Lessons Learned From Titanic Project
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Transcript of Lessons Learned From Titanic Project
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In1908WhiteStarfacingbusinessespressuresandrespondedwithstrategythat
leveragedemergingtechnology Competitionandnewentrants. Agingtechnologyinfrastructure,
inferiorservice,lossofmarketshare&customers.
Investintechnology 3newsuperlinerstosweepAtlantic.
Pushemergingtechnologytolimits.
Addressall3passageclasses,priorityonfirstclass.
Qualityofcrossing,customerexperience.
OlympicMauretania
15% faster 23% greater capacity
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TheTitanic wasamajorServiceCI,oneofthreeplannedShipsdesignedtodeliverBusinessOutcomes
HarlandandWolffshipyardwerethemostexpensivecraftsmeninEurope.
Createdluxurylinerpriorityfirstclass Lavishattentiontoluxuryimplied
equivalencyinnonfunctionalrequirements(Availability)
Designerschoiceinsafetytechnology Old
lifeboats New
bulkheads, doubleskinhull, electricdoors, automaticfogwarning.
ThomasAndrews
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ChangeManagement:ByendofconstructionTitanicssafetycompromisedseverely.ButWhiteStarbelievedit
safestshipeverbuilt.
Safetyregulationsforlifeboats,outdatedtechnology.
Titanic soldathighestsafetylevel,butreallypassengersafetylow.
Expensiveconstructioneffortincorporatedmistakesofearlierstages.
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BusinesspressuresforTitanic togolivewereenormouswithlargeinvestmentstiedupinfouryearconstruction. SisterShipOlympic3incidents RepairsaftercollisionwithHMSHawkecost17%
oforiginalcost. ExtensiveseatrialswerenotcriticalwithOlympic
inservice. Changemanagementtheorynotestablished. ToomuchfaithinlimitedexperiencewithOlympic.
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MajorIncident TheOlympicwasoutofservice TheTitanicwasunderconstruction 100%businessoutage EmergencyChange! DivertProjectresourcestosupportOperations EmergencyRelease RootCause?
HowdoesITILDealwithBusiness? BusinessPressuresalwaysexist DoesITILliveinaBubble WouldChangeandReleasehavehelpedtheWhiteStarlineimprovedecisions?
Wouldoutcomeshavebeenbetter Conjecture?
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Change/ReleaseManagement:ThebusinesspressuresandeconomicneedspushedTitanic intoserviceand
resultedinlimitedtesting Titanics testingwasmaidenvoyage. Titanics nearcollisionwithNewYork. Onelifeboatdrill. Littlepreparationcrewof900(83
mariners).
SuctionofGiantLinerBreaksHawsersoftheNewYork,WhichFloatsHelplessSource:The
NewYorkTimes,11April1912TitanicLessonsforITProjectswww.lessonsfromhistory.com
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BruceIsmay (Chairman)determinedtoproveTitanic superiortoOlympicchangedtheSLA,
dramaticallyincreasingrisks Ismay overrodeCaptainSmith Pushedcrewtolimits. Captainsuccumbedtopressure. Operationsmandateoverriden. Stringentguidelinesbroken. Everythingputinjeopardy.
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ThecollisionwasinevitableCrewalmostsucceededpullingoffabrilliantmaneuver.
Feedbacksystemscompromised.Shipreachedpeakspeed22knots,3additionalboilerslit. Californians lastradiomessageignored. Lookoutsgave37secondswarning. MurdochtriedtododgeiceberganddecelerateshipS
turn.IceShelfIceberg
ConfigurationManagement Whatdowehave? WhatisImpacted? Whatscenariosarepossible? CombinationofinformationandJudgement Inthefaceofanemergency
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TheArchitectswerewellawareoftherisksincrossingtheAtlantic.Themodeltestedworstcase
failurescenarios.
Crumplezone
Frontendcollision60feet
Sideoncollisionfloodingcontained
Doubleskinhull
60feet
7feet HullbottomTanktop
Waterline
Withinhull73watertightcompartments
15Bulkheads
Grounding floodingcontained
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AfterfirstassessmentgroupreturnsBruceIsmay madefatefuldecisiontoprove
Titanic couldsaveherself. Firstgroupinaccuratereport. Ismaysdilemmaandoptions. Secondgroupreturned
(architectandcarpenter). FirstwirelesstoWhiteStar
officeinNY. TITANICPROCEEDINGTOHALIFAX.
PASSENGERSWILLPROBABLYLANDTHEREWEDNESDAY;ALLSAFE.SMITH
Trueat11:53pm. Pumpsnotkeepingupwith
flooding. Architectpredicted2hours.
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Officersandcrewoperatedinstateofdisbeliefunabletoperformeffectiverecovery.Panicensuedamongstpassengers.
Disasterassessment 20mins 65minsbeforelifeboatsorderedfilled. Hierarchicalstructure,physicalsegregation,
skepticalcrewimpededinformationflow. Passengersgotup,wentbacktobed. Firstlifeboatlefthalffullreluctancetogetin. Launching16lifeboatstookover90minutes. Recoveryplanwouldhavebeenpoorlyexecuted.
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FollowingdisasterU.S.andBritishauthoritiesconductedpostmortems.TheU.Sinquirycameclosetouncovering
coverup. USinquiry82witnesses,
specialists,technicalexperts. Determinedshipreachedtop
speed,noattempttoslowdown.
ForcedBruceIsmaytostayinU.S.&grilledoverrole.
BritishinquirysavedWhiteStarfrombankruptcy.
Europeanwarlooming. CondemnedCaptainLordfornotrespondingto
flares. CriticizedBritishBoardofTradeforlifeboat
regulations. Titanic unnervedwesternsocietysfaithin
technology. Olympic,served24yearcareer.
USRecommendationsLifeboatspaceforeverypersonon
allshipsfromU.S.ports;lifeboatdrills;
adequatemanningofboats;24houroperationof
radiotelegraph.
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Lessonslearned whatcanyoutakefromallthis.
RootsofTitanicsdisasterinproject,compromisestosafetyfeaturesandelevationofexpectationsallowedbusinesspressurestooverrideoperationalprocedures.
Processwasoverruledbybusinessdemands
ThisleadtonumerousviolationsoftherulesofgoodseamanshipBestPractices.
Probabilityoffailureveryhighbecauseofinabilitytorecognizeintroducedrisks.
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FollowingdisasterU.S.andBritishauthoritiesconductedpostmortems.TheU.Sinquirycameclosetouncovering
coverup. USinquiry82witnesses,
specialists,technicalexperts. Determinedshipreachedtop
speed,noattempttoslowdown.
ForcedBruceIsmaytostayinU.S.&grilledoverrole.
BritishinquirysavedWhiteStarfrombankruptcy.
Europeanwarlooming. CondemnedCaptainLordfornotrespondingto
flares. CriticizedBritishBoardofTradeforlifeboat
regulations. Titanic unnervedwesternsocietysfaithin
technology. Olympic,served24yearcareer.
USRecommendationsLifeboatspaceforeverypersonon
allshipsfromU.S.ports;lifeboatdrills;
adequatemanningofboats;24houroperationof
radiotelegraph.