The best organizations in the world are not the ones with all the systems and procedures or even the most up-to-date technical solutions. They are the ones best at identifying and solving problems.
Want more success? Want a better maintenance effort? Then get better at finding and solving problems.
Problems are good when causes and effects are determined and measures taken to avoid reoccurrences or similar problems. A good illustration of this is an airplane crash and the investigation which issues directives, changes to procedures, etc.
I want to dissect the famous case of the sinking of the Titanic and show how problems, even horrible tragic ones, can be pointers to areas where some attention would improve the process, product or company.
Accidents are almost always a chain of events - sometimes an improbable series - that add up to the accident. For example: The pedestrian was wearing black at night, it was rainy, the tires were bald, the driver was tired and late for a delivery, and in that moment he changed radio stations the pedestrian tripped on a log and fell toward the street. If any of those circumstances were different, avoided or mitigated, the accident might not have happened.
Then there are the consequences of an event. If we blow an engine driving on most interstates, we can steer onto the shoulder and stop, usually with no loss of life or additional loss of property - beyond the engine. But what if the engine on a single-engine aircraft blows? Then the consequences are dire.
Airplanes have what is said to a defense in depth. Many things have to go wrong for a plane to be lost. The Titanic lacked a defense in depth and suffered a series of problems that were catastrophic.
On April 14, 1912, the Titanic, the largest ship of the day, struck an iceberg and sank within hours. Of a total of 2,223 people aboard only 706 survived.
If we look at the causes of the sinking, we can see engineering and design issues, procedure problems, faults in judgment and lapses in the laws and statutes that govern maritime affairs.
At 11:40 pm the ship hit the iceberg with a glancing blow to the starboard side, causing buckling in the hull plates along the first five compartments. The seams of the plates popped open an inch or two for almost 300 feet allowing water to rush in.
Metallurgists say the plates were brittle at the low temperatures of the North Atlantic and a different alloy would have been able to take the stress of the slicing blow against the iceberg. Other metallurgists say the rivets were substandard.
Ship experts point to major design flaws resulting from saving money in the ship’s manufacture. One was the walls of the water tight compartments did not extend all the way to the ceiling. They were well above the water line and no one thought that would be an issue. It turned out to be pivotal in the speed of the sinking.
The second piece of dicey engineering was the size of the rudder, which was designed for a much smaller ship. After the iceberg watch called out the iceberg to the starboard, the ship started to turn but couldn’t do so fast enough to avoid the collision. The glancing blow was much worse than a straight head-on collision, which the ship could have survived, the experts say.
Several procedures were causes to the accident. When the iceberg was sighted, the bridge called for reversing the engines. Only two of the three propellers could be reversed, and that caused turbulence and cavitation, further affecting the small rubber’s effectiveness. Had the bridge turned toward the iceberg at the last minute, it would have brought the back of the ship out and around the iceberg.
In addition, the iceberg was spotted too late. Despite making way at 22 knots to make its inaugural voyage a quick one, it was thought that any icebergs big enough to hurt the ship would be seen well ahead of time. Two watches were in the crow’s nest without binoculars. Other ships of the day used iceberg watches on the ship’s bow. The Titanic captain didn’t think this was necessary.
A method to finding true causes and solutions
It's about principles of reasoning
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