Reflections on the Root Causes of the Titanic Disaster; 14-15th April 1912


It sounds corny, but I couldn’t have written the article that follows, unless I had done the IMPM. My background was finance, but after my MM from McGill I left finance and joined HR. I then started working in risk and corporate governance, and for the past 10 years I have been self-employed combining my love of governance with a passion for training and development. Thanks to all the different IMPM “mindsets”, I became increasingly interested in leadership and culture, and linked to this I have a specialist skill in root cause analysis.

What follows is a summary of one of the things I cover in my training workshops, the sinking of the Titanic. This is now especially poignant given COVID 19, with a number of parallels to be made between what happened then and what’s happening now.

I hope this recounting of the Titanic story will make clear, to those of you not so familiar with what happened, why this disaster has SUCH a hold on so many people 108 years after it took place. And for those familiar with the Titanic’s sinking and loss of life, I hope you will find this useful exploration of some of the deeper, underlying root causes; and hope it will offer perspectives that can be applied to our current times. I also hope it whets your appetite to become interested in root cause analysis (RCA), I think RCA techniques and the insights we can get from them are extremely powerful, they align closely with many IMPM concepts, and also offer new angles to problem framing and problem solving.

To examine the root causes of why the Titanic sank, I’m not going to repeat the detailed stories told in many articles, books and films. Instead, I’m going to use the root cause analysis technique of asking why, why, why and see where this takes us. I’ll be using information from the two enquiries that took place shortly after the sinking of the Titanic to justify what I say, as well as more recent insights.

Doubtless, experts on the tragedy will be able to fill in any significant gaps in my account that will further enhance our understanding, and provide us with opportunities to learn.

So according to popular accounts, what were the main causes of why the Titanic sank, and why so many died?

The familiar story is that the Titanic was crossing the Atlantic in April 1912. It was travelling quite fast and it struck an iceberg, causing damage and letting water in. This happened at 11.40pm. There are arguments from some quarters that one lookout, Frederick Fleet, was to blame, whilst others believe he did everything he could have in the circumstances.

Many know that there weren’t enough lifeboats for all the passengers and crew onboard, and may also be aware that there were problems loading the passengers into lifeboats.

The Captain, Edward Smith, though an experienced sailor, is often thought to have been accountable for the tragedy, and went down with his ship, at 2.20am on 15th April, just 2 hours 40 minutes after hitting the iceberg.

The SS Carpathia came to the rescue as quickly as it could, and picked up passengers from around 4.30am. Tragically that was not quick enough for those who went into the freezing water, and over 1,500 died.

To do effective root cause analysis we ask why, why, why, why…

So, why did the Titanic hit an iceberg?

It hit an iceberg because there were icebergs in the sea. This seems a rather trite explanation, but it’s important when analysing a situation for its causes to not overlook basic things.

Why were there icebergs in the sea?

Because the Titanic was travelling through the north Atlantic in April, a time of year when icebergs might be expected. In fact, to manage the risk of an iceberg collision, ships crossing the Atlantic in winter travelled on what was called the “southern track” route, further south than the normal summer-time route. However, it appears that in April 1912, the icebergs were further south than normal.

Why was the Titanic travelling in April, and not later in the year?

She was launched into Belfast harbour in May 1911. The next 10 months were spent fitting her out. In October 1911, the White Star line announced the maiden voyage would take place in April 1912, allowing passengers to sign up for the trip and starting to give the White star line a return on its enormous investment, and to recapture its reputation as a transatlantic carrier. Over several years, the White Star line had lost ground against Cunard with its ships the Lusitania and the Mauritania, and the building of the Titanic and its sister ships was intended to rectify that.

It’s important to pause at this stage to ask ourselves whether we have arrived at one of the root causes for the sinking of the Titanic?

Did greedy ship owners demand that the Titanic set sail at the wrong time of year and on the wrong route?

The enquiries in the US and UK established that sailing at this time of year was quite normal, especially for a large ocean-going liner, and also that the Titanic was travelling close to the main shipping route with a number of other ships relatively close-by, all of whom had safe a passage across.

So, commercial motives may have been a contributing factor to the disaster but they were not the central root cause.

If this seems a controversial statement; think about travelling by plane. Many airlines are commercial enterprises, but the accident rate per mile is low in the majority of countries, thanks to strong safety regulations and enforcement.

Being commercial and being safe are not, of necessity, incompatible

Why does it seem that look-outs did not see the iceberg in time?

This is a time before radar.

The sea was very calm that night and it was recognised that such a sea could, paradoxically, hamper the ability of the look-outs to spot icebergs since foam would not be created as waves hit the ice.

It was agreed that if it became “in the slightest bit hazy” the ship would have to slow down from its speed of 22 knots.

At 9.20pm Captain Edward Smith left the bridge with the instruction “If in the slightest degree doubtful, let me know” and at 9.30pm lookouts were advised to “keep a sharp watch for small ice and growlers”.

At 11.39pm one look-out, Frederick Fleet, spotted the iceberg. He rang a warning bell, and alerted the bridge with the message “Iceberg, Right ahead”.

First officer William Murdoch ordered evasive action and the engines were put in reverse before impact, but the Titanic could not completely avoid the iceberg. She received a glancing blow, with damage to her hull around 10ft below the waterline, at intervals along 300 feet where the plates of the hull were riveted together. This meant that five of her forward water-tight compartments were breached.

In both the US and UK enquiries into the sinking of the Titanic, there was a great degree of scrutiny given to whether the iceberg should have been spotted earlier. There were questions about whether the look-outs should have had access to binoculars, which were apparently in a locked cupboard, but to counter this, there were, and still are, arguments about whether this would have made any difference.

It seems clear that the look-out Frederick Fleet was “tainted” by those with the suspicion that he may not have acted as quickly as he could, but the enquiries did not determine any misconduct on his part. As I see it there is often a bitter irony that those who play an important role in identifying and dealing with a crisis are subjected to the most scrutiny, and even criticism, for not doing even more, often by those who were not there at the time.
Continuing our search for root causes, a key point to note at this juncture, is to recognise that the risk faced by the Titanic was NOT simply a function of the ability of the look-outs to see an iceberg, it was also a consequence of the speed the Titanic was travelling, and her momentum. As the largest ship EVER build, she had the most momentum, for a given speed, of any ship in the world at that time, and that meant she was not able to stop or turn in a way that countless smaller ships might have been able to.

The question of the Titanic’s stopping distance was addressed in her brief sea trial prior to her maiden voyage. During the sea trial she was able to stop in just over 750 metres, but it seems this was at a speed that was somewhat slower than the 22 knots as she approached the iceberg.

Why didn’t the Titanic slow down when entering an area where icebergs had been spotted?

During the UK Board of Trade enquiry it became clear that the custom and practice of most ships in such a situation was not to reduce their speed even when ice might be in the vicinity, even during the night, and especially in clear conditions.

So, Captain Smith, and first Officer Murdoch, were not doing anything that was significantly different from hundreds of others before them up to that point.

It was recognised AFTER the Titanic tragedy that ships should moderate their speed in such circumstances, but the thinking up to that point was that no iceberg strike had been attributed to an excess of speed, and it was even believed that travelling at speed could enable a ship to leave the ice field danger zone more quickly.

We also need to bear in mind that many of the passengers on board would have been looking for a relatively fast passage across the Atlantic; and this may have been an implicit pressure not to slow the Titanic. It must be stressed, contrary to what many think, that the Titanic was not trying to break the speed record for crossing the Atlantic, nor was she travelling at her maximum speed.

Having struck an iceberg, why did the Titanic let so much water in, such that she sank in just 2 hours 40 minutes?

The Titanic had a double-hull around the bilge area, at the bottom of the ship (as was custom and practice at the time), but she had a hull above that built with single steel plates, around 1 inch thick, which was substantial for passenger ships at that time. The plates were joined with double rivets of iron at the aft and stern, and triple rivets of steel in midships.

There were 15 internal bulk-heads constructed, dividing the Titanic into 16 sections – significantly more than required by regulations at the time.

However, the transversal bulkheads of the Titanic did not seal off each section of the ship completely, (they were built up to certain deck levels: D, E or F, when there were 9 decks in all (up to deck G)).

In addition, the Titanic was designed to float with up to 2 bulk-heads being breached; when, on 14th April, 5 were damaged. This is one of the reasons why Thomas Andrews, who supervised the design of the ship, and who was aboard that night, knew very quickly that the Titanic had suffered fatal damage, requiring passengers be evacuated as soon as possible.

Why were the Titanic hull and bulkheads not designed and built in a more robust way?

This is an area that was discussed in the UK Board of Trade enquiry, involving participation from those working for the ship builders Harland and Wolff. First of all, the hull and bulkheads of the Titanic, a passenger liner, was built within existing regulations and inspected at regular intervals during its construction.

The “gold star” for bulkhead compartments at the time could be found in the war ship HMS Dreadnought, which had full-height transverse and longitudinal bulkheads, and watertight decks, allowing it to sustain significant damage and still stay afloat. However, the penalty for such a high level of safety was one in which crew members would have to accept being mostly confined to particular locations, and then open and close water-tight hatches when moving between compartments. This is a price worth paying when you are designing a war ship, where those on board are crew members, but is not desirable when you have paying passengers on board.

Thus the reason why the bulkheads of the Titanic were not built full height was not because of a deliberate desire to build a sub-standard ship, but rather a result of a dilemma between a desire for safety, and a recognition that paying first-class passengers would want to move freely between their cabins, dining rooms, lounges, and the promenade decks. In particular, the Titanic’s special features such as the grand staircase and first-class dining room could not be constructed with full height bulkheads.

This dilemma between safety and the utility of the ship on a day to day basis also applied to the stairways, dining rooms and sleeping accommodation for second and third-class passengers as well.

This trade-off between an ideal level of protection from sinking, and freedom of movement, is something that, to this day, is relevant to many on board a car ferry, or a cruise liner. And on a more mundane, day to day basis, a car seat belt with 4 points, over both shoulders, is safer than a 3-point safety belt, but who wants to put on such a seat belts on a regular basis, unless you are a racing driver?

When we think of actions to address COVID19 we also have many dilemmas to navigate; for example, the impact on liberty vs. the spread of the virus, and the saving of lives vs. the impact on the economy.

Why was the Titanic designed to cope with only two damaged bulkheads?

The logic of the designers was: what is the most realistic ‘bad accident’ that the Titanic might have? Their answer was: a side-on collision with another ship, when at close quarters. Based on this risk, and the size of most ships at the time, it was determined that the Titanic should be able to cope with damage to any 2 of its 15 bulkhead compartments (although it is thought that in fact it could have stayed afloat with 4 compartments flooded at the front of the ship because of the location of its boilers).
Similar considerations applied to the number and capacity of the water pumps on the Titanic. These pumps were activated when the hull was breached, but the flooding that occurred has been estimated to be more than 10 times the volume they could cope with.

It is worth making the parallel with the COVID19 pandemic: did we have a “failure of imagination”, as with the 9/11 disaster as well, when it came to the potential size and scale of what might befall us? If you don’t realise just how big and dangerous an iceberg is; including the fact that 90% is below the water-line, you will not make the necessary preparations.

Why were there not enough lifeboats on the Titanic, and why was the loading of the lifeboats a problem?

Concerning the number of lifeboats fitted, the UK Board of Trade regulations at the time were that a ship with a tonnage of more than 10,000 tonnes, should have at least 16 lifeboats with a capacity of at more than 9,600 cubic feet. The Titanic met this requirement, with 960 places available in 14 lifeboats and 2 emergency tenders. However, the Titanic had a tonnage of more than 46,000 tonnes, with the capacity to take around 3,500 passengers and staff, greatly in excess of the lifeboat capacity.
Given the number of passengers that could be on board, did the Titanic have a greater capacity than the legal minimum of 960?

The answer is yes, the Titanic had another 4 collapsible lifeboats, giving her a total lifeboat capacity of just under 1,200 places; 20% more than the legal minimum, but only just over a third of her maximum passenger capacity, and just under half of the 2500 on board on the maiden voyage.

There are two important points here:

  • In the end 1,503 persons would perish that night, so the shortage of lifeboat spaces DOES NOT explain fully the final death toll by several hundred;
  • Second, if the Titanic had been fully loaded with passengers and crew, it is almost certain, all other things being equal, that even more people would have died, both in absolute terms and as a percentage of the total.

Why didn’t regulations require more lifeboats on such a big ship?

This question was not definitively settled but it appears that – at that time – it was thought that there was no need to have a lifeboat for everyone.
The logic for this was as follows:

  1. For a large part of the year it was known that mid-ocean weather conditions could make it unsafe to launch a wooden lifeboat many feet down alongside the side of a ship’s hull. The simple swaying of the ship in choppy waters could cause lifeboats to be damaged, even destroyed, as they were being lowered;
  2. It was implicitly understood by many experienced mariners that lifeboats were primarily there to transfer passengers from a sinking ship to a rescue ship, and not to carry each and everyone on board;

What we can see from all of this is that being compliant with regulations does not automatically mean that you are guaranteed safety when things go wrong. Modern day parallels to this include: the Financial Crisis of 2007-8 and the Grenfell tower fire where cladding that was compliant with fire regulations seem, nonetheless, to have played a role in spread of the fire.

With COVID19 it is clear that there are shortages in a number of countries with regard to personal protective equipment, testing kits and respirators; raising important questions about the basis of determining whether sufficient provision had been put aside.

Why were the lifeboats not properly loaded with passengers that evening?

The newspaper headlines at the time spoke about shortcomings on the night and tried to find fault on the part of the Captain, First Officer Murdoch and Second Officer Lightoller, as well as question the conduct of the Managing Director of the White Star Line, J. Bruce Ismay, who was one of the 1st class passengers to get into a lifeboat.

The US and UK enquiries spent a considerable amount of time examining, in great detail, what happened on the night, and some of the following key points emerged: there was no ship-wide address system to notify all passengers of the emergency, this had to be done using cabin crew; first and then second-class passengers were alerted by the cabin crew already allocated to them on a timely basis, and since there were a greater proportion of staff available to explain the severity of what was happening, more first and second-class passengers were prepared to board the life boats and then subsequently loaded.

In third-class, because there were fewer staff available per passenger, and no obvious signs of a problem early on, a number of these passengers did not appreciate the severity of what was happening and the relevant staff did not have the time to impress upon them what was happening.

In any event, when on deck, early after the collision, it seemed strange to passengers to be asked to get into comparatively small wooden lifeboats, and leave the enormous Titanic behind, in the middle of the Atlantic, and at night, when there was no obvious problem (in fact there was a list of just a few degrees during the first hour after the collision).

This lack of appreciation of the gravity and urgency by the passengers of what had happened contributed to launching of lifeboats with too few passengers on board. Furthermore, and paradoxically, demanding that only women and children enter lifeboats at the beginning, may have also contributed to having spaces left in the lifeboats.

Towards the end of the loading process, as the angle of the Titanic grew more severe, and it became clear that there were not enough places in lifeboats for everyone, there was an increasingly bitter struggle to get a place on one, but at the same time, there are many heart-rending stories of selfless behaviour by many passengers and crew.

Additional reasons why the loading of the lifeboats was not smooth include the fact that crew roles for lifeboat loading were not clear and importantly, that there had been limited lifeboat training for the Titanic before her maiden voyage, due to the relatively short period of 8 days between completing her fit-out and the date of departure.

The enquiry would identify that there was a failure in the regulation and enforcement of lifeboat inspections and lifeboat training, before she set sail. But up to that point, lifeboat training had not seemed to be absolutely crucial, and a custom and practice had developed over time of doing such training exercises in a relatively cursory way, with more lifeboat practice planned once the Titanic had reached the USA.

Notice the circular logic here, up to that point in time, enforcing lifeboat practice before a maiden voyage seemed like “over-kill”, since delaying a voyage for the sake of extra practice would have resulted in delays and inconvenience for those expecting a passage. And because no serious issues had been attributed to a lack of practice up to that point, it didn’t seem to be essential to insist on this.

This is a common problem in other many other situations, checks and regulations can be seen to be a barrier to action and progress, and a cost-overhead, but if something catastrophic goes wrong, there is invariably a re-appraisal of the merits of such checks and regulations.
We are experiencing this issue to a great extent with the current COVID19 pandemic, including the extent and frequency of pandemic preparedness exercises, learning from these, and strong enforcement, and follow-up of lessons learned.

Other explanations for the Titanic tragedy

Although I have tried to give a high-level overview of the main reasons for the rapid sinking of the Titanic, and the loss of so many lives, it’s important to recognise that there are hundreds of twists and turns to this story.

The US Senate enquiry transcript into the Titanic disaster runs to more than 1100 pages, and the UK Board of Trade enquiry report contains over 2100 pages; and there are dozens and dozens of additional first-hand accounts of what happened that night. Inevitably, there have been criticisms of areas overlooked by the enquiries, but when you read the enquiry proceedings, I think it is fair to say that there was a genuine attempt to understand the many and varied range of reasons why things turned out as badly as they did.

Since then there has been a great deal of time and effort put in by many to try to uncover other reasons why disaster was as bad as it was. These efforts have included visits to the site of the wreck, analysis of artefacts, as well as detailed inspections of photographs during and after the construction and fitting out of the Titanic. Potential causes proposed by these later investigations have included questions about the quality of riveting of the metal plates, especially fore and aft, as well as concerns about a fire in a coal bunker that may have weakened one of the bulkheads, then failing as she filled with water.

In any event, even if these, and other considerations, are additional factors to take into account, they do not fully explain the death toll in themselves.

This is an important point when analysing root causes: you may believe you have found a really important factor that has contributed to a problem or disaster, but that does not mean you can necessarily explain the whole disaster from that single issue. So even if there were issues with rivets, and even if there was a weakened bulkhead, it’s important to see that the design of all of the bulkheads (such as they were not full height), AND the shortage of lifeboats, AND the lack of practice loading lifeboats, all contributed as well to the scale of the tragedy that unfolded.

This analysis most likely applies to the spread of COVID19 and the increasing death-toll, it’s not a matter of one problem causing the scale of the unfolding pandemic, but a combination of short-comings in various countries, many concerning steps that should have been taken in previous years, and not in a panic in the heat of battle in 2020.

Let’s continue with two more important factors that must be understood when explaining the Titanic disaster.

Given that the crew onboard the Titanic realised quite quickly that it was going to sink, and that there were other ships in the vicinity, why was a rescue from another ship not timelier?

First of all, because the Titanic was largely following the expected southern track route across the Atlantic, there were a number of ships relatively close to the Titanic that night:

  • SS Parisian – around 50 miles away;
  • SS Carpathia – around 58 miles away;
  • SS Temple Mount Temple – also around 58 miles away, but on the other side of an ice floe.
  • SS Californian – somewhere between 7 and around 20 miles distant (with controversy around the exact distance), stopped and surrounded by sea ice;
  • Some believe there was a “mystery ship” that was even closer still, perhaps engaged in illegal seal hunting, (and which was a confusing factor in sightings between the Titanic and the SS Californian), but this has never been established definitively.

After the iceberg strike, it quickly became clear to the Captain that the Titanic had been mortally wounded, and Captain Smith asked the Marconi Wireless operator on board, Jack Phillips, to issue a distress signal, explain the situation and position of the Titanic and request assistance. A number of ships responded and began to head towards the Titanic, however, many were some distance away.

By 12.26am the SS Carpathia had set a course to come to the aid of the Titanic and travelled at full speed to come to the rescue of the passengers. The SS Temple Mount also set a course for the Titanic, but her progress was slow, hampered by ice floes.

The SS Carpathia was the first ship to reach the location of the Titanic at around 4.00am, just over 2 and a half hours after the Titanic sank. She then spent the next few hours recovering passengers from the lifeboats. She was the only ship to collect survivors.

The SS Mount Temple arrived later that morning and picked up dead bodies in the water.

The SS Parisian had switched her radio off overnight and was not involved in picking up anyone.

More distant ships, that had been contacted in the night, eventually abandoned their rescue attempts after the SS Carpathia reported that she had picked up all survivors.

The only other ship that came to the site of the sinking later that morning was the SS Californian, and, by all accounts, she was the ship closest to the Titanic.

Why did the closest ship, the SS Californian, not come to the aide of the Titanic immediately?

The SS Californian was en-route to Boston and was captained by Stanley Lord.

By a strange twist of fate (given what subsequently transpires), SS Californian sent two messages about icebergs that night, one early in the evening, which was received by a number of ships, including the Titanic, which its radio operator, Jack Phillips, passed on to the bridge.

As the night progressed, Captain Lord decided that there were too many icebergs surrounding the SS Californian to make a safe passage, and he therefore decided to stop the ship where it was. Shortly after this, at around 10.50pm, Cyril Evans, the radio operator of the SS Californian, sent out a message that it had stopped and was surrounded by ice.

This message was also picked up by Jack Phillips, of the Titanic, who, an hour before the collision with the iceberg, was busy sending messages for passengers to the radio station at Cape Race, Newfoundland.

Since the SS Californian was close by, the message from the SS Californian was rather loud, and Jack Phillips replied: “Keep out; shut up, I’m working Cape Race.” There is no record that Jack Philips passed on this latest message of ice to the bridge, but we need to remember that:

  1. He had been passing such messages to the bridge at intervals during the day and that night (and we know that the lookouts were looking out for ice) and
  2. He had a back-log of a number of messages he was sending to Cape Race, which he returned to immediately after this exchange with SS Californian.

If the SS Californian was close-by, and knew the Titanic was there, why did it not pick up the radio distress messages less than an hour later? The answer is that shortly after sending his warning messages, with the ship stopped, Cyril Evans switched off the radio equipment of the SS Californian and went to bed. Note he was the only properly qualified radio operator on board the SS Californian.

Did the Titanic do anything, apart from sending distress signals by radio, to attract the attention of the nearby SS Californian? And if it did, why didn’t the SS Californian come to the aid of the Titanic? As far as we can establish, after the impact with the iceberg, the Titanic could see a ship nearby, most likely the Californian, and sent up flares at intervals in order to signal she was in distress. As best we can establish, these flares were seen by the crew of the SS Californian, and the sight of flares was relayed to Captain Lord. Apparently there was some confusion about whether these rockets were a distress signal, and therefore Captain Lord asked his crew send a signal to clarify what was happening. This was done with a morse lamp, which did not get a response.

One can reasonably ask why didn’t Captain Lord ask the radio operator, Cyril Evans, to get up, turn on the radio set, and find out more definitively whether there was a problem with a ship? However, Captain Lord’s testimony was that he would have ordered additional steps to be taken if he had thought a ship was in distress, but, from what he heard from his crew, he had no impression that the rockets were a distress signal.

Note that at that time radio was just coming into use, so would not have been the only means of communication at the time between ships, specifically flares and morse lamps were in regular use at the time to send messages between ships.

It was not until the morning, when Cyril Evans switched on radio of the SS Californian, that it became clear what had happened to the Titanic. The ship made its way through the ice to the location of the sinking and arrived shortly after the SS Carpathia had picked up all of the survivors.

The two enquiries disapproved of Captain Lord’s relative inaction, and there were reports of his brusque style, but neither pressed charges against him. Note that the after the enquiries were completed changes were made concerning the protocols around distress signals, effectively acknowledging the ambiguity of what had happened on the night of the sinking.

Finally, to fully understand the death toll for the Titanic, we have another important area to consider. We know that many passengers and crew went down with the Titanic, but hundreds fell into the sea wearing lifejackets, and we know that there were spaces available in a number of the lifeboats because of the way they were loaded especially at the beginning. In fact, it’s estimated there may have been hundreds of spaces on lifeboats.

Why did only 40, out of hundreds who fell into the water, survive?

In the first instance we know that the sea water was freezing and therefore a number of those who fell into the water would likely have died immediately. However, by all accounts, others survived for as long as 15, 30 and even 45 minutes, so why were not more saved?

One of the 40 who fell into the water, but survived, was Jack Thayer who said: “The most heart-rending part of the whole tragedy was the failure, right after the Titanic sank, of those boats which were only partially loaded, to pick up the poor souls in the water. There they were, only four or five hundred yards away, listening to the cries, and still they did not come back. If they had turned back several hundred more would have been saved.”

This is clearly a difficult topic to get reliable evidence on, and to discuss objectively. One analysis is that most of the crew and passengers in lifeboats would have been cold and tired and severely traumatised by what had just happened. In addition, those able to row and navigate the lifeboats may have been few in number.

However, some of the accounts of what happened in the lifeboats suggest that whilst some within wanted to go back to rescue those who were in the water (with a few lifeboats that did), the majority were afraid that their lifeboats would be overwhelmed by desperate survivors in the water, and insisted that the lifeboats remain as they were. There is even a heart-wrenching story of a man in the water being turned away from a lifeboat, despite it having spaces, and saying “God bless you” back to the passengers as he floated away to his death.

When all of the survivors were eventually accounted for, the death toll was enormous: 1503 deaths out of 2500. Mortality rates differed the most between women and children in comparison to men, but also varied between the 1st, 2nd and 3rd class passengers – 67% of 1st class male passengers drowned and around 80% of 3rd class male passengers died with approximately the same death toll amongst the ships crew. It’s worth remembering that most of the ships’ crew knew earlier and more clearly than most what had happened and the mortal danger they were in, but by all accounts the vast majority did their duty to the end.

You can make the parallel to COVID19; first, when thinking about the differences in the impacts between different socio-economic classes and second, when thinking about the countless doctors, nurses and care-home workers, and other key workers who are battling against the pandemic at clear risk to themselves (and their families) despite in some cases, very poor protective equipment and not yet being tested regularly.

So what did the two enquiries conclude in terms of the root causes of what happened? A number of key personnel were criticised, but as the whole tragic story was examined, it became obvious to the enquiry that there were a number of subtle details that had been underestimated and overlooked that, in combination, led to the scale of the disaster that occurred. The major findings were:

First, that there should be enough lifeboats for everyone on board and there should be training and practice using lifeboats and – also a regular inspections of lifeboats (even though this was not directly relevant to the Titanic disaster, it was nonetheless thought to be sensible). There was still the question of whether this would save everyone in a storm in mid-Atlantic, but it seemed obvious, with the benefit of hindsight, to be better safe than sorry.

Second, radios should be manned round the clock, and there should always be a secondary power supply for radios.

Third, it was agreed that henceforth red rockets should be understood to be a distress signal, obliging anyone seeing them to come to the rescue.

Other recommendations resulted, including changes to the southern track route, the setting up of an ice patrol during winter, and asking for changes to bulkhead design and construction.

These recommendations, and others, were encapsulated in the Safety of Life at Sea convention published in January 1914, and SOLAS has continued to this day to set modern maritime safety standards.

To stress a key point, there WAS NO SINGLE ROOT CAUSE why the Titanic disaster was as bad as it was, it was a combination of small but crucial weaknesses – call them “hairline cracks” – that combined together to make the catastrophe as bad as it was.

Holding people accountable, the actors on the stage

It is understandable that we would want to explain what happened by considering the mistakes, poor judgments, or inactions, of the key personnel involved, in particular, the lookout, the First Officer, the ships designer, the captain, the managing director, and Captain Lord of the SS Californian.
Surely we must hold some or all of these accountable for what they did or didn’t do?

I agree we need to hold people to account when they have deliberately, recklessly or carelessly acted, or when they have failed to act when they should have done. This is what the Titanic enquiry tried to do, to pin down the accountability for what happened on specific individuals.

But what was revealed, after the two enquiries and days and days of testimony is that – as far as anyone could judge – most of the key personnel had done the best they could, given the norms and expectations of the time, their own skills and capabilities, and the very specific circumstances of that night.

As I see it, what we have is a series of individuals in roles who may or may not have discharged their responsibilities as well as they could have, we should view these people like the actors on a stage. Some play their roles well, some not so well, some are cowards and some are villain’s; but, we must remember is these people are humans, they are not perfect or infallible; who amongst us is?

Another reason why; the way the stage was set

So, if the key players are like the actors on the stage, we must also remember another factor when considering root causes: the way the stage was set, the way it was built. This point is fundamental to our understanding of what the passengers and crew had to face 108 years ago. The construction of the ship and its bulkheads, decisions around the number of lifeboats and limitations with lifeboat practice etc. were all matters determined days, weeks, months and even years before the night of the disaster.

This is an important point when thinking about root causes – am I balancing my attention mostly on the actors in front of me, or am I also considering the background factors in which the people concerned were operating?

This has been poignant with the recent Grenfell Tower fire in London, UK where phase 1 of the enquiry has concentrated on the firemen and women, and other emergency services, and what they did or did not do on the night of the fire in June 2017. Phase 2 will turn to other considerations (such as the construction of the building and its cladding), but it could be argued that this has implicitly been given secondary priority when – in fact – these matters are most likely to have a long-term, systemic impact on the risks concerning fires in high-rise buildings.

This will also be an important factor with COVID19; we will need to hold people to account for what they did and did not do, but we also need to consider their actions in the context of the environment, roles, regulations, budgetary and political constraints they were operating in.

As we look to the future I am sure we will learn many lessons about pandemic preparedness for the future, but it will take concerted will to: i) learn lessons objectively and ii) implement the lessons learned, and sustain them over possibly decades. In addition, it will be crucial to recognise that pandemics are not the only existential threat that we face: catastrophic food shortages caused by climate changes, or abuse of surveillance technology would be two areas we could take our eye off the ball, but inevitably there will be others areas, as yet unimagined.

In conclusion, my thoughts go out to all those who have lost friends or family members in the Titanic disaster, and also in these current times with COVID19. I dearly hope we will make more earnest attempts to learn the lessons of the distant and not so distant past, and hope this article has made a small contribution to this end.

Thanks to Wikipedia (open source) for the images

James C Paterson
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