It is always preferential to have foresight where possible, as opposed
to hindsight. Working today to prevent the accidents of tomorrow seems to be a
sensible approach to Human Factors. With this in mind the irony of our blog
writing has not escaped us, constantly we find ourselves looking backwards for
examples of accidents to use within the articles. Often these examples are very
tragic and sometimes difficult to relive, this is also something that does not
escape us. This is important because to develop clear foresight requires an
occasional touch of hindsight. The past is where our questions wait, and more
importantly the answers to these questions lay, we need to shine a light on
these shadows to illuminate the lessons.
The crew of Titanic including Cap Smith
The Titanic presents, in our opinion, the single greatest lesson in
Human Factors. When examined, nearly every strand of modern Human Factors is
present within this single story. The Titanic lesson is so strong it has now
become a metaphor for Human Factors.
Recently it was suggested that investment in ‘prevention focused’
training should be measured against the likely occurrence of a ‘big’ event
becoming reality. Is it better to surrender to the hand of fate and hope that
chance smiles on you (and potentially save money), or invest and prepare for an
unlikely reality? This statement mirrors the corporate mentality of the White Star
Liner when designing and building the Titanic. Discussing all of the contributing
factors into this disastrous trans Atlantic crossing, from design and build to
its maiden voyage, could not be achieved in one blog. With that in mind we would
like to focus on one particular contributing element; the mindset and attitude of
those involved.
Most organisations that have experienced a sizable accident will of held
the mindset of ‘it might never happen’. Added to this investment in preventing
something that might not actually become a reality is sometimes a difficult
expense to swallow. This can create a paradox of planning and training for an
unlikely event, hence the title ‘tidying the deck chairs on the Titanic’. The
further paradox with this mindset is you can’t measure the accidents you never
had!
Is it better to ‘appear’ you are serious about accident prevention while
really focusing on the more immediate and pressing issues associated with
operating a large business? Surely as long as there is a measured approach that
complies with industry recommendations this is fine, isn’t it?
Perhaps not?
The designers of the Titanic thought they had created an unsinkable
ship, this provides the perfect conditions to test such profound humanistic
statements. There is a famous saying that nature does not respect the
qualifications or the competence of men. This statement can be applied to
avalanches in mountaineering, fog and high winds to airline pilots and, as with
Titanic, icebergs and ships Captains. Nature does not recognise their competence
nor does it spare them when the time of reckoning comes. The Titanic had
lifeboat capacity for only half of its passengers, because they presumed it was
unsinkable. Recent evidence has surfaced that before departing Southampton a
civil servant called Maurice Clarke expressed serious reservations about
Titanic’s lifeboat capacity. His superior’s threatened Mr Clarke’s job and the
original recommendation of increasing Titanic’s lifeboat fleet by 50% was overruled.
Had this come to light during either the British or American enquiry there may
have been a stronger case for corporate manslaughter against the White Star
Liner?
Computer regeneration of Titanic
This ‘invincible’ mindset was intoxicating; the passengers believed it,
the ships builders believed it and the crew did also. Even immediately after
the iceberg struck still many felt safe. Perhaps the most poignant example of
this wilful blindness was that of Wireless Officer Phillips. He was responsible
for sending and receiving messages on the one radio channel that Titanic had,
he chose to prioritise wireless transmissions of the super rich 1st
class passengers over the iceberg warnings. Mr Phillips went down with the ship,
sending SOS messages to the end.
Both parts of Titanic on the sea bed
Although this seems an extreme example from over 100 years ago, do we
still exercise this ‘wilful blindness?’ The answer in short is yes, albeit
rarely thankfully. We need look no further than the Costa Concordia for a stark
reminder of the hubristic inclination of man. Part of this fallibility is our romance with courting chance,
whether in a casino, bungee jumping off a bridge or performing a flamboyant
manoeuvre with a large ship. Human
Factors learns the lessons of the past so to implement today for a safer
future. Working with risk will always require measuring the consequence against
the likelihood; this process helps us plan with foresight. A safety culture embedded
within operational excellence allows for a clear and transparent vision for the
future. We need only use hindsight once to know that one Titanic is enough.
"Eternal
Father, strong to save, whose arm hath bound the restless wave,
Who bids't the
mighty ocean deep its own appointed limits keep;
Oh, hear us when
we cry to Thee, for those in peril on the sea!"
