Was the titanic sunk by a small key?

Published: April 13th, 2008 by John | Comments |


Second Mate David Blair - RMS TitanicThe U.K.’s Daily Mail has the story of Second Mate David Blair, the lucky Merchant Mariner who was pulled off the Titanic just prior to her infamous voyage.

(Note: We are republishing this post on Today, the 96th Anniversary of the tragedy.)

Blair was replaced with the more experienced officer Charles Lightroller, Chief Mate of the Olympic, by White Star just four days prior to the tragic events and hours before departure. In the rushed turnover he made a seemly small but potentially critical mistake.

For those readers not familiar with the duties of a merchant officer, turnover is a critical time aboard ship. Today most mariners work an equal time-on time-off scheduled. For example, you may work 3 months aboard a ship then have the next 3 months off meaning there are two officers assigned to the ship in each position. The turnover between the two, however, is often a hurried process. The industry has built in many ways to avoid problems but the fact is you have one person excited to go home and another just starting a long hitch and sometimes “things” are missed.

So the day Blair signed-off he likely briefed Lightroller on his duties and operational specifics then gave him written notes and any items needed for the job. The mistake? Blair accidentally took the key to the binocular locker home with him.

The Daily Mail tells us;

titanicBNP2808 228x344 Was the titanic sunk by a small key? Blair’s rush to leave Titanic he carried this key off with him in his pocket and forgot to hand it to his replacement, Charles Lightoller.

“Had Lightoller had the key then there probably would have been a pair of binoculars in the crows nest.

“It is supposition but, in lookout Fleet’s own words, they would have seen the iceberg sooner with the binoculars.

“It is the key that had the potential to save the Titanic.”

Senator Smith, chair of the inquiry, asked Fleet: “Suppose you had glasses … could you have seen this black object [the iceberg] at a greater distance?”

Fleet replied: “We could have seen it a bit sooner.”

Asked “How much sooner?”, he said: “Well, enough to get out of the way.”

Titanic at SeabedI must stop the story and make it clear this mistake was just that ….a small error… therefore should Blair be blamed for the accident? Of course not. While some point to the ship’s excessive speed, the vessel’s design or the positioning of the ship’s compass as the cause of the incident the facts clearly show the titanic sunk as a direct result of the accident chain. In other words the titanic sunk, not due to one large error but a combination of small errors that linked together caused the tragic circumstances. Remove one small link in the chain and the incident is avoided.

It is interesting to note that a string of small errors caused by human error is the cause of most large maritime incidents. The lesson to be learned….. next time you make a mistake aboard ship listen for the voice in the back of your mind and quickly ask yourself; is this an isolated incident or indication of larger problems?

Ship incidents caused by Error Chains;

(This article was originally posted Oct 2007)

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Categories: History · management

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  • The point that John makes "listen for the voice in the back of your mind" is very true. If something 'feels' wrong, it probably is.
  • Kennebec_Captain
    Bob Couttie, I agree with you 100% that the error chain / domino effect are not helpful analogies for the mariner. It seems to only describe the single incident as you say. Your visual model seems more useful. I took a shot at the same subject: here
  • In the past I've used 'error chain' and 'domino effect when discussing accidents but, at the risk of getting too theoretical I think both are inadequate since they are basically descriptions of single-point failure (A chain fails when a single link fails, a domino falls over when its neighbour hits it).

    The best physical description I think is the wooden tower game, "Jenga" or "Topple" in which players take turns removing blocks from a stack. The first few extractions don't do much harm but as the process continues the stack becomes more and more unstable until one reaches a point where removing any block at all will cause the stack to fall over.

    If you think of the tower as 'safety' and the individual blocks as the elements, precautions, procedures that make up safety, you've got a fairly good visual model for how accidents happen.
  • addie
    key? Just one more thing, thats all.
    There were many things, that each individually, could have sunk this darling.

    There were warning messages ignored, speed, lack of already known technology, lack of visibility that may have made the ice berg un-see-able in time at the speed the ship was soaring in anyway.

    Also, as has been suggested and stated here, no spare keys, no strong sailors, no axes???

    That captain whats his name must have been senile because he had been a good captain once.

    But the key is another interesting fact.
  • Bill
    Not to nitpick, but the officer in question was Charles Herbert Lightoller, not Lightroller.

    The circumstances leading up to his position at the time of the sinking seem to be a bit different than described above:

    "Lightoller boarded the Titanic just two weeks before her maiden voyage, and sailed as First Officer for the sea trials. As sailing day approached, however, Captain Smith made Henry T. Wilde, of the Olympic, his Chief Officer. This caused the original Chief Officer Murdoch to step down to First Officer, while Lightoller was dropped to Second Officer. The original Second Officer, David Blair was forced to drop out. The remaining officers retained their positions."

    See: http://www.encyclopedia-titanica.org/biography/...
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