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“Accidents are associated with normal people

doing normal work in normal organizations

making incremental changes to the system

over time”- Sidney Dekker

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Lessons Learnt from the

Capsizing of SS Eastland

Rodney Tan Kheng EngSenior EngrDSTA

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Jul 1915

844 killed out of 2,752

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Initial design consideration (1): Speed

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South Haven,

Michigan

Chicago,

Illinois

Overnight fresh fruits run from “farm” to “market” over

Lake Michigan

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Initial design consideration (2):

Shallow draft

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South

HavenShallow waters off

South Haven, Michigan

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1. Ship underperformed: 19 mph vs 22 mph

2. New propulsion system installed

� Weight increased

� Draft increased

� Ship machinery rearranged to reduce draft

Speed Queen of the Lakes

1903: 1st year

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1. Modifications:

� 1904: More passengers

-> additional life boats

� 1904: Reduced no. of overnight trips

-> Removed 49 cabins

� 1909: No more overnight trip

->Removed 39 cabins

� Early 1915: Upgrades

e.g. re-arranged ship compartments &

replaced rotten decking with concrete

1904 to 1915

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2. Safety Record:

� Listing occurred over the years (top-heavy)

-> Ship crew has SOP to correct listing

1904 to 1915

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Ballast water in

Starboard Port

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1912

16 lifeboats for 1,200 out of

2,200 passengers

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1915

� By Nov 15: licensed for 1,200 passengers

� In Jul 1915, still licensed to carry 2,500

passengers.

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Jul 1915

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Lessons

1. Inquiry attributed incident to

overcapacity, mishandling by crews

during incident & flawed construction.

2. Three lessons:

� Beware of changes in how system is

used.

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“The first owners of the

vessel wanted a fast

ship for transportation

of fruits…”

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“I consider the boat safe

for all uses to which it

was put which were in

my knowledge”

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Lessons

1. Inquiry attributed incident to

overcapacity, mishandling by crews

during incident & flawed construction.

2. Three lessons:

� Beware of changes in how system is

used. Beware of impact of evolving

use. Review safety assumptions. Re-

qualify if necessary.

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Lessons

2. Three lessons:

� Beware of changes in how system is

used. Beware of impact of evolving

use. Review safety assumptions. Re-

qualify if necessary.

� Conduct testing - not pseudo-testing.

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“The boat slid into the

water on its side at

launch…tilted in the

opposite direction at

45° then righted itself

as straight as a church,

satisfactorily

demonstrating its

stability”

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“The Federal Inspectors

had the right to refuse a

permit to the boat but

they are generally not

trained men and did not

make stability tests (a

must) ”

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Lessons

2. Three lessons (cont.):

� Conduct testing - not pseudo-testing.

• What assumptions are we making when

we “read across”?

• Have the assumptions been carefully

evaluated?

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WARNING: Beware of “reading across”

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Lessons

2. Three lessons (cont.):

� Beware of modifications over time

that may erode the safety envelope.

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Improve durability: 2” concrete decking: 14

tonnes

Improve safety: each life boat: 2 – 3 tonnes

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WARNING: Is the safety margin still

sufficient?

Distancing through differencing

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“Those reviewing new evidence or incidents focus

on differences, real and imagined, between the

place, people, organization and circumstances

where an incident happens and their own context.

By focusing on the differences, people see no

lessons for their own operation and practices or

only narrow well bounded responses.”

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1. “System Safety and the Unintended

Consequence”, Clifford Watson.

2. Wikipedia entry on SS Eastland:

http://en.wikipedia.org/wiki/SS_Eastland

3. Eastland Memorial Society:

http://www.eastlandmemorial.org/index.shtml

4. New York Times archive

Sources:

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