The Titanic ICAM事故讲义.ppt

Events leading to the accident 2 The Californian radios to Titanic that it is surrounded by ice. Before its position could be relayed the R.O. on Titanic tells the Californian R.O to shut up and let him broadcast his important passenger personal telegrams. Californian R.O. gives up trying. Lookout Frederick Fleet spots an iceberg and issues a warning to the bridge at 23.39 hours Bridge orders “Stop”, “Full astern” and “Hard a starboard” The Titanic struck an iceberg on Sunday, April 14, 1912 at 2340 hours and begins to flood. F.O. closes watertight doors damage inspected and estimated that the ship will remain afloat for 2 hours At 0001 hours on Monday, April 15 1912, Captain orders the crew to prepare lifeboats and send a distress signal Events leading to the accident 3 At 0025 hours the Captain orders “women and children first to the lifeboats. At 0045 hours the first lifeboat is launched Lifeboats are launched with less than full capacity At 0155 hours the last lifeboat is launched At 0220 hours, two hours and forty minutes after striking the iceberg, the unsinkable RMS Titanic slips into the sea and begins its descent to the ocean floor. At 0410 hours the Carpathia picks up the first of the Titanic’s lifeboats At 0830 the Carpathia picks up the last of the Titanic’s lifeboats and heads for New York with the 705 survivors Incident Outcome: What happened that was unacceptable? Incident Absent or failed defences What defences were in place that should have prevented the incident but failed or were absent? What defences were in place that should have mitigated the consequences of the the incident but failed or were absent? Identify absent or failed defences 6 radio warnings of ice not acted upon Extra lookouts were not posted Lookouts did not have binoculars Lack of a formal procedure for collision avoidance Collison blankets were not used after impact to stem water ingress Watertight doors did not prevent flooding of compartments Insufficient lifeb