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RMS TITANIC ACCIDENT REPORT

SUNY MARITME COLLEGE

MT 408: International Safety Management

Capt. Joseph Ahlstrom

October 8th, 2024

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[OVERVIEW]

The sinking of the RMS Titanic on April 15, 1912, stands as one of the most well-known

maritime tragedies in history. As the largest ship of its time, Titanic was celebrated as an epitome

of luxury, innovation, and invincibility. However, during its maiden voyage from Southampton,

England, to New York City, the ship collided with an iceberg, leading to catastrophic

consequences. This essay provides a detailed overview of the Titanic disaster, including the

outbreak of the incident, crew composition, the causes of the accident, and its aftermath. It

explores the multiple contributing factors that led to the tragedy and the subsequent changes in

maritime safety practices.

<Reference

1: Route of maiden voyage of RMS TITANIC>

1. THE RMS TITANIC

The RMS Titanic, constructed by Harland and Wolff in Belfast, Ireland, was the largest ship

in the world at the time of her construction. At a length of nearly 900 feet, height of 25 stories,
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and weight of approximately 46,000 tons, Titanic represented the pinnacle of early 20th-century

shipbuilding. Built with state-of-the-art technology, the ship featured sixteen watertight

compartments, which were believed to make it practically unsinkable. The ship’s builders

claimed that even in the worst possible accident at sea—such as two ships colliding—Titanic

would remain afloat for two to three days, allowing enough time for nearby vessels to assist in

rescue efforts. Because of these safety features and the opulent amenities aboard, Titanic was

regarded as a symbol of luxury and engineering marvel. Her maiden voyage on April 10, 1912,

carried a diverse group of passengers, ranging from some of the wealthiest people of the time to

immigrants seeking a new life in the United States.

<Reference 2: RMS TITANIC general overview>

Despite the shipbuilder's claim and the promotion under the phrase 'practically unsinkable'

without any qualifications. the 15 transverse bulkheads that divided the 16 watertight

compartments were designed only up to the Upper Deck (E Deck) or Saloon Deck (D Deck) to

secure luxurious open lounges, rather than following perpendicular regulations. As a result,

companies at the time did not formalize the safe operation of vessels and the safe working

environment, nor did they clearly define potential risks and related emergencies.
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Each watertight doors, which were inefficient for evacuation, were installed on the

bulkheads, isolating passengers along with the water. This design structure failed to guarantee

the safety and evacuation of passengers and crew during emergencies. The vertical sliding

watertight doors, located inconsistently from the tank top to the E Deck or Boat Deck, were

equipped with an automatic float system that closed the doors when the water rose 1 1/2 to 2 feet

above the deck level. Meanwhile, the horizontal sliding watertight doors above the engine

spaces, located on the E and D decks, used a rack and pinion system that made it impossible to

open the door once the bulkhead was closed. As a result, vertical escape ladders were the only

possible escape routes. The social norm of 'unsinkable vessels' at the time led the crew and

passengers to blindly trust the vessel’s stability and hull integrity, which became a major cause

of unpreparedness for damage control.

<Reference 3: RMS TITANIC Fore Bulkhead Plan>

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<Reference 4: RMS TITANIC Starboard Elevation Plan>

2. Outbreak of the Incident

Despite the fanfare surrounding the launch of Titanic, her maiden voyage ended in disaster.

On April 14, 1912, the ship received six separate ice warnings from nearby vessels, cautioning of

hazardous sea ice in the North Atlantic. Despite these warnings, Titanic continued at nearly full

speed, approximately 22 knots, across the icy waters. This decision reflected the prevailing

maritime practice of prioritizing punctuality over safety, combined with a misplaced confidence

in the ship’s structural resilience.

At approximately 11:35 p.m., lookouts Frederick Fleet and Reginald Lee spotted an iceberg

directly in Titanic’s path. The ship’s officers attempted evasive action, ordering the engines to

reverse and the rudder to be turned hard to port. However, due to the immense mass of the ship

and the limited time available, Titanic was unable to maneuver quickly enough to avoid the

iceberg. At 11:40 p.m., Titanic struck the iceberg, sustaining damage to nearly 300 feet of her
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starboard hull. The collision punctured six of the sixteen major watertight compartments,

allowing water to rapidly flood into the ship. Titanic was designed to remain afloat with up to

four compartments breached, but with six compartments flooded, the ship was doomed to sink.

The timeline of the accident is summarized as follows:

09:00 First ice warning, Captain Smith received from RMS Caronia.

22:30 Attempted to broadcast another ice warning from SS Californian.

Titanic’s wireless operator broke the message from Californian.

23:35 Lookouts spotted the iceberg less than a quarter of a mile ahead.

23:40 Titanic hit an iceberg, damaging 300 feet of the starboard hull below the

waterline and rupturing five adjacent watertight compartments.

00:00 Watertight compartments began filling, and water started spilling over the tops of

bulkheads.

00:15 First distress transmission from Titanic, using code CQD.

01:20 The bow pitched as water flooded through anchor-chain holes.

02:00 The bow continued to submerge, with propellers lifting out of the water.02

02:10 Last transmission from Titanic, luckily received by RMS Carpathia

02:18 The stern lifted almost vertically, before the ship finally broke apart.

02:20 Titanic sank beneath the surface of the Atlantic, taking three hours from flooding.

04:10 First lifeboat picked up by RMS Carpathia.

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The impact of the iceberg caused only a slight shudder throughout the ship, and many

passengers initially remained unaware of the severity of the situation. However, water quickly

began to fill the lower compartments, and by midnight, it started to spill over the tops of the

transverse bulkheads, setting off a chain reaction of flooding throughout the ship. Captain

Edward J. Smith, one of the most experienced captains of the Atlantic, quickly recognized the

gravity of the situation and ordered the lifeboats to be prepared for evacuation.

3. Composition of the Crew and Passengers

RMS Titanic carried a total of 2,223 people on board, including 1,320 passengers and 892

crew members. The passengers represented a cross-section of Edwardian society. Among the

first-class passengers were prominent figures such as John Jacob Astor IV, Benjamin

Guggenheim, and Isidor Straus, co-owner of Macy’s department store. Second-class passengers

included educators, professionals, and tourists, while third-class passengers were predominantly

emigrants from Europe, traveling to the United States in search of a better life.

The crew of Titanic comprised a wide range of personnel, including officers, engineers,

firemen, stokers, stewards, and galley staff. Captain Edward J. Smith was the most senior officer,

overseeing the voyage. The crew matrix included:

<DECK OFFICER>

▪ Captain Edward J. Smith, Chief Officer Henry Wilde, First Officer William Murdoch, Second

Officer Charles Lightoller, and four additional officers.

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<DECK CREW>

▪ Six watch officers and 39 able seamen, responsible for navigation and safety operations.

<ENGINEERING CREW>

▪ Engineers, firemen, and stokers, tasked with maintaining the ship's engines and managing the

ship’s power supply.

<SERVICE CREW>

▪ Stewards, galley staff, and attendants responsible for passenger comfort and services.

Many of the crew members had joined the ship just before departure from Southampton and

had little time to familiarize themselves with the ship’s layout and emergency procedures.

Notably, the ship’s lookouts were not equipped with binoculars, which hindered their ability to

spot icebergs in time. The lack of adequate training and equipment among the crew was a

significant factor contributing to the chaos during the evacuation.

4. Causes of the Titanic Accident

The rapid sinking of the Titanic was the result of a combination of material failures,

structural flaws, and human errors. The iceberg collision exposed the vulnerability of the ship’s

construction. Analysis of the wreck has shown that the steel used in Titanic’s hull was prone to

brittle fracture. The steel contained high levels of sulfur, which made it susceptible to breaking

rather than bending when exposed to cold temperatures. The wrought iron rivets used to hold the
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hull plates together also failed during the collision, popping off and allowing the hull to separate

along the seams.

The design of the watertight compartments was another critical flaw. While the

compartments were intended to prevent flooding, they were not sealed at the top, which meant

that as water filled one compartment, it could spill over into the next. As the bow of the ship

dipped lower into the water, this cascading effect allowed the flooding to spread uncontrollably.

Moreover, the decision to continue at high speed despite multiple iceberg warnings was a glaring

human error. Captain Smith, along with the White Star Line management, prioritized

maintaining the ship’s schedule over ensuring passenger safety. The prevailing belief at the time

was that icebergs posed little risk to large, modern vessels, and that any potential collision could

be managed without catastrophic consequences.

Additionally, the lack of sufficient lifeboats further exacerbated the tragedy. Titanic carried

only 20 lifeboats, enough for 1,178 people, which was far short of the total number of passengers

and crew on board. The inadequate lifeboat capacity was partly due to outdated maritime

regulations and partly due to the White Star Line’s desire to maintain the aesthetics of the ship’s

promenade decks, which would have been obstructed by additional lifeboats. During the

evacuation, poor management and a lack of proper drills resulted in lifeboats being launched

only partially full, leaving many passengers without a chance of survival.

5. Aftermath of the Incident

The Titanic sank at approximately 2:20 a.m. on April 15, 1912, just two hours and forty

minutes after striking the iceberg. The sinking resulted in the deaths of over 1,500 passengers

and crew, making it one of the deadliest peacetime maritime disasters in history. The RMS
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Carpathia arrived at the scene around 4:00 a.m. and rescued 710 survivors who were in the

lifeboats. The majority of those who perished died from exposure to the freezing waters of the

North Atlantic.

The public reaction to the Titanic disaster was one of shock and outrage. The perceived

invincibility of the ship, combined with the tragic loss of life, led to widespread calls for

accountability and changes in maritime safety regulations. The United States Senate, led by

Senator William Alden Smith, launched an inquiry into the disaster just days after the sinking.

The inquiry involved testimonies from surviving passengers, crew members, and experts, and

identified numerous failures in communication, safety preparedness, and ship design. The

findings of the inquiry, along with a subsequent British investigation, led to significant changes

in international maritime regulations.

One of the most notable outcomes of the Titanic disaster was the establishment of the

International Convention for the Safety of Life at Sea (SOLAS) in 1914. This convention

introduced requirements for ships to carry enough lifeboats for all passengers, conduct regular

lifeboat drills, and maintain round-the-clock radio communications. The disaster also led to the

creation of the International Ice Patrol to monitor iceberg activity in the North Atlantic and

prevent future collisions.

6. Conclusion

The sinking of the RMS Titanic remains one of the most infamous maritime disasters,

symbolizing both the triumph and the hubris of human engineering. The tragedy highlighted the

dangers of overconfidence in technology and the critical importance of safety preparedness. The

lessons learned from the Titanic disaster led to sweeping changes in maritime safety practices,
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many of which continue to govern the shipping industry today. Despite the improvements that

followed, the story of Titanic serves as a somber reminder of the consequences of neglecting

safety in the pursuit of progress.

[NON-CONFORMITY AND CORRECTIVE ACTION]

Before beginning this chapter, I would like to provide an explanation of this chapter. It

closely examines the RMS TITANIC accident based on the ISM Code. Before starting, I will

outline the causes of the RMS Titanic accident as proposed by various experts. After that, the

structure of the text first outlines the provisions of the ISM Code that were violated in relation to

the accident, followed by the reasons for those violations. Then, the corrective actions of each

non-conformities will be followed.

■ MAJOR Problems of the Titanic Accident ■

1. Failure to Heed Ice Warnings

Titanic received multiple ice warnings from nearby ships throughout the day on April 14,

1912. Despite these repeated warnings about dangerous ice fields, the ship maintained a speed of

approximately 22 knots. This demonstrated a critical error in risk management, as the crew chose

not to reduce speed in response to a known hazard, which greatly increased the likelihood of a

collision.
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2. High Speed in Dangerous Waters

The decision to maintain nearly full speed despite the threat of icebergs was influenced by a

desire to reach New York ahead of schedule. This prioritization of speed over safety resulted in

the inability to avoid an iceberg when it was sighted. Given the size and speed of the Titanic,

there was insufficient time or maneuvering capability to prevent the collision.

3. Inadequate Lookout Equipment

The lookouts on the Titanic were not equipped with binoculars, which would have enhanced

their ability to detect hazards at a greater distance. This lack of proper equipment hindered their

ability to spot the iceberg in time for evasive action. In addition, the calm sea and moonless night

made it even harder to identify icebergs, contributing to the disaster. However, some experts

have recently argued that even if the lookouts had been equipped with binoculars, it would have

still been difficult to spot the iceberg due to the calm Atlantic Ocean and lack of moonlight.

Nevertheless, by failing to follow the basic rules for proper lookouts, they clearly violated safety

regulations, which had a direct impact on navigational safety

4. Insufficient Lifeboats

Titanic was equipped with only 20 lifeboats, which was enough to accommodate roughly

1,178 people. With over 2,200 passengers and crew on board, the available lifeboats fell far short

of the number required to save everyone. This shortage was partly due to outdated regulations

and a desire to maintain the ship’s aesthetics, which discouraged adding more lifeboats to the

deck.
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5. Poor Crew Training and Lack of Drills

The crew was inadequately trained in emergency procedures, and no lifeboat drills had been

conducted during the voyage. As a result, the lifeboat evacuation was poorly organized, with

many boats launched only partially full. The lack of preparation led to confusion, hesitation, and

inefficient use of lifesaving equipment, costing many lives unnecessarily.

6. Flawed Ship Design

The design of the Titanic's watertight compartments was a significant flaw. Although the

ship was equipped with sixteen watertight compartments, they were not sealed at the top. This

meant that once water entered a compartment, it could spill over into the next one if the water

level rose high enough. This cascading effect led to progressive flooding, which accelerated the

sinking of the ship.

7. Material Deficiencies

The steel used in the ship's hull and the rivets holding the plates together were found to be

of inferior quality. The hull steel was prone to brittle fracture in cold temperatures, which

contributed to the ship’s inability to withstand the impact with the iceberg. Similarly, the

wrought iron rivets popped off during the collision, allowing water to enter the ship more easily.

8. Ineffective Communication

Not all iceberg warnings received by the wireless operators were relayed to the captain or

the officers on the bridge. The operators prioritized transmitting personal messages from

passengers, delaying the communication of critical navigational information. Additionally, the

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nearby SS Californian, which could have aided in the rescue, did not respond promptly due to

miscommunication and a lack of understanding of the severity of the situation.

9. Inadequate Leadership and Decision-Making

Captain Edward J. Smith’s decision-making during the critical hours leading up to the

collision reflected a lack of caution. Despite being informed of the ice warnings, Captain Smith

chose not to alter course significantly or reduce speed. This decision proved fatal when the

iceberg was sighted, as there was not enough time or space to maneuver the ship effectively.

10. Inefficient Evacuation Procedures

The evacuation process was chaotic, partly due to a lack of clear instructions and poor

crowd control. First-class passengers were more likely to reach the lifeboats due to their

proximity to the boat deck, while many third-class passengers struggled to find their way to

safety, often hindered by locked gates or a lack of communication. The absence of a proper

alarm system meant that many passengers were unaware of the severity of the situation until it

was too late.

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■ Non-Conformities and Corrective Actions Based on ISM Code ■

▪ ISM CODE 1.2.2. Safety management objectives of the Company should, inter alia:

1.2.2.2) assess all identified risks to its vessels, personnel, and the environment and

establish appropriate safeguards; and

→ Mismanagement of Safety in Titanic’s Design and Operations

The Company (“White Star Line”) failed to identify all the structural, operational, and risk

management factors that could compromise stability in emergencies, such as flooding. Their

understanding of bulkheads and watertight doors was limited to specific permissible conditions,

such as water level angles and the location of flooded compartments. The bulkhead design

allowed water to flow over it if more than four compartments were flooded. The company also

overlooked critical dangers and preventive measures, including gravity-sealed watertight doors,

vertical escape routes, the insufficient number and operation of lifeboats, and inadequate

communication between crew members and passengers. The company was unprepared for

effective damage control, having failed to recognize both structural and operational risks.

Additionally, there was no proper risk assessment for navigating and operating the vessel in icy

regions. They focused solely on the presence of watertight bulkheads without considering

stability in all emergency scenarios, leading to the promotion of the vessel as a "practically

unsinkable” vessel, which caused the crew and passengers to over-rely on its hull integrity.

1.2.2.3) continuously improve safety management skills of personnel ashore and

aboard vessels, including preparing for emergencies related both to safety and

environmental protection
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→ Failure to Evaluate and Continuously Monitor Emergency Training

The Company failed to ensure that the crew received regular training and emergency

drills, resulting in an inadequate understanding of their duties. Both the captain and crew lacked

the skills to navigate the vessel in ice regions and properly manage the lifeboats. The Company

did not provide essential manuals, including station bills, nor did they review or improve crew

training. Consequently, crew members were unaware of their assigned lifeboats or capacities,

launching lifeboats without filling them, which led to a higher number of casualties. Even though

the Titanic was on its maiden voyage, the company should have sufficiently provided and

guaranteed proper training and education to prepare for emergencies.

[CORRECTIVE ACTION BASED ON ISM CODE 1.2.2.]

The company must conduct a thorough risk assessment that evaluates all potential risks,

including structural, operational, and environmental hazards. Based on the findings, appropriate

safeguards should be implemented, such as redesigning bulkheads and watertight doors to

prevent overflow, increasing the number of lifeboats, and ensuring that passengers and crew are

properly trained in evacuation procedures. Additionally, the company should develop and

enforce detailed navigation protocols for sailing through hazardous regions, such as iceberg

zones. This approach aligns with modern safety practices, including the establishment of the

International Ice Patrol (IIP) in 1913 to monitor and report ice conditions.

▪ ISM CODE 1.4. Functional Requirements for a Safety Management System

Every Company should develop, implement, and maintain a Safety Management System

(SMS) which includes:

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1.4.1) a safety and environmental protection policy

→ Failure to Implement a Comprehensive SMS prior to the departure.

The Titanic had structurally and operationally vulnerable policies at the time, contrary to

their confidence and oversight. As a passenger vessel responsible for human lives, it should have

had strict safety management systems in place to prevent emergencies that could lead to severe

loss of life, even in the absence of appropriate regulations from government or international

organizations. Consequently, the vessel should have embarked with a fully developed Safety

Management System (SMS) to address all potential risks. However, they proceeded with the

maiden voyage without sufficiently developing an SMS. As a result, during the iceberg collision,

the vessel sustained damage far beyond what could have been prevented within the three-hour

period leading up to the sinking.

1.4.2) instructions and procedures to ensure safe operation of vessels and protection

of the environment in compliance with relevant international and flag State

legislation

→ Overconfidence and Failure to Ensure Adequate Safety Measures

Titanic was registered in Liverpool, England, and sailed under the British flag. This

meant that it was subject to British maritime laws and regulations, including those outlined in the

Merchant Vessel panning Act of 1894, which governed many aspects of its design and safety

requirements. The Company, vessel builder, and crewmembers of Titanic had in compliance

with its existing regulations, but relied too confidently on antiquated laws that didn't apply to

their vessel. This overconfidence led to a lack of urgent response to flooding, causing delays in

evacuation and increasing casualties. The Titanic's lifeboats met the Merchant Vessel planning
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Act of 1894 requirements, but there were two critical errors at the time. The first was that the

law, initially enacted in the 1800s, applied to “passenger vessels of 10,000 tons and above,” but

the Titanic, a 45,000-ton passenger vessel launched in 1911, far exceeded these criteria.

The Titanic had 20 lifeboats with a maximum capacity of 1,178 people, which exceeded

the legal requirement of “16 lifeboats with a total capacity of 9,625 cubic feet (272.5 m3), to

accommodate approximately 990 people” (57 and 58 Vict. Ch. 60. (b)). However, this was

insufficient for both the vessel's maximum capacity of 3,547 people and the actual number of

approximately 2,240 passengers on board. The flag state government failed to update the law to

reflect the increasing tonnage of vessels, leaving the outdated law unchanged. The company,

prioritizing aesthetics over financial loss, did not feel the need to install more than the 60

lifeboats that the structure could accommodate. The vessel builder, confident in the regulations,

did not question the vessel’s safety. This situation corresponds to the second phase of the safety

management process, the ‘regulation reactive phase’, where they should have confirmed whether

mere compliance with the existing regulations guaranteed safety and implemented stricter

procedures.

1.4.3) defined levels of authority and lines of communication between, and amongst,

shore and vessel board personnel

→ Overreliance on Wireless Communication and Missed Warnings Causing

Delayed Response

The period of the accident was during the early days of wireless communication, which

could only reach less than 20 miles using Morse code. The crew relied on the assumption that, in

the event of an accident, they would be able to call for help via wireless communication.
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However, wireless technology was still inadequate, and many vessels did not have wireless

systems. Even among those that did, such as the Californian and Carpathia, they typically only

had one operator, meaning that messages were dependent on the operator being awake and on

duty.

Titanic's two radio officers, Jack Phillips and Harold Bride, had been receiving iceberg

warnings, most of which were passed along to the bridge. At the time, Jack Phillips was fatigued,

either repairing a malfunctioning spark gap transmitter or sending passenger messages to Cape

Race Radio. When the S.S. Californian contacted Phillips to inform him that their vessel was

stopped and trapped in an ice field, Phillips replied with, "working Cape Race, keep out,"

completely ignoring the advice. Evans, the Californian’s operator, turned off the radio and went

to bed, so further iceberg warnings were not received, and the distress signal sent to the closest

vessel, the Californian, was not received either. Additionally, there were instances where the

Titanic could not receive iceberg warnings due to interference from passengers using their own

wireless devices. At the time, there was also no PA system onboard, meaning that there was no

effective broadcasting equipment available.

1.4.1.5) procedures to prepare for and respond to emergency situations

→ Inadequate Emergency Procedures for Immediate Evacuation

At the time, there were no adequate procedures in place to effectively handle emergencies

across multiple areas, including navigating, watchkeeping, distress communication, and

evacuation. These essential procedures, which should have been clearly documented and readily

available to the crew, were either missing or insufficiently implemented. The absence of these

critical guidelines contributed to the chaotic response during the incident and significantly
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hindered the crew's ability to manage the emergency in a coordinated and efficient manner. As a

result, this lack of preparedness became one of the major non-conformities that led to the

escalation of the disaster. This issue will be thoroughly examined in the following section under

'ISM Code 8 Emergency Preparedness,' where the gaps in emergency planning and response will

be discussed in greater detail.

[CORRECTIVE ACTION BASED ON ISM CODE 1.4.]

The company must establish a fully developed Safety Management System (SMS) prior

to the departure of any vessel, especially for passenger ships like the Titanic. This SMS should

include comprehensive risk assessments that address structural, operational, and environmental

hazards to ensure that all potential risks are identified and mitigated. The company must also

adhere to updated safety standards by regularly reviewing compliance with international

guidelines and flag state laws, going beyond outdated regulations to implement stricter

safeguards where necessary. Key elements include ensuring the vessel’s design accommodates

sufficient lifeboats for all passengers, and having fully documented emergency procedures that

cover evacuation drills, distress communication, and navigation through hazardous regions like

iceberg zones.

▪ ISM CODE 2. Safety and Environmental Protection Policy

2.1) The Company should establish a safety and environmental protection policy which

describes how the objectives, given in paragraph 1.2, will be achieved.

→ Failure to Establish a Comprehensive Safety Policy

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Even though there were no international conventions or regulations like we have today,

there were no internal company procedures or manuals for emergency situations, nor was there a

system for regulating onboard training. Additionally, there were no established navigation

procedures or response plans for iceberg warnings, which are now considered a major

contributing factor to the Titanic disaster. This incident also highlighted the need for continuous

monitoring of ships from land and the development of various safety procedures for onboard

operations.

[CORRECTIVE ACTION BASED ON ISM CODE 2.]

The company should develop a comprehensive safety and environmental protection policy,

which includes clear risk assessment procedures, emergency response plans, and safe navigation

guidelines. The policy must specifically address hazardous conditions, such as iceberg warnings,

to ensure that appropriate preventive measures are taken. Additionally, company should have

established a system for continuous monitoring and reviewing of the safety policy, incorporating

lessons learned from incidents and safety audits to keep it updated.

▪ ISM CODE 3 Company Responsibilities and Authority

3.2) The Company should define and document the responsibility, authority and

interrelation of all personnel who manage, perform and verify work relating to and

affecting safety and pollution prevention

→ Lack of Documentation of Emergency Drills and Procedures

At the time, the Titanic lacked clear and well-documented emergency response procedures,

causing both crew and passengers to be unaware of how to properly respond, which delayed
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evacuation. There was also confusion regarding which lifeboats to board and how to launch

them. Given that wireless communication was still underdeveloped, wireless procedures were

also not clearly documented. Some iceberg warnings and distress signals were not fully

conveyed, and the evacuation was further delayed due to overreliance on wireless distress

signals. The absence of proper documentation hindered the ability to anticipate the disaster and

take consistent actions, and it also made it difficult to assign responsibility. Without standardized

documentation, proper training was not conducted regularly.

[CORRECTIVE ACTION BASED ON ISM CODE 2.]

To address the lack of documentation of emergency drills and procedures, the company

must develop and maintain comprehensive safety protocols that clearly define the

responsibilities, authority, and coordination of all personnel involved in safety and pollution

prevention. These protocols should include detailed emergency response procedures for

evacuation, distress communication, and lifeboat deployment. All procedures must be

documented in accessible manuals, regularly updated, and thoroughly communicated to crew

members, ensuring they are aware of their specific roles during an emergency. The company

must also establish a robust wireless communication protocol, ensuring all distress signal

processes are clearly outlined, and operators are available at all times. Regular emergency drills

must be conducted, documented, and evaluated to identify gaps and improve effectiveness, with

ongoing training provided to ensure crew readiness.

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▪ ISM CODE 4. Designated Person

→ Lack of Designated Person for Safety Oversight.

The Titanic did not have a designated person ashore who had direct access to senior

management to ensure the safe operation of the vessel. The absence of a dedicated safety officer

contributed to poor decision-making regarding navigation and risk management, including the

failure to properly respond to iceberg warnings. Without a designated person, there was no

effective oversight of the ship's safety practices, nor was there a reliable link between shipboard

operations and the company’s management, compromising overall safety. Additionally, when

specific navigational hazards such as iceberg warnings were detected, the company’s internal

safety management team and the ship's onboard safety officers should have exchanged

information or conducted continuous safety assessments using Morse code, one of the wireless

communication methods available at the time.

[CORRECTIVE ACTION BASED ON ISM CODE 4.]

Appoint a designated person ashore who is responsible for ensuring the safe operation of the

vessel and serving as a link between shipboard personnel and senior management. This DPA

should have direct access to the highest levels of management and be responsible for monitoring

the implementation of the safety management system. Additionally, a clear designation of the

onboard safety officer, along with an official title and responsibilities, must be specified in the

company's SMS manual. Continuous communication with land-based teams should also be

maintained to ensure safety monitoring of the ship.

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▪ ISM CODE 5 The Company should clearly define and document the master's responsibility

with regard to:

5.1.1) implanting the safety and environmental-protection policy of the company

→ Failure to implant proper safety policy of the company

The Company did not implant comprehensive systems or procedures in the shipboard

documentation to address and mitigate risks, insufficient safety training for crew members, and a

lack of clear protocols for emergency situations. The company failed to prioritize safety by

relying on outdated regulations, neglecting to improve operational safeguards, and not ensuring

that the vessel and crew were adequately prepared for emergencies. This lack of a robust safety

policy led to mismanagement, increased vulnerability in hazardous situations, and ultimately

contributed to the severity of the disaster.

5.1.2) Motivating the crew in the observation of that policy

→ Failure to Prepare Crew for Potential Risks in an iceberg region

A lifeboat launching drill was scheduled for the morning of Sunday, April 14, 1912, after

departure, but it was canceled. Although the reason is unknown, it is speculated that the

cancellation was made by Captain Smith. As a result, during the actual lifeboat lowering, the

lack of training caused delays, and the boats were lowered far under capacity, leading to a higher

number of casualties. Additionally, the captain, being in an iceberg region, should have warned

and educated the crew about the importance of wireless communications watchkeeping,

including iceberg warnings, and instructed them on the specifics of navigating through ice-prone

areas. However, his failure to adequately emphasize these critical points left the crew unprepared

to observe and respond effectively to the dangers, contributing to the disaster.

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5.1.3) Issuing appropriate orders and instructions in a clear and simple manner

→ Captain's Failure in Command Decisions and Emergency Management

It is crucial for the captain to give clear, precise, and timely orders, as the captain holds

“overriding authority” on the vessel. While navigating through the iceberg region, the captain

ignored iceberg warnings and continued sailing without significantly reducing speed,

maintaining nearly full speed without reinforcing lookout efforts. Even Titanic’s master received

a letter which he had to sign and return. The letter stated that 'You are to dismiss all idea of

competitive passages with other vessels and to concentrate your attention upon a cautious,

prudent and ever-watchful system of navigation, which shall lose time or suffer any other

temporary inconvenience rather than incur the slightest risk which can be avoided.' However,

there was also a conflicting message from management. In the Titanic accident report, Lord

Mersey, the Judge heading the investigation, commented, 'Its root is probably to be found in the

competition and in the desire of the public for quick passages rather than in the judgment of the

navigators.' Additionally, the captain failed to properly monitor wireless communications with

the Californian, and he did not ensure that passengers were orderly loaded into the lifeboats.

Consequently, not all lifeboats were lowered with their full capacity.

[CORRECTIVE ACTION BASED ON ISM CODE 5.]

The company must ensure that comprehensive safety and operational protocols are in place,

while also supporting and reinforcing the captain's responsibility to prioritize risk mitigation and

emergency preparedness. The company should update its safety policy to meet modern

standards, ensuring that all potential risks, especially in hazardous regions like iceberg zones, are

properly assessed and addressed. The captain must be supported in providing clear and consistent
 26

orders, following a safety-first approach rather than focusing on operational speed or competitive

pressures. The company should also ensure that lifeboat drills and emergency preparedness

training are conducted regularly, rescheduling any canceled drills without delay to guarantee

crew readiness. In addition, robust communication protocols, particularly regarding iceberg

warnings and distress signals, must be implemented, ensuring that wireless communication is

continuously monitored and managed. The company should provide ongoing support and

training to the crew to motivate them to adhere to safety protocols and clearly define roles and

responsibilities in emergency situations.

▪ ISM CODE 6. Resource and Personnel

6.1.3) given the necessary support so that the Master's duties can be safely performed

→ Failure to provide the necessary support for the captain to safely perform his

duties.

The company failed to plan an internal emergency plan that would allow for proper

response during a crisis, and did not equip the ship with a sufficient number of lifeboats to

evacuate all passengers and crew. As a result of these shortcomings, even after the captain issued

the evacuation order, the insufficient number of lifeboats and the lack of a systematic emergency

plan led to many lives being put in grave danger.

6.3) The Company should establish procedures to ensure that new personnel and

personnel transferred to new assignments related to safety and protection of the

environment are given proper familiarization with their duties. Instructions which are

essential to be provided prior to sailing should be identified, documented and given.

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→ Lack of Familiarization with Safety Procedures (especially, new personnel)

The vast majority of the crew who served under captain were not trained sailors, but were

either engineers, firemen, or stokers, responsible for looking after the engines; or stewards and

galley staff, responsible for the passengers. The six watch officers and 39 able seamen

constituted only around five percent of the crew, with the majority having been taken on at

Southampton, and as a result lacked the time to familiarize themselves with the ship. Even if a

department is not directly related to navigation, thorough education on basic ship familiarization

and emergency response procedures is essential to ensure proper action during an onboard crisis.

However, the majority of Titanic's crew were untrained general laborers, unfamiliar with the

ship, let alone properly trained. As a result of this lack of expertise, despite having over two

hours after the accident, the evacuation was disorganized. Furthermore, like modern passenger

ships, a systematic program should have been in place to provide both crew and passengers with

ship familiarization and emergency evacuation training within 24 hours of boarding.

6.4) The Company should ensure that all personnel involved in the Company's SMS

have an adequate understanding of relevant rules, regulations, codes and guidelines.

→ Failure to ensure adequate understanding of safety guidelines and regulations to

all personnel involved in the company’s SMS

Although the Safety Management System (SMS) did not exist at the time of the incident, as

mentioned earlier, only a small number of crew members were professional sailors capable of

responding appropriately to emergencies, while the majority were not. Furthermore, even the

professional sailors had no prior experience with large-scale accidents involving significant loss

of life, and they had not undergone adequate training, which further contributed to the scale of
 28

the tragedy. Therefore, despite the absence of a formal SMS, the ship should have at least

provided basic safety guidelines and emergency response training to its crew.

6.5) The Company should establish and maintain procedures for identifying any

training which may be required in support of the SMS and ensure that such training is

provided for all personnel concerned

→ Fail to provide basic emergency training for all personnel concerned

As mentioned several times earlier, the Titanic never conducted even the most basic

firefighting drills or lifeboat launching drills, nor were there any internal company regulations

requiring them. Due to the lack of such safety manuals, the crew was unable to respond

appropriately during the actual disaster. This shortcoming served as a lesson, leading to the

creation of the SOLAS (Safety of Life at Sea) convention about two years later in 1914.

[CORRECTIVE ACTION BASED ON ISM CODE 6.]

Establish an internal emergency support plan that provides clear guidelines and resources

to support the captain in emergency situations. This plan should include specific actions that

must be taken by the company and onboard officers to ensure passenger safety during crises.

Ensure that the captain has access to adequate resources, including properly trained

personnel, sufficient lifesaving equipment, and a clear chain of command for emergency

decision-making.

Ensure that all personnel, including those newly assigned to the vessel, receive thorough

familiarization training before departure. This training must cover the ship's layout, the operation

of lifesaving equipment, emergency evacuation procedures, and any other relevant safety
 29

protocols. In particular, safety services or training should not be provided differently based on

cabin class, but must be delivered equally to all passengers.

Develop and use a checklist to verify that all new personnel have completed

familiarization training and are prepared for emergencies.

Develop a training program specifically focused on safety guidelines, rules, and relevant

regulations. Make this training mandatory for all personnel to ensure a thorough understanding

of safety requirements and responsibilities.

Develop and implement a formal emergency training program that includes basic

firefighting skills, lifeboat launching procedures, and emergency evacuation drills. Ensure all

crew members participate in these drills and assess their performance to identify areas for

improvement.

Maintain detailed records of all training sessions and individual crew assessments to

ensure compliance and readiness.

▪ ISM CODE 7 The Company should establish procedures, plans, and instructions, including

checklists as appropriate, for key vesselboard operations concerning the safety of the

personnel, vessel and protection of the environment. The various tasks should be defined and

assigned to qualified personnel

→ Failure to Prioritize Safety Over Business in Decisions

The Company itself took a complacent approach in several areas, including structural and

operational safety inspections, planning, and guidelines. Conflicting instructions were given in

the telegrams, emphasizing both the need for reinforced vigilance and safe navigation principles,

while also pushing to shorten sailing time, as directed by management. Despite the flag state's
 30

low regulatory standards for lifeboats and emergency drills, as a passenger vessel responsible for

human lives, stricter regulations should have been in place, and all potential accident scenarios

should have been considered. From design to operation, the Titanic prioritized business over

safety, reducing the number of lifeboats, failing to ensure proper training and education, and

designing bulkheads with an incomplete understanding of flooding. This focus on creating

luxurious open spaces at the expense of safety was a major contributing factor to the disaster.

[CORRECTIVE ACTION BASED ON ISM CODE 7.]

The company must prioritize safety in every aspect of vessel design, operation, and

management, ensuring it takes precedence over business considerations. This begins with the

establishment of robust procedures, plans, and checklists for all key vessel operations related to

safety, which must be developed and implemented in alignment with international safety

standards, such as the ISM Code. The company must conduct comprehensive risk assessments

and incorporate stricter safety regulations, going beyond the minimum standards set by the flag

state, especially for passenger vessels. Adequate lifeboats must be provided for all passengers

and crew, and regular emergency drills should be mandatory, with rescheduled drills promptly

conducted if necessary. The design of the vessel should focus on structural integrity, ensuring

features such as bulkheads and watertight doors are designed with a full understanding of

flooding risks. Additionally, the company should eliminate conflicting messages regarding

operational speed versus safety, clearly supporting the captain in maintaining safe navigation

practices.
 31

▪ ISM CODE 8. Emergency Preparedness

8.1) The Company should identify potential emergency shipboard situations, and

establish procedures to respond to them.

8.2) The Company should establish programmes for drills and exercises to prepare for

emergency actions.

→ Failure to Implement Effective Emergency Procedures, Lack of Regular Drills

and Emergency Exercises

Titanic lacked comprehensive emergency procedures to handle the iceberg collision. No

emergency drills were held during the voyage, and the crew’s response to the collision was

disorganized and ineffective. The absence of structured evacuation plans and training resulted in

chaotic lifeboat launches, with many boats leaving only partially filled. The lack of emergency

preparedness procedures meant that the crew was not ready to respond appropriately to the

disaster.

No lifeboat drills or emergency exercises were conducted during the Titanic's voyage. This

lack of practice left both the crew and passengers unprepared for the eventuality of an emergency

evacuation. The failure to conduct such drills violated the requirement to prepare personnel

through structured training exercises, which ultimately resulted in ineffective and disorganized

evacuation efforts during the sinking.

[CORRECTIVE ACTION BASED ON ISM CODE 8.]

The corrective actions discussed above are quite similar to those for Code 6. However, once

the company establishes the guidelines, the key challenge is ensuring they are properly

implemented and regularly inspected on the ship. Establish a detailed set of emergency response
 32

procedures tailored to potential shipboard emergencies such as collisions, fire, and abandoning

ship. These procedures must specify roles and responsibilities for crew members, communication

protocols, and steps to ensure passenger safety. Schedule regular emergency drills that simulate

real-life scenarios, including collisions and evacuations. These drills should include lifeboat

launching, firefighting, and other essential emergency procedures to ensure crew readiness.

▪ ISM CODE 9 Reports and analysis of non-conformities, accidents, and hazardous

occurrences.

9.1) The SMS should include procedures ensuring that non-conformities, accidents

and hazardous situations are reported to the Company, investigated and analyzed with

the objective of improving safety and pollution prevention.

→ Inadequate Risk Reporting and Communication Systems

The Titanic lacked a sufficient reporting system for non-conformities, hazardous situations,

or near misses, which meant that predicting, assessing, and preventing risks through such reports

was not effectively carried out. The clearest evidence of this is that iceberg warnings were not

properly relayed to the bridge, and there were no procedures in place to preemptively address

risk factors, such as altering the vessel’s course, reducing speed, or reviewing and evaluating

emergency drills.

9.2) The Company should establish procedures for the implementation of corrective

action, including measures intended to prevent recurrence.

→ Lack of Procedures to Address and Correct Risks in Advance

 33

The Titanic lacked a system to detect and report such risk factors, as well as

communication technology capable of reaching long distances. As a result, there were

insufficient procedures in place to correct risks or mitigate the scale of the disaster. Ultimately,

during the three hours before the vessel fully submerged, it was only by chance that the RMS

Carpathia arrived for rescue, highlighting the consequences of these shortcomings."

[CORRECTIVE ACTION BASED ON ISM CODE 9.]

The company must implement a robust reporting and communication system that exceeds

minimum regulatory standards, with stricter procedures for identifying, reporting, and analyzing

non-conformities and hazards. Safety-related incidents must be promptly reported, investigated,

and addressed to improve safety and pollution prevention. Enhanced protocols should ensure

critical information, like iceberg warnings, is communicated to the bridge and acted upon,

including adjustments to speed or course. The company must also introduce proactive corrective

action plans, with stricter safeguards that go beyond basic flag state regulations, to prevent risks

from escalating.

▪ ISM CODE 10. The Company should establish procedures to ensure that the ship is

maintained in conformity with the provisions of the relevant rules and regulations and with

any additional requirements which may be established by the Company.

→ Failure to Define and Document Responsibility and Authority

The Titanic was equipped with only 20 lifeboats, enough to accommodate approximately

1,178 people—far fewer than the total number of passengers and crew onboard, which numbered

over 2,200. The shortage of lifeboats was due to outdated regulation {Merchant Shipping Act
 34

1894 (57 & 58 Vict. c. 60)} and a decision made by the White Star Line to maintain

unobstructed views for passengers and to preserve the ship's aesthetics. This decision, which

significantly compromised safety, demonstrated a failure to conduct a thorough risk assessment

of the vessel's safety equipment. Proper inspection and reporting of non-conformities would have

identified the lifeboat capacity as insufficient for emergency situations

Additionally, the crew of the Titanic demonstrated insufficient training in lifeboat

operations. Many of the lifeboats were launched with fewer passengers than their capacity

allowed due to fears that the lifeboats could buckle under full load. The davits (lifeboat

launching equipment) were capable of accommodating 64 lifeboats, but only 16 were initially

fitted, plus four collapsibles. The lifeboats, when launched, were often filled well below their

capacity due to poorly executed launching procedures and a lack of supervision during the

evacuation. This lack of proper crew training and understanding of the equipment's capacity

contributed to the ineffective use of available lifeboats, violating the ISM Code’s requirement for

maintaining safety equipment in a ready state

[CORRECTIVE ACTION BASED ON ISM CODE 10.]

As explained in modern SOLAS regulations, lifeboats capable of accommodating the full

capacity of the ship must be installed on each side of the vessel, and actual launching drills must

be conducted within a period of no more than six months to ensure proper operation in

emergencies. These drills must be documented.

Additionally, not only lifeboats but also other life-saving appliances must be provided in

numbers exceeding the total number of people on board, and both crew and passengers must be

trained in their use.

 35

Develop a structured training program specifically for lifeboat operations. This should

include hands-on training in the use of davits, proper boarding procedures, launching lifeboats,

and managing them once in the water.

▪ ISM CODE 11 Documentation

11.1) The Company should establish and maintain procedures to control all

documents and data which are relevant to the SMS.

→ The Lack of Standards of Safety Management Documents

The Flag state and the Company had not yet established a proper system for safety

management operations, such as navigation in iceberg regions, evacuation and lifeboat lowering

drills, and distress signal systems. Without even basic minimum standards in place, the company

and the vessel failed to fulfill their duty to prioritize safety over profitability.

11.2.1) The Company should ensure that valid documents are available at all relevant

locations

→ The Lack of Accessibility to Safety Management Documents

The Titanic failed to implement procedures that would ensure all safety management

materials were available. In terms of structural equipment, the lower bulkhead height, designed

to allow more open spaces, meant that the vessel would lose stability and sink if more than four

compartments were flooded. Additionally, there was no strategy for efficiently distributing the

insufficient number of lifeboats and life jackets, nor was there training on essential damage

control techniques, such as how to evacuate if the watertight doors, sealed by gravity, could not

be reopened. The Company also failed to provide adequate warnings or training on iceberg risks
 36

and wireless communication limitations, leaving safety at a minimum level. The lack of proper

attention and knowledge from both the flag state government and the company was a root cause

of the disaster.

11.3) The documents used to describe and implement the SMS may be referred to as

the "Safety Management Manual". Documentation should be kept in a form that the

Company considers most effective. Each vessel should carry on board all

documentation relevant to that vessel.

→ Failure to Provide Critical Risk Information and Documentation

The company have the responsibility to verify and ensure that the vessel was equipped

with all the essential documents and information required for the safe navigation of the vessel

and proper management of passengers. This would have included crucial information regarding

potential hazards, such as the dangers posed by icebergs, the risk of flooding, and the limitations

of distress signal systems. Additionally, the company should have provided adequate warnings

about the shortage of lifeboats and the risks associated with prolonged exposure to freezing

temperatures, such as frostbite. However, no such information or telegrams addressing these vital

risk factors were communicated to the vessel, leaving both the crew and passengers unprepared

for the emergencies that followed.

[CORRECTIVE ACTION BASED ON ISM CODE 10.]

These non-conformities, much like earlier issues, underscore the need for the company to

implement a comprehensive documentation system that goes beyond the minimum regulatory

standards. All SMS-related documents, including those for navigation in hazardous regions,

evacuation procedures, lifeboat drills, and distress signal protocols, must be readily accessible on
 37

board. Regular reviews and updates should ensure that these documents are up-to-date and that

crew members are properly trained in their use. Additionally, clear strategies for managing

structural risks, distributing life-saving equipment, and conducting damage control training must

be documented. The company must also establish a system to ensure that the crew is well-

informed about risks such as icebergs and the limitations of wireless communication, ensuring a

proactive approach to safety.

 38

[CONCLUSION]

In this case study, the Titanic, launched in 1911 and tragically lost during its maiden voyage

in 1912, suffered its disaster partly from the absence of modern navigation, shipbuilding

standards, and communication technologies, as well as the lack of regulatory frameworks like the

SOLAS Convention and the ISM Code. This leads us to consider how the ISM Code, introduced

later to prevent such tragedies, could have identified non-conformities and mitigated the risks

that led to the Titanic’s sinking. The insights drawn from this analysis provide answers to the

initial questions, demonstrating that even today, the development and enforcement of safety

standards and risk assessments are vital to preventing marine disasters.

First, prioritizing safety is essential. The Titanic prioritized luxury and excessive optimism,

neglecting the ship’s vulnerability and the need for a swift, systematic evacuation plan. The

captain failed to recognize the necessary precautions for navigating iceberg regions, did not

conduct lifeboat drills, and prioritized profit by maintaining full speed.

Second, the importance of distress communication. Despite technological advancements at

the time, communication range was still limited, and there was no system to ensure that wireless

operators were always on duty. Some ships even turned off their radios and ignored signals.

Third, the need for a system to identify and report risks. Even today, all crew members—not

just international organizations or companies—must take a proactive approach to identifying

potential risks and implementing preventive measures, rather than passively adhering to

regulations. Proper observation is essential. The Titanic’s captain failed to instill a culture of

safety awareness among the crew. The ISM Code today grants captains overriding authority and

ample support from the company to ensure the safety of shipboard operations.