Root Cause Analysis, Part 2

Photos from http://www.csititanic.com/.

In an earlier post, I used the 5-why technique to determine the root cause of the RMS Titanic hitting an iceberg: communication error between the watchman and his officer regarding the availability of binoculars. While this is truly a root cause, it doesn't inform us why the Titanic, billed to be "unsinkable," sank in less than three hours once it hit the iceberg. So the next question is, once it hit the iceberg, why 1, why did it sink so quickly?

The answer to this first why unfolds in a new book called "What really sank the Titanic." In it, the authors present results of submarine recon showing the ship sank so quickly due to rivets popping along the six slits opened in the seams on the bow of the Titanic. So the next question, why 2, is why did the rivets pop?

Research indicates that the rivets used were poorer quality than standard, causing an easy fracture path for failure. The research was conducted on many rivet samples retrieved from the shipwreck site. Photomicrographs show the phosphate and sulphate inclusion level in these iron rivets is excessive, leading to a weaker fastening of the ship. You can see this on the scanning electron micrograph, shown below from www.csititanic.com, which shows a long slag inclusion provided a fracture path for this rivet's failure.

So the next question, why 3, is why the poor quality rivets were used?

These lower quality rivets were used because of a scarce supply of top quality rivets. Research on meeting minutes cites repeated references to shortages of "best best" quality rivets. So the next question, why 4, is why there was a scarce supply?

The shipbuilder, Harland & Wolff, was building three ships the size of Titanic at the same time. The Britannic and the Gigantic were ships in the same series as the Titanic, and all three were under construction at the same time. Which begs the final question, why 5, why were they building three huge ships at once?

This was a policy decision made by managers at Harland and Wolff. The basic motivator is the drive for profits which, in this case, trumped the need for quality. So to avoid the sinking of the Titanic, an executive at Harland and Wolff would have had to say, “no, we cannot meet this schedule and build the three ships safely with materials that are currently available, so we must delay one or two of the ships.” This would have allowed proper materials to be used and would have saved 1520 lives.

This analysis shows that most problems are the cause of policy decisions and ineffective management, not workers like watchmen or riveters. It was an officer who didn’t supply the binoculars, it was an executive who specified the wrong rivets rather than changing the schedule.
The root cause of the Titanic's sinking so quickly was an executive decision far removed from the sinking, both in space and time; As Deming said, “The problem is at the top, management is the problem.”

Root Cause Analysis

The RMS Titanic steamed out of Southampton England en route to New York on April 10th of 1912. This luxury liner was billed to be practically unsinkable. It struck an iceberg at 11:40 PM April 14th and sank 2:40 later. 1,520 lives were lost. This wasn’t the largest loss of life in a maritime disaster, but the Titanic still captures our imagination to this day. In fact, a recent book is out discussing the cause of the sinking. The book, called “What really sank the titanic,” is based on research conducted on samples taken from the shipwreck. I provided an earlier look at this issue, discussing how initial problems evolved into a catastrophic loss of life.

In a different angle, I looked at the root cause of the sinking, and found that Dr. W. Edwards Deming was right, yet again, when he said, "The problem is at the top. Management is the problem."

I performed a root cause analysis on the Titanic's sinking. Using the 5-Why approach, here is what I found. There are two branches to explore, first, why did the Titanic strike an iceberg at all, and second, why did it sink from the collision? This Blog entry is about the first question.

· Why 1: Why did the Titanic hit an iceberg?
o Standard operating procedures at that time for ice fields: post watchman and carry on.

· Why 2: Why did the watchman see the iceberg too late? Conditions:
o “Flat calm,” cloudless sky, 31 F. Watchmen looked for the white foam of waves crashing on icebergs' bases. That night, there were no waves.
o Moonless night: difficult to see anything.
o Not ideal conditions to see icebergs, but was the Titanic not to travel in these flat seas?
o Yes, it should be able to steam in these conditions. Since we can’t control the conditions, let’s step back up and ask why the watchmen failed to see the berg until it was too late. Did the watchman have standard tools, like binoculars?

· Why 2/B No. Why didn’t the watchman have binoculars to see in poor conditions?
o He was told they didn’t have them by an officer, even though there were two pair in the bridge.

· Why 3: Why denied?
o The officer didn't know or didn't care enough to find out. In essence, this is poor communication.

· Why 4: Why poor communication?
o If we answer this, we know why the Titanic hit the iceberg: root cause was poor communication between the watchman and the officer.

It could have been that the officer didn't know or didn't care. Either way, we are getting to the root cause. Let's say the officer didn't know...

• Why 5: why didn't the officer know about binoculars on the bridge?



• Poor training, new ship, lack of leadership and awareness... these are the problems, as Deming said, "at the top."

So we see, it wasn't that the watchman did a poor job, it was that he was not supported by the management system. This failure led to the Titanic striking an iceberg on its maiden voyage. Next we'll ask why the ship, described as "practically unsinkable," sank so quickly once it hit.