1. The Titanic: a simple example
CAUSE
Why did the Titanic sink?
The Titanic Sinks
EFFECT
February 23, 2019 1
Bev Daniels.

2. The Titanic: a simple example
CAUSE
Why did the bulkheads fill with water?
Bulkheads Fill w/Water, ship loses buoyancy
The Titanic Sinks
Don’t skip the ‘obvious’; if it’s a incontrovertible fact, document it; if it’s an assumption, test to disprove.
EFFECT
February 23, 2019 2
Bev Daniels. 2

3. The Titanic: a simple example
CAUSE
White Star requires Smaller bulkheads to ensure full size first class cabins
Why did the bulkheads fill with water?
Bulkheads Fill w/Water, ship loses buoyancy
The Titanic Sinks
An enabling cause – the smaller bulkheads filled with water faster than larger bulkheads
EFFECT
February 23, 2019 3
Bev Daniels. 3

4. The Titanic: a simple example
CAUSE
White Star requires Smaller bulkheads to ensure full size first class cabins
How did water enter the ship?
Bulkheads Fill w/Water, ship loses buoyancy
The Titanic Sinks
EFFECT
February 23, 2019 4
Bev Daniels. 4

5. The Titanic: a simple example
CAUSE
White Star requires Smaller bulkheads to ensure full size first class cabins
Puncture of steel plates
4 possible ways for water to enter the ship
Seams of the ship open up
Bulkheads Fill w/Water, ship loses buoyancy
The Titanic Sinks
Ripping or tearing of steel plates
In order to answer this question, we need specific scientific proof.
Swamped
EFFECT
February 23, 2019 5
Bev Daniels. 5

6. The causal system of the sinking of the Titanic
CAUSE
White Star requires Smaller bulkheads to ensure full size first class cabins
Seams of the ship open up
Bulkheads Fill w/Water, ship loses buoyancy
Why did the seams open up?
The Titanic Sinks
Open Seams on Olympia
Again this question requires specific scientific proof…
EFFECT
February 23, 2019 6
Bev Daniels. 6

7. The causal system of the sinking of the Titanic
CAUSE
White Star requires Smaller bulkheads to ensure full size first class cabins
Rivet Heads Shear
Seams of the ship open up
Bulkheads Fill w/Water, ship loses buoyancy
Why did the rivets shear?
The Titanic Sinks
Open Seams on Olympia
Rivets found in the debris field were found in great numbers to have been sheared at the rivet head. Shear forces are very easy to identify under metallurgical examination.
Eye witness – ear witness – accounts reported hearing ‘popping’ noises like ball bearings or marbles hitting the floor at eth time of the impact.
EFFECT
February 23, 2019 7
Bev Daniels. 7

8. The causal system of the sinking of the Titanic
CAUSE
White Star requires Smaller bulkheads to ensure full size first class cabins
Why did the rivets shear?
Rivet Heads Shear
Seams of the ship open up
Bulkheads Fill w/Water, ship loses buoyancy
Slag weakened Rivet
The Titanic Sinks
Metallurgical structure
Open Seams on Olympia
Metallurgical examination revealed the presence of extensive slag in the rivets which is known to weaken the strength of metal.
But the rivets didn’t shear on their own
EFFECT
February 23, 2019 8
Bev Daniels. 8

9. The causal system of the sinking of the Titanic
CAUSE
White Star requires Smaller bulkheads to ensure full size first class cabins
Side Swipes Iceberg; shear force applied along side of ship
Condition for Failure
Rivet Heads Shear
Seams of the ship open up
Bulkheads Fill w/Water, ship loses buoyancy
Physical Root Cause
Slag weakened Rivet
The Titanic Sinks
Metallurgical structure
Open Seams on Olympia
4 Whys (2 asked twice) to get to causal mechanism.
This is the classic strength-stress interaction.
We could go further and indentify why slag was in the rivets – although this was a scientific/manufacturing constraint at the time. But at this point we have enough specific information about the causal mechanism to develop a viable solution. The seams need to be held together by a stronger fastening system.
In this case actions to guard against the condition for failure are futile. Any sideswipe can cause the rivets to shear; in fact this is how the Olympia failed..
EFFECT
February 23, 2019 9
Bev Daniels. 9

10. The causal system of the sinking of the Titanic
CAUSE
White Star requires Smaller bulkheads to ensure full size first class cabins
Why did the titanic hit the iceberg?
Side Swipes Iceberg; shear force applied along side of ship
Rivet Heads Shear
Seams of the ship open up
Bulkheads Fill w/Water, ship loses buoyancy
Slag weakened Rivet
The Titanic Sinks
Metallurgical structure
Open Seams on Olympia
This is the classic strength-stress interaction.
We could go further and indentify why slag was in the rivets – although this was a scientific/manufacturing constraint at the time. But at this point we have enough specific information about the causal mechanism to develop a viable solution. The seams need to be held together by a stronger fastening system.
In this case actions to guard against the condition for failure are futile. Any sideswipe can cause the rivets to shear; in fact this is how the Olympia failed..
EFFECT
February 23, 2019 10
Bev Daniels. 10

11. The causal system of the sinking of the Titanic
CAUSE
Systemic Causes
White Star requires Smaller bulkheads to ensure full size first class cabins
Lookouts See Iceberg too late; swerve to avoid
Side Swipes Iceberg; shear force applied along side of ship
Rivet Heads Shear
Seams of the ship open up
Bulkheads Fill w/Water, ship loses buoyancy
Slag weakened Rivet
The Titanic Sinks
Metallurgical structure
Open Seams on Olympia
EFFECT
February 23, 2019 11
Bev Daniels. 11

12. The causal system of the sinking of the Titanic
CAUSE
Systemic Causes
Dark & overcast conditions reduce visibility
White Star requires Smaller bulkheads to ensure full size first class cabins
Lookouts See Iceberg too late; swerve to avoid
Side Swipes Iceberg; shear force applied along side of ship
Rivet Heads Shear
Seams of the ship open up
Bulkheads Fill w/Water, ship loses buoyancy
Slag weakened Rivet
The Titanic Sinks
Metallurgical structure
Open Seams on Olympia
EFFECT
February 23, 2019 12
Bev Daniels. 12

13. The causal system of the sinking of the Titanic
CAUSE
Systemic Causes
Dark & overcast conditions reduce visibility
White Star requires Smaller bulkheads to ensure full size first class cabins
Lookouts See Iceberg too late; swerve to avoid
Side Swipes Iceberg; shear force applied along side of ship
Titanic sailing too fast for conditions
Rivet Heads Shear
Seams of the ship open up
Bulkheads Fill w/Water, ship loses buoyancy
Slag weakened Rivet
The Titanic Sinks
Metallurgical structure
Open Seams on Olympia
EFFECT
February 23, 2019 13
Bev Daniels. 13

14. The causal system of the sinking of the Titanic
CAUSE
Systemic Causes
Dark & overcast conditions reduce visibility
White Star requires Smaller bulkheads to ensure full size first class cabins
Lookouts See Iceberg too late; swerve to avoid
Side Swipes Iceberg; shear force applied along side of ship
Titanic sailing too fast for conditions
Rivet Heads Shear
Seams of the ship open up
Bulkheads Fill w/Water, ship loses buoyancy
Slag weakened Rivet
The Titanic Sinks
Metallurgical structure
Captain ignores iceberg warnings
Open Seams on Olympia
EFFECT
February 23, 2019 14
Bev Daniels. 14

15. The causal system of the sinking of the Titanic
CAUSE
Systemic Causes
Dark & overcast conditions reduce visibility
White Star requires Smaller bulkheads to ensure full size first class cabins
Lookouts See Iceberg too late; swerve to avoid
Side Swipes Iceberg; shear force applied along side of ship
Titanic sailing too fast for conditions
Rivet Heads Shear
Seams of the ship open up
Bulkheads Fill w/Water, ship loses buoyancy
Slag weakened Rivet
The Titanic Sinks
Metallurgical structure
Captain ignores iceberg warnings
Open Seams on Olympia
This is a relatively simple example that really didn’t require sophisticated experimental structures to answer any of the 5 Why questions. It does show the basic flow of causal mechanism and the separation of systemic, enabling and physical causes.
White Star pushes for record crossing time
EFFECT
February 23, 2019 15
Bev Daniels. 15