 4) People achieve high levels of performance based largely on the encouragement and reinforcement received from leaders, peers, and subordinates. 5) Events can be avoided by an understanding of the reasons mistakes occur and application of the lessons learned from past events. Self-Check (STAR) Questioning Attitude Pre-Job Brief Procedure Use and Adherence Positive Reinforcement Operating Experience

OBJECTIVES Identify the sequence of events that led to the fatal shipwreck of the Titanic. Determine the contributing factors of the event. Identify the practices that should have prevented the event. Identify Human Error Prevention Techniques and practices used to prevent similar events.

Harland and Wolff build two mammoth passenger liners! Titanic and the Olympic were built at the Harland and Wolff shipyard in Belfast Ireland, for the White Star line. Titanic slipped from her Belfast dry dock on May 31, 1911 and was towed to her fitting out basin for completion. The Titanic was fitted out in a little over ten months and left Belfast on April 2, 1912 for sea trials.

Titanic was declared sea worthy after a little over eight hours of sea trials. Sea Trials are designed to prove capabilities of equipment, crew, and procedures during both normal and abnormal conditions. Only one life boat drill was conducted and several members of her crew of nearly 900 would not report on board until the day of departure.

Titanic s Maiden Voyage Titanic left Southampton, April 10 1912, first stop Cherbourg, France, final, destination New York. Scheduled 7 day voyage. Titanic was commanded by Captain Edward J Smith. Ironically, he expected this to be his last voyage and crowning achievement.

Five years prior to the Titanic, Captain Smith commented on the technology in the shipping industry. I will say that I cannot imagine any condition that would cause a ship to founder Modern shipbuilding has gone beyond that.

Titanic witnessed close call while leaving port! Suction created by her passing caused the New York to break loose from pier and swing dangerously near her path. Seven months prior, her sister ship, the Olympic passed the HMS Hawke, drawing it into its side causing damage to both vessels.

Titanic alters course! The arctic winter was unusually warm and ice had been reported at lower latitudes than normal. Titanic would proceed on a more southerly route. Other than this minor change, the first days at sea were uneventful.

Sunday night April 12th Titanic was steaming into an area of reported ice! Titanic speed was over twenty-two knots. Air temperature was dropping and below freezing. Marconi operators received ice warnings from four different vessels. Warnings were passed on to Captain Smith. Only one warning was posted in the chart room for officers information.

Iceberg Detection Radar and Sonar were unknown of in 1912. Icebergs could only be detected by vigilant observation by the crew. Light reflected by the surface or waves splashing against the base of the berg were the only signs of ice in the water. With no moon and a dead calm sea, these indicators were absent.

Change of command on bridge! At 9:20 P.M., Captain Smith left Second Officer Charles H. Lightoller in command. Smith s instructions were, If in the slightest degree doubtful, let me know. 9:30 Marconi operator received a wireless message from the Mesabe warning of pack ice and large icebergs in the Titanic s path. The message was not forwarded to Captain Smith or the bridge.

10:00 P.M. Second Change of Command takes place on the bridge. Second Officer Lightoller turned command over to First Officer William Murdoch. Murdoch was advised that they would come into the reported ice at about 11:00 P.M. Watch relief in the crow s nest also occurred at this time.

Californian sends wireless message to Titanic!! Californian stated Say old man we are stopped and surrounded by ice. Titanic replied Shut up! Shut up! I am working Cape Race. Titanic was trying to beat the record set earlier by sister ship Olympic. The Californians report was never forwarded.

11:35 Huge Ice Berg was discovered! Immediately the crow s nest rang the bell and reported huge ice berg ahead. At nearly the same time First Officer Murdoch saw the berg and ordered Hard a starboard! and Full speed astern! These orders were intended to slow the vessel and steer to the left of the ice. At 11:40 Murdoch then ordered Hard a port! in an attempt to swing the stern clear.

Knight s Seamanship The Ruling Seamanship Manual States that striking head-on with the bow was far more desirable then an oblique strike, should a collision be unavoidable.

A Seaman s Worst Nightmare!! At 11:40 the vessel grazed the ice, hull plates ripped open along a 250 to 300 foot section. This opened the the forward six compartments of the ship to the sea. Perhaps no more than twelve square feet of hull surface was opened, but the damage would begin dragging the Titanic down by the bow.

Ship s Chief Architect, Thomas Andrews inspects damage! Andrews after learning of flooding in six compartments, reported to Captain Smith that the ship had only a short time to live. 12:10 AM on April 15, Captain Smith ordered Marconi operator to send out a CQD, Calling Distress. Many on board including some officers were not aware that the ship had struck an ice berg.

Carpathia answers distress signal! From approximately 60 miles away the Carpathia responded to distress signal. The Californian, who was possibly 5 to 18 miles away failed to answer. She had shutdown for the night in heavy ice and the Marconi operator was no longer at his station.

Lifeboat operation progressed slowly and with significant confusion. Only 16 regular lifeboats and 4 collapsible boats were on the Titanic. This was only half the lifeboats that was needed for the passengers and crew. Titanic had capacity for sixty lifeboats. British Board of Trade regulations did not require vessels to carry enough lifeboats for all on board.

Lifeboats Passengers did not realize the danger and were slow to get to the lifeboat stations. Ships officers were unfamiliar with lifeboat davits and their capacities. Most lifeboats were half full when they were lowered into the water. Crew members were unfamiliar with small boat handling and had to be taught how to row by passengers.

Mystery Ship Spotted!! Shortly after midnight, Fourth Officer Boxhall sighted the mast light of another vessel, apparently a steamer. His Morse signals would go unanswered. At 12:45 A.M. Quartermaster Rowe began firing distress rockets at five minute intervals.

Could it be the Californian? Even though distress rockets had been sighted by the Californian and reported to her captain, Stanley Lord, they went unanswered. Captain Lord, upon hearing of the signals, ordered the Morse lamp manned. With no response Captain Lord did not investigate the rockets nor did he re-station his Marconi operator who had secured at 11:35 P.M.

Even today it is unknown whether the mast lights sighted were those of the Californian or another ship in the area - possibly the Norwegian Samson, operating illegally in the area for seals.

The Titanic Sinks The bow sank and the stern rose into the air. The ship broke in half with the stern settling back into a horizontal position for a few moments. The bow drifted to the bottom, two and one half miles below, followed by the stern. Passengers still on board either jumped or were thrown into the 33 degree water.

By 3:30 A.M. the Carpathia arrives at the scene! The Carpathia began picking up lifeboats. At 8:50 A.M. she headed for the New York harbor. The Californian, after learning of the accident, had arrived at the scene and remained in the area searching for survivors. No others were found.

Carpathia arrived in New York, Thursday evening April 18, 1912. Of the 2,227 enthusiastic passengers, only 705 would survive.

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