Titanic Mistake

This photo of the Titanic under construction comes from the NY Times article describing a recent discovery concerning the sinking of the great ship. The Titanic was designed to be unsinkable, yet it sunk on its maiden voyage. The discovery shows why the Titanic sunk from striking an iceberg, and why it sunk so quickly, taking so many with her.



In the article, reported by William J. Broad, research by Jennifer Hooper McCarty and others shows the cause of the disastrous sinking was faulty rivets located in the bow. A transition from iron rivets to steel rivets was underway in shipbuilding of the times, and steel was the newly preferred, stronger material. Steel rivets were used in the areas designers felt it was most needed, in the main hull, but not in the bow nor stern. Iron rivets were specified, and there were shortages. A lower grade iron rivet was used in the Titanic, as demonstrated in samples recovered from the ship. When compared to standard wrought iron, there is up to three times the inclusions, or trapped slag, in the iron. Inclusions make the steel weaker, providing fracture paths for failure propagation.



How could this be? This was a premium luxury liner of the time and there were cheap rivets? It is a story of a crisis with seeds in decisions far removed from the chilly arctic where the Titanic lays today. In an earlier post, I described a model for a crisis with an adverse outcome:

- An initial problem, often minor in isolation, that goes uncorrected
-A subsequent problem that compounds the effect of the initial problem
- An inept corrective effect
- Disbelief at the accelerating seriousness of the situation
- Generally, an attempt to hide the truth about what is going on while an attempt is made at remediation
- Sudden recognition that the situation is out of control or “in extremis”
- Finally, the ultimate disaster scenario involving significant loss of life, financial resources, or both, and ultimately, the recriminations.

* Initial problem: material shortages. There were three huge ships being built at the same time and materials and labor were in short supply. Iron rivets were substituted for steel and used in the bow.

* Subsequent problem compounding the initial one: the proper iron rivets were not ordered (due to a shortage?) and the ones received had inclusions, weakening them. They came from smaller forge shops not normally used by the shipbuilder.

* Corrective Effect: There was none that we know because the iron rivets were not tested and found to be weaker than required. The Board of Trade stopped inspecting iron rivets at the time, deciding they were a mature technology and the focus went to steel.

* Disbelief at the accelerating seriousness: this had to occur the night the Titanic hit an iceberg. Due to the weaker rivets, the Titanic literally fell apart at the seams in the bow, allowing water to rush in and sinking the ship faster than anyone could respond.

* The final disaster scenario: the sinking of the Titanic with all the loss of life and property associated with it.

Interestingly, denial and recriminations persist to this day. When asked about the research findings, the shipbuilder, "Harland and Wolff, after its long silence, now rejects the charge. 'There was nothing wrong with the materials,' Joris Minne, a company spokesman, said last week. Mr. Minne noted that one of the sister ships, the Olympic, sailed without incident for 24 years, until retirement. (The Britannic sank in 1916 after hitting a mine.)"

The Titanic rests at the bottom of the Atlantic, with six slits in its bow. The slits replace seams once held closed by iron rivets, and the slits stop where the steel rivets hold the seams together still.

Patterns of Crises

The direct translation of these Chinese characters, which mean crisis, is "an opportunity riding a dangerous wind." Although crises present opportunities, most crises are unwanted and we feel better off without.

In his book, Will Your Next Business Mistake Be Fatal? Avoiding a Chain of Mistakes that Can Destroy Your Organization, Robert E. Mittelstaedt, Jr. describes a pattern traced back from crises. Mittelstaedt finds that the pattern includes these components (and I quote, from the book):

"- An initial problem, often minor in isolation, that goes uncorrected
- A subsequent problem that compounds the effect of the initial problem
- An inept corrective effect
- Disbelief at the accelerating seriousness of the situation
- Generally, an attempt to hide the truth about what is going on while an attempt is made at remediation
- Sudden recognition that the situation is out of control or “in extremis” (In extremis is a Latin phrase meaning "in the furthest reaches" or "at the point of death".)
- Finally, the ultimate disaster scenario involving significant loss of life, financial resources, or both, and ultimately, the recriminations."

If this pattern seems familiar, it should, because most business problems that become crises follow this pattern. Also, the large crises our governments face can be traced back through the same pattern.

What to do, then, to avoid these crises? Clearly, the chain of escalation must be broken. The first component of the pattern is the initial problem. So many crises start out small, in a manageable scope, yet go unfixed. An effective method of problem detecting and corrective action nips these problems in the bud.

When the initial problem gets past the first wave of defence, an interacting problem often amplifies the first one. Now a real mess is brewing. If corrective action fails here, the next phase in escalation is when those responsible begin hiding the problem or downplaying its significance. This can be done through filtering information as it goes up the chain of command. A boss can work to avoid filtering by having several lines of communication to compare messages and validate what he or she is hearing. When there is a disconnect, one of the sources is either filtering information or out of touch. Regardless, this is when help is needed but somehow doesn't show up.

Next, the crisis erupts in some undeniable way. People ask, "how could this happen?" There is enough blame to go around and lessons are learned and spread throughout the organization, but the key question is, is there a system in place to root out problems in their infancy and solve them completely? If not, be ready for more "opportunities riding dangerous winds."

With years of problem solving and corrective action experience, The Flying Toolshed implements corrective action systems so crises may be avoided all together. We believe creating opportunities for our clients rather than having opportunities thrust upon them.

bob@flyingtoolshed.com