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HTML>Essay on Risk Management -R.Brander The Titanic Disaster: An Enduring Example of Money Management vs. Risk ManagementRoy Brander, P.Eng.I've put off starting this essay for days, because today is so appropriate.As I sit down to write, it is 11:40 PM, April 14th, 1995. Ignoring the time zone difference, it was 83 years ago this minute that theRMS Titanic, on her maiden voyage in 1912, struck an iceberg. The collisionwas not head-on. The berg bumped and ground along the starboard side and thenwas gone into the calm, moonless night. At first, few thought the damageserious. It was difficult to coax passengers into the lifeboats. Yet threehours later, the Titanic slammed into the ocean floor almost 4000 metresbelow, torn in two. Over 1500 of her passengers and crew were dead. And thedesign and operation of sea vessels changed dramatically and permanently.Most of the discussion of the accident revolves around specific problems.There was the lack of sufficient lifeboats (enough for at most 1200 on a shipcarrying 2200). There was the steaming ahead at full-speed despite variouswarnings about the ice-field. There was the lack of binoculars for thelookout. There were the poor procedures with the new invention, the wireless(not all warnings sent to the ship reached the bridge, and a nearby ship, theoperator abed, missed Titanic's SOS). Very recently, from recovered wreckage,"Popular Science" claimed the hull was particularly brittle even for themetallurgy of the time. (A claim now debunked.) Each has at one time or another been put forward as"THE reason the Titanic sank".What gets far less comment is that most of the problems all came from alarger, systemic problem: the owners and operators of steamships had for fivedecades taken larger and larger risks to save money - risks to which they hadmethodically blinded themselves. The Titanic disaster suddenly ripped awaythe blindfolds and changed dozens of attitudes, practices, and standards almostliterally overnight.The perception persists that the Titanic was, if obviously not "unsinkable"(though the White Star line actually never used that word in advertising),then very safe, as safe as the art could build her. That, despite variouserrors, the accident was mostly enormous bad luck. Nothing could be furtherfrom the truth. It was amazing good luck that there had been no similaraccidents years earlier. For over 50 years, safety standards had beensteadily deteriorating in various ways - almost always because of pressures tobe "competitive".Walter Lord, author of the classic "A Night to Remember", describes theprocess vividly in his 1986 sequel, "The Night Lives On". He compares theships of Titanic's day to the first great liner, the "Great Eastern", built in1858. She was designed by I.K. Brunel, England's most celebrated engineer, whogot every feature he wanted. The Great Eastern was not the most profitableship, but she was a triumph of safety. She had an entire inner hull two feetinside the outer. Inside that, the ship was divided by 15 transversebulkheads, and one lengthwise into 32 compartments. Watertight lower decksfurther divided those.The decades passed, and dozens, then hundreds of liners werebuilt. Competitive pressures between some 11 lines were fierce. As WalterLord relates: "But the engineers did not have the last word for very long...the perfect ship was no longer the vessel that best expressed the art of the shipbuilder. It was the ship that made the most money." "Passengers demanded attention; stewards could serve them more easily if doors were cut in the watertight bulkheads. A grand staircase required a spacious opening at every level, making a watertight deck impossible. ... Stokers could work more efficiently if longitudinal bulkheads were omitted... A double hull ate up valuable passenger & cargo space; a double bottom would be enough." "One by one the safety precautions that marked the Great Eastern were chipped away in the interests of a more competitive ship. ... When the "unsinkable" Titanic was completed in 1912, she matched the Great Eastern in only one respect: she, too, had 15 transverse bulkheads." "But even this was misleading. The Great Eastern's bulkheads were carried 30 feet above the waterline; the Titanic's, only 10 feet." -"The Night Lives On", pg. 21The Titanic's designers thought her quite safe enough, because she could floatwith any two of her 16 compartments flooded, and only the worst possibleaccident, a collision right at a bulkhead, could even flood two. Indeed, atthe bow where the ship was narrowest and the compartments much smaller, shecould float with the first four flooded, and collisions were most likely atthe bow.As the Titanic nudged and shouldered her way past the huge iceberg, we can nowestimate that a gash was torn in her almost 100 metres long. It was probablymore an irregular series of holes and rips, but the cumulative area along thatgreat length was square metres. The ship's builder, Thomas Andrews, wasaboard and inspected the damage with the Captain. They found that the firstfive compartments were flooding rapidly, and the sixth leaking.Andrews quickly visualized the awful, inevitable mathematics. As the frontcompartments filled, and the bow sank, the transverse hull between the fifthand sixth compartments would drop over 10 feet - below the waterline. Thewater would spill over into the next compartment. So the ship would sinkfurther, and water would spill into the next, and the next - and the pumpscould only slightly delay it. The accident that nobody could imagine hadoccurred just that simply. Andrews underestimated her remaining time at onlyan hour. She lasted two.By contrast, 50 years earlier on August 27, 1862, the Great Eastern hadscraped on an uncharted rock off the coast of Long Island. It ripped a gashin her skin some 9 feet wide and 83 long, worse in some ways than the breachin the Titanic. However, the Great Eastern's inner hull was unbroken and theengine room remained dry. She not only floated, but limped into New York thenext day under her own steam. Not a soul was hurt.Engineers today, who work in such safety-conscious designs as nuclear plants,use the military term "defense in depth". Behind the first safety system liesanother, and behind that, still another...each with its own backups. TheGreat Eastern had defense in depth against hull breach. By the era of theTitanic, liners had contented themselves with but a single "layer", theall-too-short transverse bulkheads. Soon after the disaster, the sister shipOlympic, and many other liners with comparable designs, were being expensivelyretrofitted with an inner, second hull. Suddenly the "impossible costs" ofsuch "extravagances" seemed affordable after all.Various other corners ceased to be cut in safety standards, as well. Sinceall lines did the same, competitive positions remained relatively the same.(Of course, the White Star line never recovered from the loss of the Titanicand the settlements for cargo and loss of life; it was absorbed by Cunardlines some years later. So much for competitive advantage from trimmingstandards.)The most dumbfounding cut in retrospect was the lack of lifeboats. It was notjust the price of the lifeboats themselves that bothered the businessmen, itwas the deck space they ate up...one of the most precious commodities aboard.The committee of the British Board of Trade that made the regulations onlife-boats was dominated by shipbuilders. They proved very able to convincethemselves that boats for every person were not necessary. Thus theregulations of the time required only that a ship of Titanic's size carryboats sufficient for 962, though she could potentially carry over 3500passengers and crew.White Star's General Manager Harold Sanderson pointed out that the NorthAtlantic was so stormy that boats could not be lowered safely 95% of the time,and even once down, the passengers would be subject to additional dangers onthe tossing sea. "They could avoid all this by drowning at once" joked themagazine "Fairplay", when he continued with this view even after the accident.Needless to say, following the disaster, complicated formulas requiring somany cubic feet of lifeboat space per thousand tons of ship were replaced witha simpler one: enough seats for everyone aboard. Again, a supposedly highcost was suddenly affordable, and has never been questioned since.The lifeboat problem was exacerbated by poor procedure. Only at the last didlifeboats leave full; at first, many left partly empty because passengers werenot queued up to them. Second Officer Herbert Lightoller took the instruction"Women and Children First" so literally that he let lifeboats leave with emptyspaces rather than let men or boys as young as thirteen aboard...and was neverso much as reprimanded for this part in seeing just over 700 saved when 1200could have been.Those of us who design and operate public services, and bear the title of"civil servant", may be much sobered by this transcript from the inquiry.Captain Maurice Henry Clarke, the inspector who cleared the Titanic forsailing, was being examined on the reasons for Titanic's only "lifeboat drill"having been conducted at the dock, consisting of only two boats, manned byhand-picked crew. Having conceded that he had since tightened requirements, hewas asked: "Did you think your system was satisfactory before the Titanic disaster?" "No, sir." "Then why did you do it?" "Because it was the custom." "Do you follow a custom because it is bad?" "Well, I am a civil servant sir, and custom guides us a good bit." Custom still does, and not just for civil servants. A few decades ago, seatbelts in cars were thought a little-needed luxury; today vastly more expensiveairbags are becoming a standard feature. Those who make and sell vehiclesfought the transition step-by-step as the added cost naturally reduces thenumber that can be afforded by the buying public. The public itself haseither resigned itself to the cost, or embraced it with enthusiasm, once thestatistics of death and crippling were considered. The first hockey players to use helmets were jeered by other athletes until it became the new"custom". Now most parents willingly accept the cost of helmetssimply for their children to ride bicycles.All risks need rational consideration, and some must be accepted. Sooner orlater, it will be pointed out that a few head injuries occur to pedestrians,but I hope that it will never be made mandatory to wear ahelmet to take a walk. Even today however, it is still often the case thatmoney management wins out over risk management.What this lead to with the Titanic was that a lesson was only learned becausethe tuition was paid in blood. Has much changed? This week's news was fullof the story that tractor-trailers are now being carefully examined fordefects in their wheels and many pulled off the road, which costs money.This, after two people were killed by runaway wheels broken loose, both in thesame week. There had been other such cases...but then two, close together,stimulated realization of a need for systemic change, not just a focus on thespecific trucks involved.I've been typing for hours, and my watch says it is 2:10. This is anothertime I recall from my Titanic reading. The ship went down about 2:20, and2:10 was when her builder, Thomas Andrews, was last seen. After helping toorganize the confused lifeboat loading, and personally assisting many to thelast boats, he remained aboard. A survivor recalled seeing him at this time,alone in the Gentlemen's First Class Smoking Lounge, staring into space. Thesteward called to him to come try to swim for it, but he did not answer.This room was one of the most remarkable on the ship, paneled in richmahogany inlaid with mother-of-pearl, lit through stained glass, and evenpossessing a working fireplace. (No expense was spared here!) Andrews haddone much of the architecture and interior design, as well as the structuraland mechanical work.I sometimes like to think that in his reverie, he realized the basicmistakes that he and a half-century of his predecessorshad made. I hope it comforted him that this disaster was going to be sotraumatic as to bring about tremendous changes despite all their costs, changesthat would save more lives in the long run. Were it not for the Titanic,the safety standards might have continued for a long time, causing a longstring of smaller disasters - each too small in its own right to bringabout basic changes to the whole industry.As the sinking bow lifted the stern a hundred feet in the air,Titanic's own weight broke her back and ripped her in two. Theenormous screaming of tons of metal tearing was a sound that hauntedthe survivors all their lives. I hope Andrew's thoughts had given himsome sense of consolation when the hungry North Atlantic stalked intothe lavish Georgian drawing room to take away his sorrow and his shame.© Roy Brander, 1995 Index to all my Titanic material, including a lecture based on this essay with much more detail and graphicsMy Home Page Home Page for the Calgary Unix Users Group (where this document lives)Thanks to Yahoo! Canada which named thisA pick of the week ![[Yahoo Logo]](http://www.cuug.ab.ca/~branderr/risk_essay/titanic.html/bl_pick.gif) for the week of February 13, 1998.A few days later, the same came from the American original Yahoo! "Pick of the Week" for the week ofFebruary 16, 1998.About Yahoo! and other sites that have links to this essay. (Copr) Roy Brander, 1995 |
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