Titanic: The Sinking Of The Unsinkable Ship Organizational Accident Analysis Saulo de Pieri Romulo Gabriel Ingy Guergues Esteban Roldan Manil Shah Team Iceberg 12/08/14

● Titanic was one of a 3 ship series by the White Star Line Company. ● One of the largest ships of its time and largest peacetime maritime accident during maiden voyage. ● Out of 2224 passengers on board, only about 710 survived The Unsinkable Ship Sinks One of the most Influential accidents of all time: Source: Titanicberg (

● Massive amount of life loss ● Many operational failures Impact and Importance Catastrophic Failure: Source: Titanicberg ( ● Major improvements in maritime safety ● Changed the way ships were engineered and designed from that point on ● Establishment of Safety of Life at Sea (SOLAS) regulatory agency Change in Regulations: Prime Example of Bad Project Management

● Latent Failures ○Rivets ○Watertight Compartments ○Bulkheads ○Double Hull ○Rudder ○Regulations The Unsinkable Ship Sinks Remembering the facts: ● Activities Failures ○Leadership ○Safety drill cancellation ○Binoculars ○Wireless messages ○Ship speed

Bankruptcy / Catastrophe Chart Double Hull Watertight compartments Messenger center Luxury Room Long term expectations Short term decisions ●1 st Scenario ●2 nd Scenario What is the ‘product’ of Star Line Company? Transportation of people

Titanic Swiss Cheese Model ● They understood the hazards but they chose to ignore it. ● No regulatory body to provide guidance, everything is up to the Captain. ● Captain decided when to sound alarm. ● Double hull, but only partial. ● Bulkheads, but not tall enough for the hazards. ● Not enough lifeboats/training. Death & losses ICEBERG

At the core of all these contributing factors and pervading all of them is the issue of culture. -Commitment -Competence -Cognisance Safety Information System

Conclusion ●A combination of Project Management and Safety Information Systems caused this accident. ●Project Management is defined as: ○“ The application of knowledge, skills and techniques to execute projects effectively and efficiently. It’s a strategic competency for organizations, enabling them to tie project results to business goals and thus, better compete in their markets. ●Safety Information Systems is defined as: ○“System that provides occupational injury, illness, and fatality data to safety professionals and policy makers to target interventions for the prevention of workplace accidents.”

Conclusion ●Lack of Project Management contributed to the holes of the swiss cheese. ○ Active Failures ●Lack of the Safety Information System contributed to the hazards. ○ Latent Failures

Lessons Learned ● Safety should be the priority of every organization. ○Safety Information Systems should be in place by qualified individuals. ○The Safety Information Systems should be implemented in all units of operation by Project Managers. ○Organizations should realize the future impact of all rapid decisions.

Recommendations ●Organizations should not just be complacent with upholding safety regulations but rather to be one step ahead of the regulators.

References ● ● ● ● ●Reason, James T., and James T. Reason. Managing the risks of organizational accidents. Vol. 6. Aldershot: Ashgate, 1997.