Читать книгу Root Cause Failure Analysis - Trinath Sahoo - Страница 25

The TITANIC passengers included some of the wealthiest and most prestigious people at that time. Captain Edward John Smith, one of the most experienced shipmasters on the Atlantic, was navigating the TITANIC. On the night of 14 April, although the wireless operators had received several ice warnings from others ships in the area, the TITANIC continued to rush through the darkness at nearly full steam. Suddenly, the captain spotted a massive iceberg less than a quarter of a mile off the bow of the ship. Immediately, the engines were thrown into reverse and the rudder turned hard left. Because of the tremendous mass of the ship, slowing and turning took an incredible distance, more than that available. Without enough distance to alter her course, the TITANIC sideswiped the iceberg, damaging nearly 300 feet of the right side of the hull above and below the waterline.

The two official investigations back in 1912 started with a conclusion – the TITANIC hit an iceberg and sank. They made somewhat of an attempt to answer why that happened without attaching too much blame. The result was not so much as getting to the root cause but found out the immediate cause.

Richard Corfield writes in a Physics World retrospective on the disaster that caused 1514 deaths on 14–15 April 1912. He described it was an event cascade followed by a perfect storm of circumstances conspired the TITANIC to fail. The iceberg that the TITANIC struck on its way from Southampton to New York is No. 1 on a top‐9 list of circumstances. Here are eight other suggested circumstances from Richard Corfield's article and other sources:

 Climate caused more icebergs: Weather conditions in the North Atlantic were particularly conducive for corralling icebergs at the intersection of the Labrador Current and the Gulf Stream, due to warmer‐than‐usual waters in the Gulf Stream. As a result, there were icebergs and sea ice concentrated in the very position where the collision happened

 The iron rivets were too weak: Metallurgists Tim Foecke and Jennifer Hooper McCarty looked into the materials used for the building of the TITANIC at its Belfast shipyard and found that the steel plates toward the bow and the stern were held together with low‐grade iron rivets. Those rivets may have been used because higher‐grade rivets were in short supply, or because the better rivets couldn’t be inserted in those areas using the shipyard's crane‐mounted hydraulic equipment. The metallurgists said those low‐grade rivets would have ripped apart more easily during the collision, causing the ship to sink more quickly that it would have if stronger rivets had been used.

 The ship was going too fast: Many investigators have said that the ship’s captain, Edward J. Smith, was aiming to better the crossing time of the Olympic, the TITANIC’s older sibling in the White Star fleet. For some, the fact that the TITANIC was sailing full speed ahead despite concerns about icebergs was Smith’s biggest misstep. “Simply put, TITANIC was traveling way too fast in an area known to contain ice, which was one of the major reason of the TITANIC disaster.

 Iceberg warnings went unheeded: The TITANIC received multiple warnings about icefields in the North Atlantic over the wireless, but Corfield notes that the last and most specific warning was not passed along by senior radio operator Jack Phillips to Captain Smith, apparently because it didn't carry the prefix “MSG” (Masters’ Service Gram). That would have required a personal acknowledgment from the captain. “Phillips interpreted it as non‐urgent and returned to sending passenger messages to the receiver on shore at Cape Race, Newfoundland, before it went out of range,” Corfield writes.

 The binoculars were locked up: Corfield also says binoculars that could have been used by lookouts on the night of the collision were locked up aboard the ship – and the key was held by David Blair, an officer who was bumped from the crew before the ship’s departure from Southampton. Some historians have speculated that the fatal iceberg might have been spotted earlier if the binoculars were in use, but others say it wouldn’t have made a difference.

 The steersman took a wrong turn: Did the TITANIC’s steersman turn the ship toward the iceberg, dooming the ship? That’s the claim made by Louise Patten, who said the story was passed down from her grandfather, the most senior ship officer to survive the disaster. After the iceberg was spotted, the command was issued to turn “hard a starboard,” but as the command was passed down the line, it was misinterpreted as meaning “make the ship turn right” rather than “push the tiller right to make the ship head left,” Patten said. She said the error was quickly discovered, but not quickly enough to avert the collision. She also speculated that if the ship had stopped where it was hit, seawater would not have pushed into one interior compartment after another as it did, and the ship might not have sunk as quickly.

 Reverse thrust reduced the ship's maneuverability: Just before impact, first officer William McMaster Murdoch is said to have telegraphed the engine room to put the ship's engines into reverse. That would cause the left and right propeller to turn backward, but because of the configuration of the stern, the central propeller could only be halted, not reversed. Corfield said “the fact that the steering propeller was not rotating severely diminished the turning ability of the ship. It is one of the many bitter ironies of the Titanic tragedy that the ship might well have avoided the iceberg if Murdoch had not told the engine room to reduce and then reverse thrust.”

 There were too few lifeboats: Perhaps the biggest tragedy is that there were not enough lifeboats to accommodate all of the TITANIC's more than 2200 passengers and crew members. The lifeboats could accommodate only about 1200 people.

Do these nine causes cover everything, or are there still more factors I'm forgetting? Are there some lessons still unlearned from the TITANIC tragedy?