Page9

In1908WhiteStarfacingbusinessespressuresandrespondedwithstrategythat

leveragedemergingtechnology Competitionandnewentrants. Agingtechnologyinfrastructure,

inferiorservice,lossofmarketshare&customers.

Investintechnology 3newsuperlinerstosweepAtlantic.

Pushemergingtechnologytolimits.

Addressall3passageclasses,priorityonfirstclass.

Qualityofcrossing,customerexperience.

OlympicMauretania

15% faster 23% greater capacity

Page10

TheTitanic wasamajorServiceCI,oneofthreeplannedShipsdesignedtodeliverBusinessOutcomes

HarlandandWolffshipyardwerethemostexpensivecraftsmeninEurope.

Createdluxurylinerpriorityfirstclass Lavishattentiontoluxuryimplied

equivalencyinnonfunctionalrequirements(Availability)

Designerschoiceinsafetytechnology Old

lifeboats New

bulkheads, doubleskinhull, electricdoors, automaticfogwarning.

ThomasAndrews

Page11

ChangeManagement:ByendofconstructionTitanicssafetycompromisedseverely.ButWhiteStarbelievedit

safestshipeverbuilt.

Safetyregulationsforlifeboats,outdatedtechnology.

Titanic soldathighestsafetylevel,butreallypassengersafetylow.

Expensiveconstructioneffortincorporatedmistakesofearlierstages.

Page12

BusinesspressuresforTitanic togolivewereenormouswithlargeinvestmentstiedupinfouryearconstruction. SisterShipOlympic3incidents RepairsaftercollisionwithHMSHawkecost17%

oforiginalcost. ExtensiveseatrialswerenotcriticalwithOlympic

inservice. Changemanagementtheorynotestablished. ToomuchfaithinlimitedexperiencewithOlympic.

MajorIncident TheOlympicwasoutofservice TheTitanicwasunderconstruction 100%businessoutage EmergencyChange! DivertProjectresourcestosupportOperations EmergencyRelease RootCause?

HowdoesITILDealwithBusiness? BusinessPressuresalwaysexist DoesITILliveinaBubble WouldChangeandReleasehavehelpedtheWhiteStarlineimprovedecisions?

Wouldoutcomeshavebeenbetter Conjecture?

Page15

Change/ReleaseManagement:ThebusinesspressuresandeconomicneedspushedTitanic intoserviceand

resultedinlimitedtesting Titanics testingwasmaidenvoyage. Titanics nearcollisionwithNewYork. Onelifeboatdrill. Littlepreparationcrewof900(83

mariners).

SuctionofGiantLinerBreaksHawsersoftheNewYork,WhichFloatsHelplessSource:The

NewYorkTimes,11April1912TitanicLessonsforITProjectswww.lessonsfromhistory.com

Page16

BruceIsmay (Chairman)determinedtoproveTitanic superiortoOlympicchangedtheSLA,

dramaticallyincreasingrisks Ismay overrodeCaptainSmith Pushedcrewtolimits. Captainsuccumbedtopressure. Operationsmandateoverriden. Stringentguidelinesbroken. Everythingputinjeopardy.

Page17

ThecollisionwasinevitableCrewalmostsucceededpullingoffabrilliantmaneuver.

Feedbacksystemscompromised.Shipreachedpeakspeed22knots,3additionalboilerslit. Californians lastradiomessageignored. Lookoutsgave37secondswarning. MurdochtriedtododgeiceberganddecelerateshipS

turn.IceShelfIceberg

ConfigurationManagement Whatdowehave? WhatisImpacted? Whatscenariosarepossible? CombinationofinformationandJudgement Inthefaceofanemergency

Page19

TheArchitectswerewellawareoftherisksincrossingtheAtlantic.Themodeltestedworstcase

failurescenarios.

Crumplezone

Frontendcollision60feet

Sideoncollisionfloodingcontained

Doubleskinhull

60feet

7feet HullbottomTanktop

Waterline

Withinhull73watertightcompartments

15Bulkheads

Grounding floodingcontained

Page20

AfterfirstassessmentgroupreturnsBruceIsmay madefatefuldecisiontoprove

Titanic couldsaveherself. Firstgroupinaccuratereport. Ismaysdilemmaandoptions. Secondgroupreturned

(architectandcarpenter). FirstwirelesstoWhiteStar

officeinNY. TITANICPROCEEDINGTOHALIFAX.

PASSENGERSWILLPROBABLYLANDTHEREWEDNESDAY;ALLSAFE.SMITH

Trueat11:53pm. Pumpsnotkeepingupwith

flooding. Architectpredicted2hours.

Page21

Officersandcrewoperatedinstateofdisbeliefunabletoperformeffectiverecovery.Panicensuedamongstpassengers.

Disasterassessment 20mins 65minsbeforelifeboatsorderedfilled. Hierarchicalstructure,physicalsegregation,

skepticalcrewimpededinformationflow. Passengersgotup,wentbacktobed. Firstlifeboatlefthalffullreluctancetogetin. Launching16lifeboatstookover90minutes. Recoveryplanwouldhavebeenpoorlyexecuted.

Page22

FollowingdisasterU.S.andBritishauthoritiesconductedpostmortems.TheU.Sinquirycameclosetouncovering

coverup. USinquiry82witnesses,

specialists,technicalexperts. Determinedshipreachedtop

speed,noattempttoslowdown.

ForcedBruceIsmaytostayinU.S.&grilledoverrole.

BritishinquirysavedWhiteStarfrombankruptcy.

Europeanwarlooming. CondemnedCaptainLordfornotrespondingto

flares. CriticizedBritishBoardofTradeforlifeboat

regulations. Titanic unnervedwesternsocietysfaithin

technology. Olympic,served24yearcareer.

USRecommendationsLifeboatspaceforeverypersonon

allshipsfromU.S.ports;lifeboatdrills;

adequatemanningofboats;24houroperationof

radiotelegraph.

Page23

Lessonslearned whatcanyoutakefromallthis.

RootsofTitanicsdisasterinproject,compromisestosafetyfeaturesandelevationofexpectationsallowedbusinesspressurestooverrideoperationalprocedures.

Processwasoverruledbybusinessdemands

ThisleadtonumerousviolationsoftherulesofgoodseamanshipBestPractices.

Probabilityoffailureveryhighbecauseofinabilitytorecognizeintroducedrisks.

Page24

FollowingdisasterU.S.andBritishauthoritiesconductedpostmortems.TheU.Sinquirycameclosetouncovering

coverup. USinquiry82witnesses,

specialists,technicalexperts. Determinedshipreachedtop

speed,noattempttoslowdown.

ForcedBruceIsmaytostayinU.S.&grilledoverrole.

BritishinquirysavedWhiteStarfrombankruptcy.

Europeanwarlooming. CondemnedCaptainLordfornotrespondingto

flares. CriticizedBritishBoardofTradeforlifeboat

regulations. Titanic unnervedwesternsocietysfaithin

technology. Olympic,served24yearcareer.

USRecommendationsLifeboatspaceforeverypersonon

allshipsfromU.S.ports;lifeboatdrills;

adequatemanningofboats;24houroperationof

radiotelegraph.