By Vince Shiers – Managing Director.
OK, so many of us have seen the film “Titanic,” or even the older film, “A Night to Remember.” We have also seen documentaries about the Titanic disaster. But I am probably in a pretty small group of living people who have read the transcriptions of the official British Inquiry into the Titanic disaster[1]. Why would I do this?
Firstly, I have to admit, I didn’t read every word; it was not an easy read due to the nature of the tragedy and the language of 114 years ago. But it was worth reading to compare how the recommendations and learnings from that tragedy still resonate today in businesses crisis planning and resilience. It is remarkably relevant!
Take a look below at some of the recommendations that came out of the Official British Inquiry from 1912 along with how I interpret these for current crisis management advice. I also include further notes from the inquiry about the investigation and how that relates to your post incident reviews.
[1] The Official Transcript of the British Inquiry into the sinking of the RMS Titanic May 2-July 3, 1912. Titanic Inquiry Project.
| Notes from the Titanic inquiry | How this applies to your crisis resilience and crisis management processes |
| Explore practicality of new ships having double skinned hulls up to above the water line and watertight decks and compartments. | Improve product design to ensure improved consumer and user safety |
| Every man taking a look-out in such ships should undergo a sight test at reasonable intervals. | Ensure all team members are able to complete their incident response and crisis management roles fully. |
| The Titanic’s lifeboats only had capacity for 1,178 of the 2,201 persons aboard which was within the legal requirements of the day. | Even though a system is compliant with regulations, these should be seen as the minimum. Companies should always be aiming to achieve higher standards. |
| The provision of lifeboats on board ships should be based on the number of persons intended to be carried in the ship and not upon tonnage of the ship. | Ensure incident management, lifesaving processes and equipment is readily available to all, working and fit for purpose. |
| All lifeboats should carry lamps and pyrotechnic lights for purposes of signalling. All boats should be provided with compasses and provisions and should be very distinctly marked in such a way as to indicate plainly the number of adult persons each boat can carry when being lowered. | Ensure your “crash box” and other response emergency equipment is readily available; all listed equipment is present and regularly checked via internal audit. Make sure your team know where it is! |
| Multiple ice warnings were received throughout the day yet the vessel maintained near service speed into darkness and calm seas, which reduced visible wave break around ice. The decision was consistent with prevailing maritime custom rather than action decided by real time situational risk assessment. | The modern parallel is the continuation of standard operating procedure despite emerging indicators that the operating environment has changed. Equivalent to ignoring environmental monitoring trends or near miss data in a production environment. |
| Instruction should be in all Steamship Companies’ Regulations that when ice is reported in or near the track, the ship should proceed in the dark hours at a moderate speed or alter her course so as to go well clear of the danger zone. | If you can see risks are increasing via early warnings or near misses, take prompt and decisive action before the crisis hits. |
| All such ships should have an installation of wireless telegraphy and that such installation should be staffed with a sufficient number of trained operators to secure a continuous service by night and day. | Personnel need to be available who are trained in crisis management 24/7/365. |
| The Board of Trade inspection of boats and life-saving appliances should be of a more searching character than hitherto. | Internal audits and checks of crisis readiness should be thorough and effective, not just tick box exercises. |
| In cases where there are not enough deck hands to man the boats, other members of the crew should be trained in boat work to make up the deficiency. These men should be required to pass a test in boat work. | Deputies for all key incident response and crisis management roles should be identified and trained. They should be tested in simulated exercises. |
| It is a misdemeanour not to go to the relief of a vessel in distress when possible to do so. | In a crisis situation, all colleagues must pull together and assist where possible. |
| The “Californian” could have reached the “Titanic” if she had made the attempt when she saw the first flare. She made no attempt. | Ensure support resources (consultants, labs etc) are available and ready to assist at all times. Know who you can rely on. |
| As well as specific findings about the disaster, the inquiry identified good practice for reviewing a major incident. The Inquiry’s emphasis on gathering testimony from all available witnesses and reconstructing sequence of events parallels modern root cause analysis methodology. Importantly the investigation sought contributory conditions rather than a single guilty party, a principle central to effective contemporary incident review systems and directly aligned with modern no blame near miss reporting culture. | |
| A few of these good practices from the inquiry are listed below along with a “translation” for modern post incident reviews. | |
| Notes from the Inquiry | Carrying out a post incident review |
| “The above-named ship left Queenstown for New York on or about the 11th day of April 1912, with a crew of about 892 hands all told, and about 1,316 passengers. “On the night of Sunday the 14th day of April 1912, the vessel struck ice …, and at about 2 a.m. on the following day foundered in about the same locality, and loss of life thereby ensued or occurred.” | Summarise the facts of the incident to establish the background to the facts. |
| “…Inquiry should be made with the object of ascertaining as fully and as precisely as possible the circumstances surrounding the casualty, and also of deducing such lessons and arriving at such conclusions as may help hereafter to promote the safety of vessels and life at sea.” | You must learn from past crises and so will carry out a review following any incident to identify learnings and reduce the risk of recurrence and improve crisis resilience. |
| “…I desire to add, in the public interest, that every possible source of information and all available evidence will be placed before your Lordship in this Inquiry.” | A post incident review must be comprehensive and a true reflection on what happened so the best learnings can be made. |
| “…any suggestion which you may think fit to make during the course of the case or after the evidence has been called on behalf of the Board of Trade will be accepted by us most willingly.” | You should encourage all colleagues to provide input into the post incident review to ensure its findings are robust and comprehensive. |
| “…today we should just decide upon the course of procedure, and that tomorrow I should open the case as well as I am able from the material which will be before me…” | You will have a clear procedure for carrying out post incident reviews and will follow that to ensure most effective outcomes. |
It is remarkable how much of the Titanic Inquiry findings are still relevant today. Individual failings, on their own appear minor and benign, but when collected together create the conditions for a major incident. Some organisations rely on past success, survival from near-misses, absence of previous crises and achieving minimum standards to justify the management of risk. However, crises still happen in all industries and walks of life. The concerning part is that lessons are learnt, but over time, they are also forgotten.
Make sure your crisis plan is fit for managing a crisis today.
Finally, Edward Smith, Captain of the Titanic was quoted[1] as saying “I cannot imagine any condition which could cause a ship to founder. I cannot conceive of any vital disaster happening to this vessel. Modern shipbuilding has gone beyond that.”
Make sure you regularly and robustly review your risks and never become complacent.
[1] Captain Edward J. Smith, R.M.S. Titanic. Interview on maiden trip of the Adriatic, 1907. Quoted the day after the Titanic sunk in Disaster At Last Befalls Capt. Smith, The New York Times newspaper, page 7, 16 April 1912.