Steering into the Iceberg
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Andrew Sullivan called his piece on the Atlantic web site:"Human Error." Here's the opening.
"He turned the steering wheel the wrong direction. That is the latest revelation about what happened to the greatest ocean liner of all time, Titanic. This fact, claims Louise Patten, granddaughter of Titanic's Second Officer Charles Lightoller, was kept a secret until now."
How could that happen? The answer has been a staple of informed discussion about the Titanic disaster for some time. Here's a quote from one of the Titanic discussion boards.
"The orders given were in reference to tiller commands. In the days before ships had wheels, the rudder was put over by one or more guys pushing on the tiller which was directly attached to the rudder. If you wanted to go to port, you pushed the tiller arm to starboard, and vice versa."
The theory is that First Officer Murdoch, the officer in charge on the bridge, gave commands that turned the Titanic toward the iceberg, instead of away from it.
That's certainly possible. Murdoch learned his trade on sailing ships. And sailing ships were still plying the oceans in 1912. The last voyage of the famous Cutty Sark did not occur until 1938.
I'll leave it to experts, like my friend Peter Mello, whose firm is called Sea-Fever consulting for a reason, to apply expert knowledge to what I've written above. In this case, though, even if I've got it a bit wrong, there's an important lesson here.
Whether the commands were wrong or the execution was wrong, the situation wasn't corrected. And the result was tragic. And if you're the boss it's your job to make sure things are right.
Boss's Bottom Line
You may never give instructions where lives are at stake. But part of your job is assigning work and making your expectations known. Telling is not enough. You must check for understanding. Then you must check to see if understanding turns into performance. It's up to you.
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Interesting.
First things first. While the Internet is full of Titanic "experts", I am not one of them. I am a simple sailor who claims he knows one or two things about leadership.
I find it extremely difficult to fathom that the officer of the watch gave the exact opposite command than he should have and that this caused the casualty. The Titanic represented the latest in technology and serving aboard her would have been a plum assignment. Murdoch may have learned many of his maritime skills aboard sailing ships; however, so did practically every other experienced sailor in those days. Ironically, today many navies around the world still use sailing ships to train their elite officer candidates even though no battles at sea have been fought under sail for 200 years.
Another reason that this is hard to believe is that it's standard protocol on ships that when a command is given by the officer of the watch to the helmsman, such as "rudder hard right," the helmsman repeats it exactly back to the person who gave the order and generally loud enough for anyone in the general vicinity on the bridge to hear it. Wikipedia actually addresses this here: http://en.wikipedia.org/wiki/Helmsman#Relieving_the_helm
Several reasons for this are #1 to avoid "mishearing" a command and #2 confirming that the command was a correct one. If this protocol was being followed, it's pretty doubtful that the watch officer, the helmsman and anyone in earshot on the bridge all made an uncorrected directional mistake as alleged.
I was intrigued by following the links a couple levels deep though. When you read Morgan Meis original post (The Cold Truth) on the Smart Set blog, you realize that this is more about storytelling and myth than a maritime casualty analysis.
For maritime matters like this, I turn to gCaptain.com which is the #1 web destination for professional mariners. Way back in 2007 they had a post entitled "Was the titanic sunk by a small key?" (http://gcaptain.com/maritime/blog/was-the-titanic-sunk-by-a-small-key?695)
You can (and should) read the gCaptain.com post but I'll cut to the chase:
"In other words the titanic sunk, not due to one large error but a combination of small errors that linked together caused the tragic circumstances. Remove one small link in the chain and the incident is avoided.
It is interesting to note that a string of small errors caused by human error is the cause of most large maritime incidents. The lesson to be learned….. next time you make a mistake aboard ship listen for the voice in the back of your mind and quickly ask yourself; is this an isolated incident or indication of larger problems?"
Good advice for captains of industry and other organizational leaders too.
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Thanks for that thorough and helpful comment, Peter. What you describe as typical of maritime accidents matches what investigators of airline crashes, hazmat spills, and other land-based accidents have found. Their term of art is "event cascade" and it usually has two components.
First there are at least two low-possibility failures that affect each other. Then that combination sets off a chain of falling dominoes. Investigation almost always reveals changes that should be made in either equipment or procedure.
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Trust, but verify.
Unfortunately, I have noticed that if my staff knows that I will be checking behind them, occasionally, they may not "finish the job" as they figure I'm going to change something anyway.
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Thanks, Ray. I think all bosses deal with that to some degree. I know I did.
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Totally agree it's the boss's job to check understanding but it's hard to imagine someone who didn't know how the tiller worked was in a job where he gave steering orders. Or that he couldn't at least learn it on the job by the time they reached the ice berg.
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Thanks, Laura. I don't think the proponents of this theory are saying that Murdoch didn't know the proper procedure. I think they're suggesting that there was a breakdown that might have sprung from old habits.
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As Peter Mello says one good strategy is to get confirmation that the instruction was heard and understood. Many environments where communication is critical adapt this (military, ships, airplanes, space, medical...). It is a for of mistake-avoiding (rather than mistake proofing) a process. And it is wise to use to various degrees depending on the situation.
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Good points, John. It's also important to remember that the command-confirm or checklist ritual can become a thought-free exercise.
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