“Not Even God Himself Could Sink This Ship!”

Not even God himself could sink this ship.

5 days after Captain Edward John Smith uttered those overconfident words the RMS Titanic lie 12,000 feet under the sea in a pile of ruin and just over 1,500 lives had been lost.

109 years ago, this year a series of independent missteps, oversights and hubris were metaphorically frozen together in the form of an iceberg that was struck by a ship sailing under the power of perceived invincibility.

The Titanic is a story of ‘unnecessary risk taken and that of unnecessary risk realized.’ It is a story that parallels situations and decisions made around the world every day in business, government, industry, personal lives and of course, in the fire service.

It is a story of lack of imagination, error creep, lack of preparedness, complacency and ego.

What is ironic about this tragedy 109 years later is that this is a story of lessons recorded but not learned.

Every day prior to the Titanic sinking, and every day since, humans have set about their day and in one way or another taught us lessons in failed risk management and complacency. And every day, in what
is likely the most significant act of complacency and hubris in human history, we’ve paid little to no attention to or outrightly dismissed what has happened right in front of our faces.

The fire service is no exception. Though we elaborately celebrate and honor those killed in the line of duty, issue after action and investigative reports of the events surrounding their deaths and create bullet points of initiatives that we must follow, rarely are these lessons effectively heeded.

How can you say that, you might ask? It’s simple, actually read the reports, look at the recommendations and see that the causal factors to these terrible events are the same things over and over.

I only wish that EGO was a category that NIOSH added to their list of factors attributing to firefighter death and injury.

It is a constant factor that we rarely talk about.

The Titanic is clearly not the only lesson in history that applies these lessons not learned. There are many, the Battle of the Little Bighorn, the Johnstown Flood, Pearl Harbor, the Space Shuttle Challenger and Three Mile Island are just a few in a long list of situations that got away from those in charge for reasons of failure and ego.

There are many factors that lead to the sinking of the Titanic, but a few stand out. While you read them consider how someone might have changed the course of history if they took action or did the right thing.

1. Ice warnings and reports were available and in hand, yet no action was taken in heed of their message of danger. Clearly, ice fields are dangerous. Was this information interpreted improperly or ignored intentionally?

When information is coming in it must be vetted and given appropriate consideration. Dismissing or ignoring information without doing so leads to misinformed risk assessment and misinformed risk assessment leads to predictable outcomes and most times those outcomes are less than desirable.

2.The Captain provided several unclear and confusing orders in relation to the loading of the lifeboats leading to those coordinating each side of the ship applying his order differently, likely leading to several hundred additional lives lost. This was both literarily and figuratively Captain Edward John Smith’s last voyage as he was to retire upon its completion. Was his mind elsewhere, was he retired in place? Did he consider it a ‘chip shot’ on the most advanced ocean liner to date?

It is hard to know, but regardless of his mind set, there is no simple ocean voyage through the North Atlantic. This situation is a good reminder that when in command you are responsible for all things and for all time. The responsibility is yours until it is officially transferred to your successor.

3.The Captain of the ship knew of the ice field dangers but chose to steam on. Bruce Ismay, Chairman and managing director and the White Star Line consistently placed success and finance over safety by rushing repairs, pushing timelines and ignoring warnings.

Retrospectively, and under investigation Mr. Ismay said, “I am candid to admit that until I had had actual experience in a wreck, I never fully realized the inadequacy of the rules of our and other lines with reference to the preservation of life in case of an accident in mid- ocean. I had gone along like the rest of the steamship men on the theory that our ships were unsinkable.” These were words that likely offered too little too late to those effected by this preventable tragedy.

Accountability is both a personal and a personnel issue.

On a personal level the Captain knew of the ice and failed to take action. On a personnel level, responsibilities were unassigned, training not conducted and passengers not tracked or accounted for. To this day a complete listing of those lives lost has not been attainable.

4.Adequate communication of the urgency of the situation, misinterpreted SOS signals and pleas for assistance not acted upon played a key role in additional lives not being saved. At one point the telegraph operator was so overwhelmed by messages from the passengers that he told another ships operator to ‘shut up’. That operator was attempting to warn them of ice danger.

5.There were clear policies and procedures on the loading and operation of the lifeboats. There were lists of who was to do what. They were never distributed, discussed or trained upon. Coupled with ambiguous orders, their use was haphazard and largely ineffective in the larger scope of the incident. According to a crew member testifying at the investigative hearings:

“Officers and crew were strangers to one another ... When the crisis came there was a state of absolute unpreparedness ... Titanic‘s crew had never acted as a team to lower the ship’s boats ... Untrained and untried, and ... unfamiliar with the lifeboats’ capacity ... [they failed] to utilize lifeboats to their capacity ... [resulting] in the needless sacrifice of several hundred lives which might otherwise have been saved.”

Plans without training, thoughts without action led to action without thought.

These are just a few of the issues that have been attributed as causal factors in the sinking of the Titanic. Boiling them down to a simple list we can see their familiarity to causal factors in fire service incidents.

1. Improper Risk Assessment

2.Lack of Command

3.Lack of Accountability

4.Inadequate Communications

5.Lack of SOP’s or Failure to Follow Them

Well, would you look at that.... It’s the NIOSH 5.

Lessons recorded but not learned.

It was said during the investigative hearings that, “... Titanic rushed onward on her true course, one recognized as appropriate ... yet dangerous at this season of the year, when the Labrador current
may be bearing vast masses of ice across the track of ships ... Ice positions so definitely reported to the Titanic just preceding the accident located ice on both sides of the track or lane which the

Titanic was following ... No general discussion took place among the officers; no conference was called to consider these warnings; no heed was given to them. The speed was not relaxed, the lookout was
not increased, ... [Smith’s] indifference to danger when other and less pretentious vessels doubled their lookout or stopped their engines ... was one of the direct and contributing causes of this unnecessary tragedy ... Overconfidence seems to have dulled faculties usually so alert.”

“Overconfidence seems to have dulled faculties usually so alert.”

There are many cases just like this where these lessons are recorded again and again, yet we seem to not learn from them.

I believe that the reason most often lies with hubris and ego. Very often our own assertions are that we are appropriately trained, educated and experienced, and that these situations only happen to others who we deem as less prepared.

That’s not really the case though, and therein lies another lesson that we’ve recorded ourselves over and over, but not learned.

There is no ship unsinkable. There is no firefighter unkillable.

As a service this is a lesson we must heed. A lesson that we must do our best to apply to our training and education, to our operating guidelines, to our accountability and leadership and most importantly to our ego.

Captain Edward John Smith on an unsinkable Titanic, “... I have never been in an accident of any sort worth speaking about ... nor was I ever in any predicament that threatened to end in disaster of any sort ... I cannot imagine any condition which would cause a ship to founder ... Modern shipbuilding has gone beyond that.”

Until April 15, 1912.

There is no ship unsinkable. There is no firefighter unkillable.