Story of Fire and Ice – What did we learn from RMS Titanic in Root Cause Analysis?
The sinking of RMS Titanic happened over century ago on April 15, 1912 resulting in the deaths of more than 1,500 people, making it one of the most tragic maritime disasters in history.
Having the most advanced technology of the time and an immense size, the vessel had been marketed as being “Unsinkable”. The key question still surrounds the cause of the sinking - was it really the iceberg that caused this tragic event?
While the cause of the disaster has long been attributed to the iceberg, fresh evidencehas arisen of a fire in the ship’s hull. Experts have discovered black marks along a 30 foot section of the front right-hand side of this section, just behind where the ship’s lining was pierced by the iceberg – this fire may have happened before the ship even left Belfast.
This weakness caused significant damage to the structure of the ship and weakness, due to the temperature levels. Other theories suggest that the coal bunker fire that was kept secret to avoid delay on maiden voyage and as correction, burning coal was fed or transferred to ship’s engine.
Management’s decision to meet strict deadlines and cut corners also played a huge role, as they could not afford any further delays after the Titanic’s sister ship "Olympic" also had incident when it was damaged by British cruiser HMS Hawke off the Isle of Wight.
Another crucial factor from the investigation was the ship’s speed. This was due to two underlying reasons – cost cutting and feeding the coal that was loaded to all bunkers for the six day journey to New York – slowing the engine down and picking up speed again would consume more coal, thus increasing the risk of being stranded halfway of journey. The crew would have no choice, as any fire on board would have continued to be continuously fed by this burning coal within the engines.
Titanic was designed to stay afloat even with four water tight compartment flooded and is also the reason why there were only a number of lifeboats onboard – there was no “what if” factors accounted for. History was written and out of 2,224 passengers and crew that fateful night, only 710 escaped in lifeboats and later rescued by the RMS Carpathia.
More recent events, such as the Costa Concordia off the coast of Italy - which resulted in 32 fatalities - have highlighted the need for overcapacity within emergency egress methods, such as lifeboats. Safe disembarkation of modern passenger vessels should also be able to be achieved in less than ten minutes.
This is supported by the International Maritime Organization’s SOLAS (International Convention for the Safety of Life at Sea) regulations that are enforced to enhance safety and seaworthiness. These standards were first written in 1914, in response to the Titanic disaster.
After a committee inquiry which lasted more than a month, they concluded that the sinking was an unavoidable accident and caused by excessive speed – frequently termed by some as “an act of god”. Although the unofficial evidence of the continuous coal bunker fire was made known during the enquiry, but little of this light was shone on this potential causation and the report made no mention of the fire.
I couldn’t help but wonder, have the committee made a thorough and effective Root Cause Analysis? Have they really accounted for “the iceberg of risks and factors” that sets in motion the entire cause-and-effect chain causing the problem?
Root Cause Analysis (RCA) is of paramount importance as having a focus on correction of root causes has the goal of minimising the impact of the issue or entirely preventing problem recurrence – we see this modeled in risk management methods, such as bow-tie.
At present, we conduct RCA as a reactive and post-event method of identifying causes, with the aims of revealing problems and solving them. There are a number of lessons learned from other such tragedies that has helped to make industry a safer place (such as the Lord Cullen report into the Piper Alpha offshore disaster in 1988).
Insights from RCA make it potentially useful as a preemptive method as it can be used to forecast or predict probable events even before they occur.
Despite the fact that there was no way of truly predicting that this disaster would strike, RCA played a vital role in helping us fully understand what has happened and help put measures in place to try to ensure it wouldn’t happen again.