What is Lessons From History? - Association for Project Management

Transcription

Avoiding Project Disasters
Titanic Lessons for
Modern Projects
Presentation to APM
London and South
East branches
March 16/17th 2011
Mark Kozak-Holland
“Lessons From the Past that Assist the Projects of
Today to Shape the World of Tomorrow”
www.lessons-from-history.com
Titanic Lessons for Modern Projects
© 2011 Mark Kozak-Holland
Objectives: Analyze Titanic‟s construction project and
voyage
 It uses lessons learned to understand key project issues.
 It looks at key decisions that led to project compromises.
 It questions why captain was unable to prevent disaster.
 It makes a step by step comparison to today‟s IT projects.
 Please prepare questions for the end of the presentation.
Page 2
The success rate of Projects is stubbornly low as first
shown by the “Chaos” reports from Standish Group
 PMI reports $15 trillion in 2010 spent worldwide on projects, 20% of world’s GDP.
 $260 billion wasted due to project failures in US in 2009.
 Hypothesis:
– Projects set seeds for future operational failures.
– Problems attributed to poor decisions making in the project.
Succeeded
Failed
Challenged
1994
16
31
53
1998
26
28
46
2000
28
23
49
2002
34
15
51
2004
29
18
53
2006
35
19
46
2008
32
24
44
Through 2010, government agencies will
cancel 30% of the IT projects that they
initiate, including at least 10% of projects
budgeted at more than $200,000 (0.7
probability).
60
50
Source: “Chaos, a
recipe for success,”
Standish Group,
280,000 projects
evaluated
1996
27
40
33
40
30
Source: Garner Group
20
10
0
Page 3
Check www.lessons-from-history/Project Success or Failure/
Some notable project failures during the project
implementation or into operation
 Oct. 2009, eHealth Ontario, 30 full-time employees and 300 consultants many in senior positions.
 Aug. 2009, Digital trunked radio system failures Public-Safety Radio, Technology in Government
 May 2009, Google suffers major failure, various Apps kicking back in after widespread outage
 Sep. 2008 London Stock Exchange failed for 7 hours hurting clients who trade $17.5 bn a day.
 February 2008 - American LaFrance (ALF), “leading brand of custom-made fire fighting, rescue
vehicles, and ambulances,” declared bankruptcy, blaming IBM and failed ERP implementation.
 Nov. 2007, passengers lineup terminal length (1 km), after glitch in Air Canada resv. system.
 January 2007, Sweden's largest Bank, Nordea, the biggest heist of customer accounts on record
more than $1m was stolen.
 2006 LCH.Clearnet shut down its Generic Clearing System (GCS) project at a cost of EUR67.9 m.
 2006 Maine Medicaid Claims System project 1 year on “is a disaster of major proportions. Since
the new system went live, it has cost the state of Maine close to $30 million.”
 Hershey‟s ERP implementation failure ($112m), distribution problems, 27% marketshare loss.
 The FoxMeyer Drug ERP system implementation failure led to collapse of entire $5 bn company.
 June 2004, RBC fell behind processing salary deposits thousands of Canadian workers as
millions of transactions were affected by a computer glitch that caused payroll delays.
 June 2004, an air traffic control computer failure saw massive air disruption across the UK. All
flights from UK airports were grounded after a problem at the National Air Traffic Service.
Page 4
Notable project failures during projects. Why do problems
still occur and IT projects fail catastrophically?
 August 2008 Unencrypted memory stick lost with names/dates of birth of 84,000 inmates,
England 's entire prison population. Home addresses of 33,000 who had six convictions.
 Feb. 2007 £20bn UK NHS computer system 'doomed to fail„a senior insider has warned.
 2007 laptop with records of 600,000 recruits was stolen from Royal Navy recruiter's car
 2006 Department of Homeland Security scuttles its $229m Emerge2 program (new financial
IT system).
 2005 US Justice Department stated $170m FBI Virtual Case File project a failure, after 5 yrs
& $104m. In a 18-month period, FBI gave contractor 400 requirements changes.
 2005 UK Inland Revenue gave $3.45 bn of tax overpayments because of software errors.
 April 2005 Australian inter-departmental warfare resulted in failure of $64m federal project.
 2005 British food retailer J Sainsbury wrote off $526m in automated supply-chain system.
 IRS project on taxpayer compliance took decade to complete and cost $50 bn.
 Oregon DMV conversion to new software took 8 years and public outcry killed the project.
 State of Florida welfare system plagued with numerous errors & $260m in overpayments!
 May 2005 major hybrid car manufacturer installed software fix on 20,000 vehicles. The
automobile industry spends $2 to $3 bn per year fixing software problems.
 July 2004 new welfare management system in Canada costing $200m unable to handle
simple benefits rate increase. Contract never tested this in 6 weeks of acceptance tests.
Page 5
Bad IT service performance, IT project success rates, & IT
investments are not a CIO problem affect all c-levels
 Most project management mistakes are either lack of adequate planning or
communications breakdown (among project team or with project sponsors).
• Source: Chaos, a recipe for success, Standish Group, 2008
 “…serious deficiencies in senior executive skills with IT projects. Lack of PM
skills cut benefits of IT projects by 25%.”
 “Executives are involved in selecting and approving projects, but rarely
delivering them. 49% experienced one project failure in past 12 months.”
• Source: KPMG's Global IT Project Management Survey, July 2005.
 C-levels need to understand:
– Relationship IT projects / on-line operations
– What can go wrong in complex on-line operation?
Page 8
To understand relationship between operations & IT projects
imagine yourself in 1912 in a Titanic lifeboat being rescued.
Page 9
In 1907 White Star Project Sponsor (Bruce Ismay) responded
with a strategy that leveraged emerging technology
 Invest in technology - 3 new super
liners to sweep Atlantic. First new
ships for a dozen years
 Push emerging technology to
limits.
– Steel production
– Propulsion system (steam turbine)
– Communications (phone and
wireless telegraph)
– Automated control systems
(mechanical)
 40% larger than anything else
available.
 Displacement - 52,310 tons
 Length - 882 feet 6 inches.
 Beam - 92 feet 6 inches
 Draft - 34 feet 6 inches.
 Height - 175 feet from keel to stack (the boat
deck was 60 feet above the waterline).
 Decks - 9 total, A through G with the boilers
below.
Page 10
Focus on luxury through increased space and capacity
 Address all three passage
classes, priority on first-class.
 Quality of crossing, customer
experience.
 Built for a Wednesday ship (7
versus 6 days).
Mauretania
15% faster
Page 11
Olympic
23% greater capacity
White Star‟s strategy (and business case) were based on
priority for first class space allocation
 White Star‟s class segregation =
today‟s customer segments.
 Passenger space allocated:
– 60% for 905 first-class.
– 7% for 1134 third-class.
Bridge
2rd class quarters, berths
1st class quarters, staterooms, berths
Engine rooms/Coal bunkers/Boiler rooms
Page 12
3rd class
berths
3rd class dining/kitchen
Crew
quarters
Cargo hold
Project Integration Management - Project Charter
 Developed by Project Sponsor Ismay, and Pirie
– Business reasons for project
• Transform White Star’s business model & replace aging fleet
– Luxury drives customers back, rather than speed of crossing
– Project objectives (purpose)
• Deliver 3 super liners over 7 year period
– Staggered delivery so revenue from first two ships can fund the third
– Principal considerations for ships were safety, comfort and luxury, with a
reasonably fast speed.
– Project’s criteria for success (must be measurable)
• Each ship is in operation within 4 years
• Meets terms and standards of contract
 Change Control performed
– Through contract
Page 15
White Star‟s initial Business Case was driven by revenue and
cost savings
Page 22, Fig 2.1
More space &
luxury in cabins
More frequent
service
 Case based on 70% capacity
Increase
customer
revenue
Increase
revenue
Increase
cargo
revenue
First class
More superior
service classes
Second class
More passenger
classes
Third class
Equivalent to
1st class on
other ships
Greater
capacity
Equivalent to
2nd class on
other ships
More efficient
labor, lower
wage bill
Increase
margin
Decrease
operational
costs
Decrease
costs
Fewer larger
ships
Economy
of scale
Lower provisions
bill
More efficient
Decrease
marketing
costs
Decrease
manufacturing
costs
More efficient
use of total fuel
PR around
largest ship
Lower
maintenance
costs
Fewer larger
ships
Publicity stunt
More media
coverage
Lower build
costs
Page 17
The strategy required new technology investments but the
business case was really solid
 Profitability analysis breakeven 2 yrs.
 6 year construction project.
 75% of revenue first-class.
– 1st class suite - $4,350,
– 2nd class suite - $1,750,
– 3rd class ticket - $30-46
•
Titanic‟s class segregation = today‟s
customer segments.
•
Passenger space allocated:
–
–
Page 18
60% for 905 first-class.
7% for 1134 third-class.
Project Scope Management
 Collect requirements (business)
– Deliver 3 identical super liners
– Focus on luxury (especially in first class) and
size
– Improve the current levels of service for all 3
classes
• Second equivalent to first on other lines
• Third equivalent to second on other lines
 Ismay stayed fully involved in design
development
– He played a major role in the final project
specification.
Page 19
 Define scope
– Based on previous ships but scaled up
• Tried and tested approach of keel and ribs
– Scope affected by the introduction of new emerging technologies
Page 20
 (WBS) Work Breakdown
Structure subdivision of effort
– For all 3 ships
• Design <6 months
– For each of the ships
• Construction ~ 3 years
– Launch/Internal fitting 12 months
• Sea trials < 2 months
• Maiden voyage = 1 week
• Total effort ~ 4 years
Page 21
Project Time Management
 Timeline
– For 3 ships
– Each delivery took waterfall approach
– First 2 ships built almost in parallel delivered 11 months apart
– Activities tried and tested over time
 Rolling workforce
– Use of industrial practices to build two ships in parallel
– Most effective use of workers time
 Gantt Charts
– Gantt had used his charts first time to build dreadnoughts in
1907
Page 22
The project timeline was extensive, but it had a solid ROI and
was well funded
 1907 - Vision/strategy for White Star Line
 1907 - First public announcement in September
 1908 – Design approved & Olympic's construction begins
 1909 - Titanic's construction begins
 1911 - Olympics maiden voyage in June
 1912 - Titanic's maiden voyage in April
 1913 – Britannic completed
Page 23
•ROI – year two from construction.
Staggered launch off set investments.
Project Schedule (High level)
1907
1908
1909
1910
1911
1912
1913
1914
Idea
Design
Gantry
Olympic
Construction
Launch
Sea
Trail
s
Titanic
Construction
Launch
Sea
Gigantic
Tr
ail
Construction
s
H1
H2
Page 24
H3
H4
H5
H6
H7
H8
H 9
H 10
H 11
H 12
H 13
H 14
H 15
Project Cost Management
 Most expensive activities
– Propulsion systems
• Turbines
– First and second class quarters
• Required craftsmanship of highest level
– Communications
• Marconigram equipment
 Estimated Budget
– Final cost a fixed price of £3 million for the pair was agreed at
the time of signing ($7.5 million dollars per ship)
 Control costs
– Regular audits
– Budget tracked
Page 25
Project Quality Management - Harland and Wolff
 Premium world ship builder
– Best reputation for quality
– Perceived as craftsmen
 Workforce operated within trades
– Trades based on system of guilds
 Quality control through
inspections
– Internally, within trades
• Ship builder’s model used
– Externally through Board of Trade inspectors
• with several thousand visits
 Quality Assurance
– Throughout and sea trials with final acceptance of deliverables
Page 26
Project Human Resource Management - White Star
 Sponsors
– Ismay representative
of Board of Directors
– Role to define vision
and requirements
 Operations Team
– Captain and senior
officers
– Role to complete
testing, acceptance of
deliverables and sign
off
– Crew
Page 27
Project Human Resource Management - Harland and Wolff
 Design Team
– Lord Pirrie interface to White Star
– Thomas Andrews, managing director of
design dept (responsible every drawing)
– Edward Wilding, Andrews' deputy
(responsible for design calculations)
– Laying of ships lines in mould loft
Page 28
 Construction Workforce
– Total of 15,000 organized into system of
trades, simultaneously working on six
other liners, and two White Star tenders
(Nomadic and Traffic) use at Cherbourg
– 3,000 working on project any time ~ 49
hours per week, for 50 weeks
– Alexander Carlisle managing director
shipyard
Page 29
 Construction Workforce
– Hired men – little security
• 25 shillings per week
– Established men
• 24 shillings per week
– Elite - Shipwrights (boat builders) had 7 year
apprenticeship
– Trades (skilled) - Platers, rivetters, drillers, pattern
makers, fitters, founders, smiths, boilermakers, and
electricians
– Trade laborers
Page 30
Project Human Resource Management - White Star
 Operations Team
– Captain
• Paid £1250 pa, plus £200 pa non-collision bonus
– Senior officers
• Paid £100-500 pa
– Crew - role to run ship
•
•
•
•
•
•
Page 31
Stewards, bell boys, housekeepers, maids
Paid £3 15, and relied on tips
Engineers, firemen, stokers, coal porters
Paid £5
Slept in 40 to a dormitory
Paid only when ship sailing
Project Communication Management
 Communication
– Project based at Harland and
Wolff shipyards in Belfast
– White Star offices in
•
•
•
•
London,
Southampton,
Liverpool (headquarters),
New York
– Key decisions made with
sponsors
• Finalization of design
Page 32
Project Communication Management identifies and manages
Project Stakeholders – Executive Sponsor
 1891- Bruce Ismay becomes partner in White Star.
 1899 Ismay takes over on his fathers death.
 1869-70- Harland & Wolff build first ships for White
Star.
 1894- William J. Pirrie becomes chairman of Harland
& Wolff.
 1902- White Star purchased by International
Mercantile Marine (IMM) headed by J.P. Morgan.
– IMM allows White Star to fly Union Jack, and man
ships with British crews.
 1904- Bruce Ismay becomes president of IMM, with
complete control over operation.
– William J. Pirrie also becomes a director within IMM.
– Captain EJ Smith becomes Commodore of the fleet.
Page 33
Project Stakeholders, and the roles in the project
 Project Sponsor - Bruce Ismay
– Experience in projects and operations, marketing
 Project Integrator - Lord Pirie
– Experience in projects, expert in ship building and emerging
technologies
 Project Financier/Chief Executive - JP Morgan
– Experience in financing projects (1902 - purchased White
Star Line)
 Project Manager/Chief Architect - Thomas Andrews
– Experience in projects expert in integration of
emerging technologies
 Chief of Operations - Captain EJ Smith
– Experience in operations, accepts the deliverables
Page 34
Project Risk Management
 Plan covered risks
– In project
• Define inaccurate scope (includes functional and non-functional
requirements), financials (costs/return), schedule and resources
• Select wrong integrator to meet contractual obligations
• Poor communication in project team and externally
• Integration to a single point
• Use of unproven emerging technology
• Long construction project 6 years. Changes in business model,
technology, or events
• Inadequate sea trials and failure to test
• Not transferring track record between ships
Page 35
Project Risk Management
 Potential risks
– In operation
•
•
•
•
•
Page 36
Not meeting Government regulations
White Star may accept delivery although it does not meet goals
Operational readiness and preparedness of officers and crew
Risk in the Atlantic, storms, traversing “Iceberg Alley”
Certain months like April worst month for icebergs
Project Procurement Management - contract between White
Star and Harland and Wolff
 Contract for a project to deliver two Olympic Class Liners
 Contract is delivery oriented
– Based on a cost-plus basis
• No matter how high project costs (specification changes or
increases in material costs), Harland & Wolff guaranteed 5% profit
on contract.
– Contains penalties and fees
– Standard practice in the industry
Page 37
Project Procurement Management
 Harland and Wolff
procured
– Large gantry
• Cost of £100,000
• Over 6,000 tons,
supported complicated
crane system to reach
every part of the ship
largest built in length,
height, capability.
– 200-ton floating crane
from Germany
• Cost of £30,000
• To lower ships’ massive
engines.
Page 38
Harland & Wolff had to create a new dry dock to complete
ships
Page 39
In comparison for an IT project today the project team can
minimize risks with the following techniques:
B
EST
PRACTICES
 Ensure business justification is completed.
 Ensure project charter, stakeholders are in place.
 Due diligence in business problem, competitive
services, potential costs, and risk.
 Determine by segments customer/target audience, value
propositions, create profiles and scenarios for these.
 Determine integration to existing services & data
dependencies.
 Establish service level targets to guide architect.
 Assess solutions driven by new emerging technology.
Page 40
In Titanic‟s architecture stage like in IT projects, Architects
faced many investment options
Thomas
Andrews

Harland and Wolff most expensive
craftsmen in Europe.

Created luxury liner priority first-class
functional requirements (What).

Lavish attention implied equivalency
in non functional requirements (How).

Designers choice in safety technology
– Old
• lifeboats
– New
•
•
•
•
Page 42
bulkheads,
double-skin hull,
electric doors,
automatic fog warning.
Meet certain Government regulations
 Relative to ship crossing Atlantic (3200 miles)
 Seaworthy
 Machinery (within specifications)
 Safety
– Protect all on board
 Provisioning
– Food
– Water
– Fuel
Page 44
White Star invested in ship-builder‟s model (IT pilot). Used
to analyze all exposures to the possibility of loss.

Flow analysis,
“static testing” to
review ship
characteristics,
test design, and
identify
vulnerabilities.

Sound strategy
with limited
testing options
available,
identified
problems.

Atlantic risks 400
years of travel.
Page 45
The Architects were well aware of the risks in crossing the
Atlantic. The model tested worst case failure scenarios.
 Running aground
Waterline
60 feet
Tank top
Hull bottom
7 feet
 Collisions
Grounding - flooding
contained
Within hull 73 watertight
compartments
Front-end
collision
60 feet
15 Bulkheads
Page 46
Double skin hull
Side-on collision flooding contained
Crumple zone
•1910 White Star's
'Baltic' and the
'Standard' had been in
a head on collision the
result of an eastbound
ship cutting too far to
the north.
Examples of where the bulkhead design worked. The Guion
Line "Arizona" hit iceberg going 15 knots in heavy fog 1879.
 It telescoped 25 feet of
her bow.
 She had 7 transverse
bulkheads up to the
top deck.
 The collision bulkhead
held, letting them make
Halifax.
 Increased public
perception that iron
liners were unsinkable.
 Increased industry
traffic in general, and
Arizona's ticket sales.
Page 47
Mitigating risks within the design of the ship
 Evacuation with lifeboats
48 main lifeboats
Waterline
60 feet
– The British Board of Trade Rules antiquated regulations were based on cubic feet of lifeboat space per
ton of ship not on the number of people aboard.
Page 48
Mitigating risks with visibility into the environment
 Visibility through lookouts in crows nest
– Back up lookouts on the forepeak and bridge wings
– Phone systems, telegraphs
– Submarine bells
– Main steam whistles
 Wireless Marconigram
– Ships sending/receiving telegrams
from other ships 100s of miles away
Page 49
Page 50
In the architecture stage the project team can minimize
risks with the following techniques
B
EST
PRACTICES

Walkthrough the design, to catch problems early.

Walk along critical transaction paths end-to-end.

Complete “component impact analysis” - single failure points.

Build security zones for access.

Avoid under-investing in non-functional requirements.

Avoid one technology, lack of diversity increases susceptibility.

Avoid complexity, strive for simplicity, design for manageability,
operability, scalability, performance, security, and ease of use.
Check http://lessons-from-history.com/node/83
Page 51
Titanic‟s construction stage integrated many complex
technologies and selected safety features to reduce risks

Disparate technologies integrated to single
point.

Finalized non-functional requirements.

Invest in expensive safety features (new
technology).

Over confidence in ship safety.

Perception Titanic was unsinkable.
Page 52
Decisions with esthetic factors compromised individual
safety features and escalated the level of risk
 No construction dollars diverted from
safety to enhance first-class.
 Lifeboats - 16 single vs 48 triple
stacked, uninterrupted 1st-class view.
 The double skin not continued up, only
7 feet deep, below waterline.
15 Bulkheads/16 Compartments
Page 53
Location of dining room - 15 Bulkheads (every 60 feet)
two were compromised.
 1st Class Dining Saloon
and Reception Room
(200 ft)
 Total ship length 900 ft
 Deck D dining saloon
over 100 ft (10,488 sq
ft), seating 554
 Waterline
54
3/21/2011
By end of construction Titanic‟s safety compromised
severely. But White Star believed it safest ship ever built.
 Safety
regulations for
lifeboats,
outdated
technology.
 Titanic sold at
highest safety
level, but really
passenger
safety low.
 Expensive
construction
effort
incorporated
mistakes of
earlier stages.
Page 55
Publicity continued to push the message that Titanic was
designed to be unsinkable
 White Star Line publicity brochure produced in 1910 for
Olympic and Titanic –
– “these two wonderful vessels are designed to be
unsinkable.”
 On June 1, 1911, the Irish News and Belfast Morning
News contained a report on the launching of Titanic's
hull.
– System of watertight compartments and electronic
watertight doors and concluded that Titanic was
practically unsinkable
 In 1911, Shipbuilder magazine published an article on
the White Star Line's sister ships Titanic and Olympic
– described the construction and concluded that “Titanic
was practically unsinkable.”
Page 56
Ismay‟s had another message in his marketing effort – “largest, most
luxurious, and SAFEST liners in the world.”
Page 57
In the construction stage the project team can minimize
risks with the following techniques:
B
Page 58
EST
PRACTICES

Identify building blocks (components vs prefab) and
solution alternatives (build versus buy).

Identify non-functional alternatives (safety features).

Build in cycles. Start small (prototypes), and scale up.

Tier solution, scale independently, and create redundancy.

Review Government regulations that may impact.

Ensure execs/sponsors involved through construction.
Risks in operation - faith in Olympics track record (in service
June 1911), and mitigating Titanic‟s risk - first incident
 Maiden voyage on June 14, 1911,
onboard Bruce Ismay and Thomas
Andrews.
 Olympic docked by 12 tugboats
 June 21st Hallenbeck (198 tons) sucked
under Olympic resulting in badly
damaged sternframe.
 Olympic unscathed except for some
scratches in the paint.
 Blame shifted on tugboat operator
 Page 43, Fig 4.2
Page 59
Risks in operation, Olympic‟s most serious incident, with HMS
Hawke on 20th September 1911
 Huge 45,000-tonner sucked smaller 7,350ton Hawke towards her with such power the
warship had no chance to steer away.
 Two of her aft compartments
were flooded. She was down by
the stern.

Page 60



 Her starboard main engine was
out of commission.
Olympic‟s most serious incident with HMS Hawke resulted in a
20‟ x 15‟ gash.
 Harland & Wolff's repair yard took 2
weeks to patch Olympic up to even
attempt the voyage back to Belfast.
 A gigantic patch, a big sticking
plaster, made of heavy timbers above
the waterline and steel plates below
it, was placed over the damaged hull
plating to seal up the hole.
 By the time the ship made it back to
the Belfast yard the patch on her hull
had failed and two aft compartments
were once again flooded.
Page 61
Once back at Belfast , with the water pumped out of her, she
could be properly examined.
 Repairs were costly (17% of original cost)
– Huge hour glass shaped hole in plating,
– Starboard propeller was damaged and
unserviceable,
– 18 feet of outer steel propeller shaft
covering was crushed,
– Propeller shaft was bent,
– Crankshaft of the starboard engine was
badly damaged,
– Stern propeller shaft bearings damaged.
 Frames intended to last lifetime with no
provision for replacement.
 Repairs take 4 weeks.
Page 62
October 1911 Titanic's maiden voyage is rescheduled from
March 10 to April 10, 1912.
Page 44, Fig 4.3
63
3/21/2011
Risks in operation, Olympic‟s third incident on 24th February
1912
 Lost propeller-blade during eastbound
crossing, return leg of roundtrip. Knockedoff by well-known wreck in the Grand
Banks floating beneath surface.
 Olympic sailed to Belfast for repairs and
Titanic switched out of dry dock March 2nd
 Olympic hauled out of dry dock, and turned
180 degrees where her port side bow was
grounded. Put back in dry dock for
examination.
 Back in service March 7th
Page 64
Business pressures for Titanic to go live were enormous
with large investments tied up in four-year construction.
 Questioning of
extensive sea trials
and testing were
not considered
critical partly
because Olympic
was established in
service.
 Changemanagement
theory not
established.
 Too much faith in
Olympic.
Page 65
Level of testing typically required by Harland and Wolff before
a ship was passed over to White Star
 Both organizations needed to be assured that Titanic would meet
the conditions in the contract.
 Testing gave shipbuilder opportunity for adjustments and avoid
financial penalties or having ship sent back to the shipyards.
 To fulfill contract terms of ship:
– operationally tested for seaworthiness,
– checked for stability,
– assessed for weight and loading particulars,
– check on earlier manual calculations,
– main and auxiliary machinery tested,
– Formal speed trials required achieving a certain speed under specific
conditions of draft and deadweight.
Page 66
Titanic‟s testing was very brief for a number of reasons . Page
48, Figure 5.1

Olympic was a
test bed or
yardstick for
Titanic. Debatable
how well Olympic
experiences were
transferred.
Page 67
Titanic‟s testing (sea trials) was cut down to 1 day, started on
April 2nd
 One day of sea
trials with focus
on engine &
speed, turning
with rudder, and
propellers.
 Lowering of
both anchors.
 Fine tuning of
radio equipment
 No s-turns.
 No incline
Page 68
Titanic‟s passes testing (sea trials) and gets a certificate
 Board of Trade
surveyor
Carruthers
issued the
safety
certificate and
declared her
“Good for one
year.”
 Titanic sails for
Belfast
Page 69
In the planning stage the project team can minimize risks
with the following techniques:
B
EST
PRACTICES

Review existing/previous projects with PMO for commonality.

Follow a change-management process, use risk assessments.

Plan level of testing, select right tests, and acceptance criteria.

Assign operations services ownership and control of process.

Define alternatives to launch (withdrawal), and back-out plans.

Create a test environment that mirrors live environment.

Prepare for increase in frequency of changes with the Internet.

Deploy in test environment, run parallel to live environment.

Ensure testing is broad not just on functions.
Page 70
Accepted by White Star on April. 2, 1912, Titanic raced from
Belfast to Southampton
 April 2nd at 8pm (same day as sea
trials) rushed to make second tide
into Southampton
– Chaotic 24 hours Officer Murdoch
was quoted
• “took days to get acclimatized to the
layout of the new ship.”
 April 4th arrived at White Star dock
berth #44 midnight.
 April 6th general cargo and rest of
crew are added.
 April 8th fresh food arrives, final
preparations over seen by Thomas
Andrews.
 April 10th Titanic departs on her
maiden voyage at 12:00.
Page 71
Titanic‟s testing consisted of maiden voyage cross the
Atlantic fully loaded with passengers.
 Architect on board to
collect feedback
 Hand picked 8 workers
to accompany him
 Called Guarantee
Group to tend to any
teething problems
 Only the best
employees would make
the grade and make the
voyage.
Page 72
Titanic‟s captain and officers were well aware of “Iceberg
Alley” and the associated risks.
 North Atlantic features, mild Winter,
April worst month Sailing path moved.
 Fate of French liner Niagara.
 Cunard liner Carmania felt her way
through ice dead slow for 2 hours.
Page 58, Fig 6.1
Page 73
French liner Niagara ran headlong into the ice on Thursday
evening, April 11, 1912
Page 74
J.P. Morgan Owned White Star
 Richest man in world
 His passage reinforced confidence in Titanic
 Backed out last minute due to illness, as did
the general director of Harland & Wolff.
Page 75
Ismay‟s marketing effort was to create the “event” of 1912. If
you were of importance you had to be on board
Page 76
Olympic‟s prestige
 Between May 1911-April 1912 100 articles on Olympic, 30 articles on Titanic,
mentioned in connection to Olympic. Interest in Olympic largest ship in the
world and called „a floating palace,‟ and the new „Queen of the Seas.‟
 Much comment about UK‟s need to maintain maritime supremacy, and
optimism about British shipbuilding.
 Seen as ushering new
class of large ocean
liners
 After maiden voyage
Olympic became popular
& successful
 Described by Bruce
Ismay as „a marvel‟
 Titanic seen as similar
but moderately improved
version of Olympic.
Page 77
Bruce Ismay compromised the project Service Level
Agreements shipping announcement in NY Times.
 Passengers “who‟s who” public life 300 very
famous people, 53 millionaires collective
worth $500m.
Page 78
The business pressures and pressing economic needs
pushed Titanic into service with limited testing completed.

On leaving port, Titanic (1) nearly collided with the steamer New York
(2) coming within four feet (3) indicating the challenges in operating a
very large ship.

The tug Vulcan (4) and quick thinking of Captain Smith prevented the
accident.
Page 52, Fig 5.4




Page 79
“Suction of Giant Liner Breaks Hawsers of the New York, Which
Floats Helpless” Source: The New York Times, 11 April 1912
Page 53, Fig 5.5
Page 80
The wake off to starboard confirms Frank Brown's description
of the 'winding pathway 'eor the waters'
 An irregular course
was being taken in
order to test the
compasses.
Page 82
In Cork Ireland the British board of inspectors came on
board taken out by tenders
 Board of Trade
inspector Carruthers
visited Titanic almost
2,000 times during
construction.
 Checked for adequate
– Provisions
– Water
– Fuel (coal)
Page 83
Only one lifeboat drill was performed to satisfy the British
board of inspectors.

No time was spent in preparing the crew
for the maiden voyage.

The crew of 900 had 83 mariners.

The crew was unprepared to handle a
disaster and the launch of all lifeboats.
Page 84
In the testing stage the project team can minimize risks
B
Page 85
EST
PRACTICES

Undertake business and technical risk assessments.

Ensure independent test teams - incentives to test objectively.

Establish the ability to stop an implementation if testing fails.

Ensure that major testing, once under way, can be halted.

Ensure change process strategies for rapid implementation.

Avoid change process that lacks support and “teeth.”

Avoid giving developers rights to live environment.

Refine your service level objectives and agreements.
Risks in operation – Ismays presence increases risk as he
overshadows Captain Smith‟s leadership
 Why was Ismay on board?
– Ensure ultimate customer experience.
– Beat Olympic’s best crossing time.
– Shipping announcement in NY Times.
 Relationship boss to employee
 Smith showed Niagara telegram to Ismay
 Did Smith restrain himself?
 Why was Smith so intimidated by Ismay?
Page 87
The operating stage required the deployment of the ship into
production and her maiden voyage.

Titanic had a number
of built-in feedback
mechanisms that were
discounted, fudged
(ice bucket test), or
just ignored.

The officers kept their
binoculars and did not
share them with the
lookouts, limiting
operations to provide
any early warning.
Page 88
The third feedback mechanism was wireless, up to 400 miles
range
Page 89
The operating stage saw Titanic‟s built-in feedback
mechanisms compromised on her maiden voyage

Titanic‟s built-in feedback mechanisms
– Marconigrams Operators overloaded by commercial traffic (noise) did
not pass the ice warnings (signal) along in a timely fashion.
– In the 36 hours between leaving Southampton and the collision, the
Titanic's received and sent 250 passenger telegrams.
Page 90
Risks in operation - False sense of security general
overconfidence in the ship
 Capt. Smith not posted additional
lookouts on forecastle/bridge wings.
 Conditions
– Air temperature 33 degrees F or 1 degree
C.
 The captain very resistant to technology
relied on “gut” feel and experience.
 He undermined the significance of
Marconigram information.
Page 91
Bruce Ismay determined to prove Titanic superior to
Olympic changed the SLO, dramatically increasing risks
 Ismay overrode Smith
 Pushed crew to limits.
 Captain succumbed to pressure.
 Operations mandate overriden.
 Stringent guidelines broken.
 Everything put in jeopardy.
Page 92
At 7.50 PM the MV Mesaba of the Atlantic Transport Line sent
the following telegram to the Titanic
 " In lat 42N to 41.25N long 49W to long
50.30W saw much heavy pack ice and
great number of large icebergs also
field ice. Weather good, clear."
 This telegram gave precise details of
the massive icefield already in the path
of the TITANIC.
Page 93
The two lookouts, without binoculars, hesitate on sounding
the alarm.
 No extra lookouts posted.
 Very hazy atmospheric conditions common to
large sheets of ice.
 The lookouts confused in what they see ahead.
 At least 7 minutes pass between spotting and
reporting a “dark mass” and raising alarm.
Page 94
The collision was inevitable and Murdoch almost
succeeded pulling off a brilliant maneuver.
 Feedback systems compromised.
 Ship reached peak speed 22 knots, 3 additional boilers lit.
 Californian‟s last radio message ignored.
 Lookouts gave 37 seconds warning.
 Murdoch tried to dodge iceberg and decelerate ship “S turn.”
Ice Shelf
Iceberg
Page 95
Close examination of inquiries shows officer and passenger
testimonies differed greatly.
Officer
Passenger
 Sharp side-swipe against ice
spur causes 300 foot gash. Ship
bumps along the side to a stop.
Water pumps could not keep
pace with flooding.
Page 96
 Gradual deceleration and grinding
noise like a thousand marbles.
 A “grounding” from the bottom of
the ship.
The ship grounded itself on the ice shelf and consistent
testimonies of the collision describe it as innocuous.
 “I heard this thump, then I could feel the boat quiver and could feel a sort of
rumbling..”
– Joseph Scarott Seaman
 “... It was like a heavy vibration. It was not a violent shock.”
– Walter Brice Able Bodied Seaman
 “…I felt as though a heavy wave had struck our ship. She quivered under it
somewhat.”
– Major Arthur Peuchen First Class Passenger
 “I was dreaming, and I woke up when I heard a slight crash. I paid no
attention to it until the engines stop.”
– C E Henry Stengel First Class Passenger
 “We were thrown from the bench on which we were sitting. The shock was
accompanied by a grinding noise….”
– Edward Dorking Third Class Passenger
 “It was like thunder, the roar of thunder…”
– George Beauchamp Fireman
Page 97
Unperturbed the bridge sends two assessment groups to
survey the ship for damage.
 No sharp jolt of ship slamming immovable object.
 No rebound effect.
 Breakfast cutlery in dining rooms barely rattled.
 No injuries or broken bones, no deaths.
 Ship quivered for several seconds.
Page 98
Passenger descriptions of QEII‟s grounding 1992 parallel
Titanic‟s
 QEII grounding (Cuttyhunk Island Vineyard
Sound, Ma)
– August 7, 1992 vessel sustained $13.2 million in
damages, and leaked 50 gallons of fuel oil from
empty fuel tank ruptured in incident.
 Soft landing
– At the time of the accident, the ship was making
about 18 knots.
– Her bottom was ripped open by large boulders,
but there was no violent impact.
– Just as in Titanic, the passengers of QE2 were
not thrown about by the accident.
– The lesson - grounding of a large liner over a hard
object at speed produces only a relatively mild
impact.
Page 99
U.S. Navy aircraft carrier Tarawa 1951 CRASH STOP
("reverse engines") in Straits of Messena
 Passenger ferry suddenly cut across
the warship's bow.
 "All back emergency!“
 The stern of the ship began jumping
up and down 6 feet.
 The collision was avoided.
 Next morning, dozens of crew were
sporting slings, casts and neck braces
from being flung to the deck.
 So much china was broken ship put
into port to buy more.
 In few weeks, ship drydocked to repair
damage propeller shaft.
 displacement: 27,100 tons
 length: 888 feet beam: 93 feet; width
flight deck: 147 feet
 draft: 28 feet speed: 32.7 knots
 complement: 3,448 crew
Page 100
Titanic did not run into an iceberg; it ran over an iceberg.
 An iceberg that has a length of 100 feet above the waterline can be
expected to be 120 to 130 feet wide under the water.
 The sloping ice shelves that extend outward beneath the water
pose a significant threat to ships operating near icebergs.
 Titanic's fragile underbelly scraped across an underwater shelf
called an "ice ram."
 Icebergs are typically 20% to 30% longer under the water than
above
Page 78, Fig 9.3
Page 101
Unperturbed at 11:42 the bridge sends two assessment
groups to survey the ship for damage.
 First group returns with inaccurate
report.
– Pumps where put into place to offset
minor flooding.
– Boxhall's visit to the Third Class berths
and scanty information about the extent
of damage and the ability of the pumps
to cope with the flooding.
Page 102
Bruce Ismay made fateful decision to prove Titanic could save
herself.
 At 11:50 Titanic had lost 3 holds.
 Ismay and Smith assumed their ship
was safe to steam again at 11:51.
 Ismay was not noted for his
patience.
 Ismay‟s dilemma and options.
 At 8 knots ship would arrive in
Halifax (450 miles away) on
Wednesday.
Page 103
Further evidence of restarting engines and the ship moving
after the grounding.
 First wireless to White Star office in NY.
– “TITANIC PROCEEDING TO HALIFAX. PASSENGERS WILL PROBABLY
LAND THERE WEDNESDAY; ALL SAFE. SMITH,” True at 11:53 pm.
 White Star had dispatched trains to Halifax, but these were
cancelled well after the ship had foundered.
 Wireless Radio Operator
Philips sent a message to
his parents 12 minutes
after the grounding
“Making slowly for
Halifax. Practically
unsinkable. Don‟t worry.”
 Hitchens was kept at the
wheel for more than 40
minutes after the
accident.
Page 105
Second assessment group returns.
 Second group returned
– (architect and carpenter).
 At 12:00 Captain makes an
inspection.
 Pumps not keeping up with
flooding.
 Architect predicted 2 hours.
 Engines stopped at 12:09.
 Ship was hogging, and
tearing itself apart.
Page 107
In the operating stage the project team can minimize risks

Ensure the business/operations refine SLAs,
and adhere these.

Structure support for holistic client view of
service, avoid technology silos, assign
operations sole responsibility.

Build problem-management processes around
recovery clock.

Base proactive problem-avoidance around early
warning system.

Synthesize/route timely feedback to decisionmakers.
Page 108
B
EST
PRACTICES
And take a comprehensive approach to organization,
processes, and tools, a basis for continuous availability:
B
EST
PRACTICES

Monitor strategic components critical to availability.

After implementation monitor whole environment.

Investigate environmental anomalies quickly.

Identify meaningful metrics “User outage minutes” vs 99.999%.

Re-evaluate initial business case with returns and metrics.

Avoid claiming a project success too soon.
Page 109
Officers and crew operated in state of disbelief unable to
perform effective recovery. Panic ensued amongst
passengers.

Disaster assessment - 20 mins

65 mins before lifeboats ordered filled.

Hierarchical structure, physical segregation,
skeptical crew impeded information flow.

Passengers got up, went back to bed.

First life-boat left half full reluctance to get in.

Launching 16 lifeboats took over 90 minutes.

Recovery plan would have been poorly
executed.
Page 110
Evacuation in lifeboats (#s) many of the early launched
lifeboats were half empty
Boat
#
Time of
launch
Total
People
Boat
#
Time of
launch
Total
People
6
12:55
28
7
12:45
27
8
1:10
39
5
12:55
41
10
1:20
55
3
1:00
50
12
1:25
42
1
1:10
12*
14
1:30
63
9
1:20
56
16
1:35
56
11
1:25
70
2
1:45
26*
3
1:35
64
4
1:55
40
4
1:35
70
D
2:05
44
C
1:40
71
B
Floated off
A
Floated off
* Emergency boats with 40 person capacity
The last 2 Englehardts were floated off
upside down.
Page 111
In the operating stage the project team can minimize risks
B
EST
PRACTICES

Ensure disaster recovery enacted according to plan and
without hesitation.

Ensure disaster recovery plans accessible to organization.

Nominate 1 group guardian (ops) of disaster recovery plan.

Ensure staff adequately trained to follow disaster recovery
plans.

Practice and rehearse disaster recovery plans regularly.
Page 112
U.S. and British Titanic inquiries were set up in competition
to each other
 President got no response from Carpathia, sent navy
which failed to get further information
 U.S. Inquiry set up when disaster numbers known
– Started one day after ship landed, Friday 19th April, 1912
 British Wreck Commissioner‟s Inquiry
– Set up to start Monday, 22nd April, 1912
 Competition between two which more thorough
http://www.titanicinquiry.org/
Page 113
Following disaster U.S. and British authorities conducted
post-mortems. The U.S inquiry came close to uncovering
cover up.
 US inquiry 82 witnesses, specialists,  British inquiry saved White Star from
technical experts.
bankruptcy.
 Determined ship reached top speed,  European war looming.
no attempt to slow down.
 Condemned Captain Lord for not
 Forced Bruce Ismay to stay in U.S. &
responding to flares.
grilled over role.
 Criticized British Board of Trade for
Recommended
lifeboat regulations.
•
Page 115
Lifeboat space for
every person on all
ships from U.S.
ports;
•
lifeboat drills;
•
adequate manning
of boats;
•
24-hour operation
of radiotelegraph.
 Titanic unnerved western society‟s
faith in technology.
 Olympic, served 24 year career.
Fate of Olympic – went through a refit
 Already in service for 10 months
difficult to modify
 Provided with full compliment of
lifeboats
 Dry-docked for installation of inner
watertight skin
 Watertight bulkheads extended up to
"B" deck
 Ready by the spring of 1913 & back in
service
 Olympic, served distinguished 24
year career before being scraped.
 Evaded torpedoes in WW1
Page 116
Fate of Britannic – went through a refit, with substantial
increase in lifeboats
 Britannic, served as hospital ship
and sunk by mine in 1916
 New giant sized lifeboat davits
capable of holding 3 lifeboats
 Full compliment of lifeboats
 Bulkheads top to bottom
Page 117
Lessons learned - what can you take from all this. Your IT
project is little different to Titanic‟s project.
 Roots of Titanic‟s disaster in project,
compromises to safety features and
elevation of expectations allowed
business pressures to override
operational procedures.
•
Page 118
This lead to numerous violations of
the “rules of good seamanship”.
Probability of failure very high
because of inability to recognize
introduced risks.
Mitigate risk from the project outset through the application
of best practices at each IT project stage
Executive Sponsor
 100s of best practices listed by project stage:
1. Project life cycle, deliverables and iteration
2. Business case for an online operation
3. Mission critical application dependencies
4. Architectural models and frameworks
5. Enterprise application integration and interdependency
of data
Bruce
Ismay
B
6. Organizational and process elements
7. Change and problem management
EST
PRACTICES
Project Team
8. Use of metrics, service levels objectives and
agreements
9. Use of automation and Early Warning Systems
10. Disaster recovery & business continuity plans
Implementation of one best practice can save
thousands of pounds
Page 120
Thomas
Andrews
Questions
This presentation will be available on-line
Mark is available to work with you and your
organization (PMs and Executives), speak
or run workshops.
Sign up for a lessons-from-history newsletter (subscribe/unsubscribe).
Page 121
What is Lessons From History?
 Lessons From History is a publishing imprint for a series of
publications for today‟s business world.
 This series of business publications is based on historical
case studies.
122
Overview of Lessons From History
What does Lessons From History do?
 The series uses relevant historical case studies
to examine how projects and emerging
technologies of the past solved complex
problems
 The series then draws lessons for today‟s world
 The series is designed to inspire people
 The historical case studies are significant,
unique and inspirational
 It makes the whole learning experience more
memorable.
 The series should inspire the reader as these
historical projects were achieved with a lesser
technology.
123
What is Lessons From History based on?
 In 1978 James Burke showed an alternative way to view
history
 Connections was the weaving path through history to 8
of the most significant inventions
 It describes a process
– Where ideas are developed but then put on the shelf.
– The time is not right or the technology required for further
evolution not available.
– At a future the ideas are picked up again and reused.
– This time it succeeds into a stupendous result.
 Lessons From History uses a similar approach
– It connects today’s project with historical projects and best
practices that permeate across projects
124
How did Lessons From History originate?
 In the aftermath of a major project disaster trying to convince a senior
executive in a bank to make the right decisions and investments
 The use of a story set the project on the right path to success
 “Whilst recovering a failed
Financial Services project I first
used the Titanic analogy to
explain to business executives
why the project had failed.
 The business executive was
flabbergasted that the project
had failed in operation.
 The project originally cost $2m
and took 1 year.
 The project recovery cost $8m
and took 2 years.” 1994
125
Why was Lessons From History evolved?
 The story became a powerful learning lesson
 It resonated with people
 Lessons From History provided a vehicle for
individuals to have discussions about the
intangibles of projects and business, things
difficult to classify and talk about
 It made it safe way to talk about issues without
disclosing an organizational name or
individuals
 People enjoyed the stories
126
Who is Lessons From History for?
 Business organizations and people
– For example, profits, NPO, private, public
 Universities and colleges
 Professional Associations
– Project Management Institute
– Association of Project Management
– Professional Engineering Organization
– Certified Information Professionals
– British Computer Society PROMSG
– Data Architects Management Association
– International Institute of Business Analysts
– APICS
– CSCMP
127
The Lessons From History series is part of the
Project Management course
 Project Lessons from the Great
Escape is integrated into:
– ICT 4115 Project Management
Dynamics
– It has been used in 5 classes to date
– 2009 to 2011
– Over 80 students
 Course Instructor
– Raymond Kaufman
–
128
[email protected]
Ray Kaufman talks about how the Great Escape
book helps students learn?
 “The book is a quick read and the
movie paints a visual story. We
can identify with the characters
and understand their plight and
struggles. That frames the need
for project management. It
provides motivation to find out the
ending. While they are on that
journey they read examples of
problems and how they were
overcome using the project
management framework. They can
judge if they would make the same
mistakes or could fix the
problems.” RK
129
The team
 Growing group of authors
 All business people
– project managers and architects
 All share common passion for history
 Much collaboration
130
The Lessons-from-History series
 Available at http://www.mmpubs.com/catalog/lessons-fromhistory-c-4.html
 Or call 1-866-721-1540
 Please contact MMPUBS
131
Where is Lessons From History going?
 LFH is developing into a series of books and presentations
that are the foundation to learning experiences
 Future catalogue
 Lessons in Project Leadership from the Manhattan Project
by John Byrne
 Governance in Times of Challenge
by Glenn Le Clair and Mark Kozak-Holland
 ITIL Case Study: The Launch of the Titanic
by Glenn Le Clair and Mark Kozak-Holland
 Legendary Leaders: Project Management Case Studies
by Joe Luttrell and Mark Kozak-Holland
132
Quotes
 Quotes on events
– "This was one of the most enjoyable professional events I've attended in a long time. It was
fascinating to learn that the problems involved in working with new technology haven't
changed much over the years."
– Brian Baskerville, OSQA Logistics
 Quotes on books
– If we could somehow get this type of writing about history into the public schools I think that
children would only learn facts about significant events, but would also retain it because all
the wonderful examples. I really feel that I learned not only some history about the great
escape, but also see the PMBok applications that were used. This is a great method of
teaching and learning!!
– by Eric Peterson, January 17, 2009
 Publisher is MMPUBS
– An ideal publisher with a very strong track record in project
management
133
Wrap up
 “What Mark has done with The Great Escape is transform it
into a brilliant case study of how PMBoK can be applied to
almost every sort of venture,”
– said David Barrett, ProjectWorld organizer and executive
director of the Schulich Executive Education Center.
 “This year he conducted a seven hour marathon workshop
that was not only an incredible dissection of history, but it
addressed the most pressing problems confronted in
business operations today. How to be innovative and
survive. How to draw maximum output from talented staff.
Managing impossible obstacles. The parallels are all there.”
134
Credits and Sources
 1998 MERIT Project. Best Practices in Enterprise Management.
 Bonsall, Thomas E. Great Shipwrecks of the 20th Century. New York: Gallery Books.
 Bristow, Diana. Titanic: Sinking the Myths.
 Brown, David. The Last Log of the Titanic. McGraw-Hill.
 Davie, Michael. The Titanic: The Full Story of a Tragedy. The Bodleyhead Ltd.
 Hyslop, Donald, Alastair Forsyth, and Sheila Jemima. Titanic Voices. New York: St.
Martin‟s Press, 1998.
 Lord, Walter. A Night to Remember. New York: Holt, Rinehart, & Winston, 1955.
 Lord, Walter. The Night Lives On. New York: Holt, Rinehart, & Winston, 1985.
 Spignesi, Stephen. The Complete Titanic. Birch Lane Press Group, 1998.
 Thompson, Harvey. Customer Value Management. McGraw-Hill, 2000.
 Wade, Wyn Craig. The Titanic: End of a Dream. New York: Rawson, Wade, 1979.
 Wels, Susan. Titanic: Legacy of the World‟s Greatest Ocean Liner. Alexandria, VA:
Time-Life Books, 2000.
 Illustrations were used courtesy of the Ulster Folk & Transport Museum
Page 135

What is Lessons From History? - Association for Project Management

Transcription

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Saving the Titanic: Could Damage Control Have Prevented the

Passenger ship safety since 1912

Inquiry Curriculum context planning form Titanic - imaginative