R.M.S. Titanic. Image from Wikipedia Commons.
This morning I was browsing through TLT magazine and I found a great column on Titanic which clearly illustrates one of the critical thinking processes involved in solving problems by attacking root causes.
If asked why Titanic sank, most people would say it was because it hit an iceberg. However, that was not the real cause of the sinking, as demonstrated by this interesting article. Titanic sank because of defective rivets.
How come? What do rivets have to do with large chunks of ice?
In order to find out what the real cause of an event is, you need to ask why over and over. That is a technique we use frequently at work when conducting investigations of loss incidents. For example, if an employee crashes the company car, we ask why? Maybe the guy hit the car in front when the other driver suddendly stopped. Why? Because he was not following at the right distance. Of course. Be more careful next time.
Most people would stop investigating at this stage. And conclude that in order not to crash you have to follow the car in front at a larger distance. However, that may not have been the root cause of the accident.
If we ask why a second time we might begin to find interesting things. For instance, if the second answer is "I didn't know I had to follow at such and such distance" we may begin inquiring into training. Other possible answers might lead to fatigue, poor eyesight, etc. In all those causes, the solution needed to prevent a repeat accident would be different - training, journey planning, eye testing, etc.
Going back to Titanic, I found most interesting that the old ship can still teach us new lessons. In this case, when asking why the ship sank after hitting the ice, the answer is that it developed a large leak that flooded too many watertight compartments. Going further into the why asking questions and combining this technique with recent research, it was found that rivets used in the bow and stern of the ship were not steel but iron and they were of substandard quality. It turns out that Harland & Wolff probably knew about the poor quality of the rivets but used them anyway - a typical case of "nothing bad has happened before so I keep on doing it". In the end it all came down to a case of trying to manage through difficult financial and logistical conditions.
That is what critical thinking leads to. In order to prevent a repeat disaster, ships had to be built with steel, not iron, rivets. Had rivets in the bow of the Titanic been steel, we might today have a Titanic museum.
So, it was not the route, the decision to turn the engines, etc. what sank the mighty ship. And the way through to that knowledge was pure critical thinking and root cause analysis.
More information on Titanic can be found here linked from the Harland & Wolff website
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