Category Archives: Forensics

WAS PRINCESS DIANA REALLY A HOMICIDE VICTIM?

It’s been 20 years since Diana, the Princess of Wales, was killed in a horrific car crash. This tragic event ended of one of the world’s most famous people’s life. It shocked everyone. Millions lined London streets paying respect to her funeral procession. Over 2 billion watched her funeral on TV. But Princess Diana’s death was far more than a loss to the world. It left her two young boys without a mother.

Circumstances surrounding Diana’s death are exhaustively investigated. Everyone knows basic facts that Diana and her new boyfriend, Dodi al-Fayed, were leaving a Paris hotel for a private apartment and trying to avoid the ever-present Paparazzi. They got in the back seat of a Mercedes sedan driven by Henri Paul—a hotel security agent. Diana’s bodyguard, Trevor Rees-Jones, rode shotgun in the passenger front.

But exactly what happened next is still cloudy. To escape prying eyes and cameras out front of the Ritz Hotel, the four used a rear escape route—sneaking away to the apartment. Several Paparazzi members clued in. They raced to follow. As the Mercedes entered the Pont de l’Alma road tunnel along the Seine River in central Paris, Henri Paul somehow lost control and smashed head-on into a solid concrete column.

The car was destroyed. Henri Paul and Dodi al-Fayed were dead at the scene. Princess Diana passed away from massive internal injuries two hours later. Only Rees-Jones survived. However, he had no recollection of what happened.

Those are the bare case facts. There were two extensive investigations. One by the French police and one by the British authorities who held a public inquest. Both inquiries concluded Diana’s death was from her fatal injuries—the result of a drunk-driving, motor vehicle incident with excessive speed a contributing factor. So was Diana’s neglect to wear her seat belt.

And both inquiries viewed the pursuing Paparazzi as a non-direct, contributing factor despite five photographers charged with manslaughter and three others prosecuted for obstructing justice and violating human rights. No one was convicted. But that didn’t end speculation that Princess Diana was murdered. In fact, Lord Stevens who oversaw the British inquest stated, “This case is substantially more complicated than once thought.”

Rumors ran rampant. There were stories of Paparazzi intentionally overtaking the Mercedes and cutting it off into the column. There’s an unresolved issue of a notorious white Fiat that’s never been found. The Royal Family were accused of masterminding Diana’s murder because she’d been impregnated by a Muslim foreigner. Even the British SAS and MI6 were implicated. And most accusatory was Dodi’s father, Egyptian billionaire Mohammed al-Fayed.

But where was proof the Peoples’ Princess was really a homicide victim? Well, two decades later it turns out that the homicide declaration was right all along. And the evidence—the undisputed truth that Princess Diana really was a homicide victim—is absolutely clear.

Facts Surrounding Diana’s Car Crash

Although Princess Diana and Dodi al-Fayed were officially an item, they’d only been seeing each other just over a month. That’s hardly enough time to get engaged let alone planning a pregnancy. Diana was far too smart than getting accidentally knocked-up never mind rashly getting married. Both of those stories are blatantly false.

They rendezvoused on Mohammed al-Fayed’s yacht before arriving by private jet into Paris on August 31, 1997. Then dined at a popular restaurant before dropping by the Ritz Hotel where the Paparazzi laid in wait. Diana and Dodi had a nightcap. Rees-Jones was nearby. Henri Paul made a plan to bring the staff Mercedes around to the rear door where the celebrity couple could quietly slip out. Then, Paul would chauffeur the group to a private apartment that Mohammed al-Fayed kept in the heart of Paris.

The plan almost worked. Unfortunately, the Paparazzi were crafty. They set several sentries out back. Diana and her entourage were spotted as they sped away. The time was approximately 12:20 am Paris time. Three minutes later, at 12:23, the Mercedes entered the Alma tunnel. Henri lost control and the Mercedes swerved to the left or driver’s side. It hit a concrete column support with such force the engine was shattered and the radiator shoved through to the front seat.

The Mercedes rotated 90 degrees counterclockwise and rocketed backward into the right tunnel wall. It came to rest but was so severely damaged that emergency responders had to cut off the roof in order to extract the crash victims. It was 20 minutes before Diana was freed.

By this time, the Paparazzi were present in full force. Some were arrested. Some had their cameras confiscated after taking gruesome victim death photos. The scene was nearly impossible to control, especially as word spread about who the famous victims were.

Emergency personnel reported that Princess Diana was semi-conscious when they arrived. She softly cried “Oh my God”—repeatedly—and said, “Leave me alone.” By the time Diana was pulled from the wreckage, she’d gone unconscious. Then she suffered acute cardiac arrest when laid on a stretcher. Her heart was restarted by manual resuscitation however her blood pressure severely dropped on route to the hospital.

Diana arrived at the emergency department approximately 2:06 am. That was an hour and a half after impact. She was still breathing and displayed a weak pulse. X-rays immediately determined she had massive internal bleeding. A thoracic surgeon incised her interior to drain the blood then found her heart’s left ventricle was lacerated. While suturing this main blood vessel, Diana went into full cardiac arrest. Extensive resuscitation efforts by the trauma team failed to revive her.

Diana—the Peoples’ Princess—was Declared Dead at 4:00 am.

The bodies of Henri Paul and Dodi al-Fayed were taken to the city morgue. It was a separate building adjacent to Diana’s emergency ward. Because of the massive crowd now assembling outside the hospital, the Paris coroner felt disrespectful removing Diana’s body past the crowd. He conducted an external examination in a private hospital room but didn’t order a full autopsy. The medical cause of Diana’s death was abundantly clear.

This left the problem of keeping Diana’s now-decomposing body in a warm room. The ER had no cooler. Pursuant to French law, the coroner legally authorized Diana’s embalming to retard decomposition while transportation arrangements were made to take her body to England. This was the right thing to do but led to fuel conspiracy theories, some which abound today.

Full autopsies were conducted on Dodi al-Fayed and Henri Paul. Both clearly died of internal injuries—both suffering severed aortic arteries which are immediately fatal. They had both been on the driver’s side which absorbed more of the impact. This explains why Diana was not killed instantly and why Rees-Jones walked away. His front airbag deployed but there was none in the back to protect the Princess.

Toxicology Testing on Henri Paul Found Interesting Results.

These are Henri Paul’s official and reliable toxicology results. They were later confirmed to be his through DNA testing to dispell accusations of evidence tampering.

Blood Alcohol Count (BAC) — 174 milligrams per 100 milliliters of blood or commonly termed a BAC of 0.174% (This was corroborated by his vitreous humor or eye fluid count being 0.173%, his urine being 0.218% and his stomach BAC being 0.191%.)

The legal BAC limit for impaired driving in France is 0.05% making Henri Paul 3 times over the drunk driving tolerance limit.

Small traces of the anti-anxiety medication fluoxetine were noted but were well within the therapeutic range. So was the medication tiapride. Carboxyhemoglobin and nicotine levels proved Paul was a heavy smoker.

Examination of the Wrecked Mercedes

Although the Mercedes was a total write-off, it was sufficiently sound to inspect. There were no mechanical defects found mechanically contributing to the crash. One tire was punctured but wasn’t a blowout. It happened because of impact. The brakes and steering were sound and the car was only two years old with low mileage.

Thorough testing was done on the seatbelts. All were in perfect operation. It was obvious none of the occupants were wearing their restraints, however, it’s questionable if Paul or al-Fayed would have been saved given the massive force of the left side impact. Overall, there was nothing mechanically wrong with this vehicle that made it veer hard so hard to the left.

So what caused the Mercedes to spin out of control? Did the Paparazzi cut it off? Did the mysterious white Fiat force it into the column? Why did a perfectly good car fail and, by the way, just how fast was the Mercedes traveling?

Totally fraudulent information circulated for years about the Mercedes traveling at 120 mph (190 kph) when it hit the column. Proof of this—they said—was the car’s speedometer sticking at that measurement. That’s rubbish. Total bullshit, like so many myths surrounding Princess Diana’s death. Truth is the Mercedes was doing 65 mph (120 kph), +/- 5 mph, when it hit the column. This was established by a meticulous accident reconstruction conducted by the French police.

Still, this is a significant velocity given the Mercedes’ gross vehicle weight with 4 passengers being over 4,000 lbs (1815 kg). The kinetic energy transfer of this weight multiplied by high speed resulted in Diana’s heart being—literally—ripped inside her chest. It’s surprising Diana lived as long as she did.

The real reason Henri Paul lost control is hidden in the details of the accident reconstruction report. It’s written in technical jargon but clearly understandable. There were no skid marks indicating pre-braking. No out of control swerve. One moment the car was going fast and straight. The next it cut sideways.

The Answer is in Tunnel Design and Vehicle Dynamics.

The Alma tunnel has a posted speed of 20 mph (30 kph). That’s for a good reason. The tunnel is low and narrow. It also sharply dips at the entry and is protected by a perpendicular drainage grate to keep the flat area from flooding with water.

The collision reconstruction analyst deduced when Paul declined the entry ramp and struck the bumpy metal grate at 65 mph, the Mercedes reacted by going slightly airborne. This reduced the road surface friction adhered by the tires, effectively causing a dry hydroplane incident. The analyst surmised that Paul, in his impaired state, never braked but misjudged an overcorrection and simply steered the fast-moving Mercedes into the column.

The Operation Paget Report

Many people who followed Princess Diana’s death story don’t know about Operation Paget and its incredibly detailed 871-page report. Operation Paget was a London Metropolitan Police special task force detailed to investigate conspiracy and murder allegations involving the Princess’ tragic end. They also addressed cover-ups. You can download it here.

The British inquest overseen by Lord Stevens relied heavily on the brilliant work uncovered in Project Paget. The police went to amazing lengths dealing with every listed allegation. They fairly answered with truth. They dispelled insinuations of government plots and sinister cover ups.

They established a fact—there were no credible eye witnesses to the crash and pursuing Paparazzi were nowhere in sight when the impact occurred. They even dealt with the white Fiat nonsense by pointing out white paint on the Mercedes door was probably from a previous parking lot incident.

As much as everyone wants to blame the Paparazzi for killing Princess Diana—well, that’s just plain wrong. Certainly, Paparazzi presence was a contributing factor as Paul was no doubt driving this speed to evade them. One can’t blame the Spencer family and Diana’s two sons, Princes William and Harry, holding the Paparazzi responsible for essentially murdering their beloved Diana. That’s a natural emotional response. But the Paparazzi, as individuals or as a  group, are innocent.

The truth is Diana, the Princess of Wales, was no accident victim. Her death was clearly a homicide. Let me explain.

On April 7, 2008 Lord Stevens’ inquest returned a verdict. They ruled Princess Diana was the “victim of an unlawful killing by the grossly negligent chauffeur, Henri Paul, who’s driving ability and judgment were severely impaired by alcohol”. The secondary contributor to Diana’s death was her failure to buckle up. Not the Paparazzi.

The jury made no mention of Diana’s death being an accident. That’s because they couldn’t rule it an accident. Death classifications are universal throughout the civilized world. Coroners and their juries have only five classifications to choose from: Natural, Accidental, Suicide, Homicide and Undetermined.

You can immediately rule out Princess Diana’s death as natural, suicide and undetermined. The cause and means of Diana’s death are clear. She died because of internal bleeding and hypovolemic shock resulting from injuries received in her car crash. That’s clear. What’s not clear to most people is why this can’t be classified as an accidental death. It’s because of the legal definition of homicide.

Homicide means a person dies because of direct actions by another person. A homicide classification doesn’t necessarily mean a culpable or intentional killing of one person by another. It includes lesser degrees of acts like manslaughter and criminal negligence that cause death. Homicide also includes deaths that result from any form of a criminal act including impaired driving. Henri Paul was criminally drunk and grossly negligent. He directly caused Princess Diana’s death.

That makes the Peoples’ Princess a homicide victim.

*   *   *

SUN DANCE — FATAL LAST WORDS FROM FAMOUS FOLKS

Ordinary people have a sun dance fascination with famous folks. They worship bright lights but rarely waltz with military heroes and historical figures. Same with movie stars like Sundance’s Robert Redford. Sports jocks are honored. Some politicians are revered. So are daredevils. Religious and spiritual leaders. Business successes. Inventors. Philanthropists. Chauvenistic cooks and reality TV show hosts. Even the odd crime writer has their day of fame and following. Some people are famous for being famous like the Kardashian Klan but most in the spotlight have earned it. Some are good folks. And some are disastrous. Like those in the fatal sun dance between Sitting Bull and Custer with his men of the United States 7th Cavalry. 

It’s not surprising when celebrities check-out and say goodbyes that the unwashed masses take notice. Some last words from dying demigods are inspirations from the departed. Some deathbed utters are foundations for lasting legacies. And some dying words are just plain stupid or hilariously funny.

In no particular order of importance — except for the last oneread to the end — here are a few fatal words from famous people checking-out.

Diana, Princess of Wales – “My God. What’s happened?”

John Lennon – “I’m shot.”

Bob Marley – “Money can’t buy life.”

Curt Cobain – “It’s better to burn out than to fade away.”

Terry Katch (Rock musician) – “Don’t worry, it’s not loaded.”

Humphrey Bogart – “All you owe the public is a good performance.”

Joe DiMaggio – “I’m finally going to see Marilyn again.”

Elvis Presley – “Just a minute. I have to go to the bathroom.”

Leonard Nimoy (Spock’s last Tweet) –  “A life is like a garden. Perfect moments can be had, but not preserved, except in memory. LLAP.”

Bing Crosby – “That was a great game of golf, fellers.”

Oscar Wilde – “Either that wallpaper goes or I do.”

Hunter S. Thompson – “Relax – This won’t hurt.”

Adolph Hitler –  “I myself and my wife – in order to escape the disgrace of deposition or capitulation – choose death. It is our wish to be burnt immediately on the spot where I have carried out the greatest part of my daily work in the course of a twelve years’ service to my people.”

Robert Alton Harris (California Gas Chamber, 1922) – “You can be a king or a street sweeper, but everyone dances with the Grim Reaper.”

William Somerset Maugham – “Dying is a very dull and dreary affair. My advice to you is to have nothing whatever to do with it.”

Surgeon Joseph Henry Green – “Stopped.” (Checking his own pulse as he lay dying.

Salvador Dali – “I do not believe in my death.”

Queen Elizabeth I – “All my possessions for a moment of time.”

Errol Flynn – “I’ve had a hell of a lot of fun and I’ve enjoyed every minute of it.”

John Quincy Adams – “This, is the last of earth. I am content.”

Buddha – “Work hard to gain your own salvation.”

George Bernard Shaw –  “Sister, you’re trying to keep me alive as an old curiosity, but I’m done, I’m finished, I’m going to die.”

Erskine Childers (Irish Nationalist facing firing squad) – “Take a step forward, lads. It will be easier that way.”

Che Guevara – “I know you have come to kill me. Shoot, Coward. You are only going to kill a man.”

Julius Caesar – “Et tu, Brute?”

Leonardo Da Vinci – “I have offended God and mankind because my work did not reach the quality it should have.”

Thomas Edison – “It is very beautiful over there.”

Karl Marx – “Last words are for fools who haven’t said enough.”

Sir Winston Churchill – “I’m bored with it all.”

Luciana Pavarotti – “I believe that a life lived for music is an existence spent wonderfully, and this is what I have dedicated my life to.”

Crazy Horse – “Hokahey! Today is a good day to die.”

James W. Rodgers – “Bring me a bullet-proof vest.” (Asked for a last request when facing a Utah firing squad in Utah.

Dylan Thomas (Welsh poet) – “I’ve had 18 straight whiskies. I think that’s the record!”

Alfred Hitchcock – “One never knows the ending. One has to die to know exactly what happens after death, although Catholics have their hopes.”

Charles Darwin – “I am not the least afraid to die.”

Thomas J. Grasso –  “I did not get my Spaghetti-O’s. I got spaghetti. I want the press to know this.” (Convicted murderer using his last words to complain about his last meal.)

Amelia Earhart – “Please know that I am quite aware of the hazards. Women must try to do things as men have tried. When they fail, their failure must be but a challenge to others.” (Last radio communiqué before her disappearance.)

George Washington – “It is well, I die hard, but I am not afraid to go.”

Prophet Mohammed – “Oh Allah. Pardon my sins. Yes, I come.”

Jesus Christ – “It is finished. Father, into your hands I commend my spirit.”

Francis ‘Two-Gun’ Crowley (Texas Electric Chair, 1931) – “You sons of bitches. Give my love to mother.”

George Armstrong Custer (Lieutenant Colonel – Brevet General, U.S. 7th Cavalry) – “There aren’t enough Indians in the world to defeat the 7th Cavalry.”

General John Sedgwick – “They couldn’t hit an elephant at this distance.”

Crowfoot (American Blackfoot Indian Orator) – “What is life? It is the flash of a firefly in the night. It is the breath of a buffalo in the winter. It is the little shadow which runs across the grass and loses itself in the sunset.”

General Philip Sheridan – “The only good Indian is a dead Indian.”

General Alfred Terry – “Now Custer, Don’t get greedy.”

Custer – “Holy cow! Look… at all… the fuckin’… Indians.

There’s an untold story about Custer and his death at the last stand. It’s about the American Indian Sun Dance and how the immense psychological impact on native warriors was the root cause of Why Custer Really Lost The Battle of the Little Bighorn.

What started as a blog post about forensic evidence found at archaeological excavations on the Little Bighorn Battlefield National Monument in southern Montana turned into a book. For years, I’ve researched a subject that fascinates me. Why did a small, old-west American skirmish become a huge historical happening?

The answer is because the white society of the time simply couldn’t comprehend how a crack cavalry unit led by a fearless, military genius like “Boy-General” Custer being wiped out by a bunch of primitive savages. Well, Custer was no genius and the Sioux and Cheyenne were not primitive. Nor were they savages. That’s a myth. It’s bullshit. It’s part of 140 misleading years of Custermania.

While reading accounts of the Little Bighorn Battle, I came across a quote. “Custer’s troops instantly changed from offense to defense and were immediately overrun by an overwhelmingly aggressive force”. I stopped and said, “What instantly and immediately changed?

The fight changed because of a complex and universal mindset the Sioux and Cheyenne soldiers had. Their Cavalry opponents had no concept of it. That’s the mental clarity and collective consciousness a determined human force has when psychologically prepared and dedicated to a greater purpose. Sitting Bull’s leadership through Sun Dance ceremonies properly prepped his men. They broke their opponent’s will to fight and supercharged their own. That’s Why Custer Really Lost the Battle of the Little Bighorn.

In the late 1800’s, U.S. Government policy of genocide on indigenous citizens was a crime against humanity. Custer’s defeat solidified a Euro-American mentality that demanded revenge on native people. The Little Bighorn was a pivot point. It led to century-long injustice from white on red that’s slowly being repaired. Sun Dance Why Custer Really Lost the Battle of the Little Bighorn is a small step towards helping people understand the insightful and emotionally powerful impact the Sun Dance had on Custer’s foe. The Sun Dance caused Custer’s annihilation. It’s an incredibly powerful force and a universal lesson we need to learn.

If anyone would like an Advanced Reading Copy (ARC) of Sun DanceWhy Custer Really Lost the Battle of the Little Bighorn — I’d be happy to give you one when it’s ready. Just email me at garry.rodgers@shaw.ca.

 

FATAL FLAW – WHAT REALLY CAUSED THE TITANIC TRAGEDY

t29The R.M.S. Titanic was the world’s largest man-made, mobile object when the ship was commissioned in 1912. Everyone knows the Titanic hit an iceberg in the North Atlantic and sank within 2 hours and 40 minutes. It was the highest-profile marine disaster of all time and most people still blame the accident on the iceberg. What few people know is the real root cause — the fatal flaw that sunk the Titanic and killed over 1,500 people.

There were two official inquiries into the Titanic’s sinking. Both concluded the iceberg was the root cause, although the investigation processes considered many contributing factors — natural, mechanical, and human. There were errors found in the Titanic’s design, production, navigation, communication, and especially in the motivation of its builder, the White Star Line. While fingers were pointed, no blame was attached and the only real outcome of the Titanic inquiries was adopting the International Convention for the Safety of Life at Sea (SOLAS) that still governs marine safety today.

t11The Titanic accident investigations used the best resources of the time however, the inquiries were conducted long before the wreckage was found, a forensic analysis was applied, and computer-generated recreation was available. Today, we have a clear picture of exactly how the Titanic disaster took place from a mechanical perspective but finding the root cause has remained buried as deep as its bow in the muddy bottom. It shouldn’t be, because the true cause of what really sunk the Titanic is clearly obvious when analyzed objectively.

Both official inquiries into the Titanic sinking called sworn testimony of the surviving crew members, passengers, rescuers, builders, and marine regulators. They used an adversarial approach that was common for investigations at the time. That involved formulating a conclusion — the iceberg — then calling selective evidence and presenting in a way that supported the iceberg findings.

t28One investigation by the U.S. Senate concluded the accident was an Act of God — the iceberg was a natural feature and shouldn’t have been there under normal conditions. The second investigation by the British Wreck Commissioner agreed with the natural cause conclusion but qualified it with a statement, “What was a mistake in the case of the Titanic would, without a doubt, be negligence in any similar case in the future“. In other words, “In hindsight, it shouldn’t have happened and we’re not going to tolerate it again.”

Both twentieth-century investigations concluded that when the Titanic collided with the iceberg, a gigantic gash was ripped in its hull allowing massive water ingress and compromising the ship’s buoyancy. At the root of the accident, they found the cause to be simply the iceberg.

They were wrong and failed to identify the real cause of the Titanic tragedy.

t31

Today’s professional accident investigators take a different approach to fact finding. They take a “Root Cause Approach” to accident investigation and the industry leaders in Root Cause Analysis or Cause Mapping are the front line company Think Reliability.

t9Think Reliability has done a root cause analysis of the Titanic sinking that’s outlined in an instructional video and a detailed event flow chart that identifies over 100 points of contributing factors. They’re excellent presentations but even Think Reliability missed a few contributors and did not categorically identify the one fatal flaw that caused the deaths of so many innocent people.

In getting to the root cause and finding the fatal flaw, it’s necessary to look at the stages of how the Titanic came to be and then determine exactly what caused it to go down.

History of the Titanic

The Royal Mail Ship Titanic was one of three sister vessels planned by the British ocean liner company, White Star Line. The Olympic was commissioned in 1910 and already in operation when the Titanic was under construction. A third ship, the Britannic, was in planning.

t23The Titanic’s construction was under an extremely tight timeline. Politics were at work, as was economics. Transcontinental ocean travel was rapidly expanding and the once-dominated British control on this lucrative industry was being threatened by German built and operated liners. In protective reaction, the British Government decided to subsidize White Star’s competitor, the Cunard Line. This left White Star resorting to private funding in order to compete and it came from American financier, J.P. Morgan, who put tremendous pressure on White Star to perform.

Harland & Wolff shipbuilders in Belfast, Ireland, built the Titanic. She was 883 feet long, stood 175 feet to the top of the funnels from the waterline and weighed 46,329 tons in water displacement. Her keel was laid in March, 1909, and was set to sea trials on April 2, 1912. Eight days later, on April 10, 1912, the Titanic disembarked Southampton, England on her maiden voyage destined for New York City. Officially, 2165 passengers and crew were on board but this figure is not accurate due to no-shows, an inaccurate crew count, and additional passengers who were taken on in Ireland as well as inevitable stowaways.

t37Some of the world’s most influential and wealthy people were on the Titanic which included the ship’s designer, Thomas Andrews, as well as the head of White Star Line, Bruce Ismay. It was beyond a voyage — it was a cultural event and a chance for White Star to regain its place in international shipping by proving the fastest and most luxurious way to sail between Europe and America. A lot was riding on the Titanic’s success.

The Iceberg Collision

The route Titanic took to New York had been traveled for several hundred years. It was the standard passageway for international liners and the main shipping lane between Europe and North America. The Titanic’s master, Captain Edward Smith, was a thirty-two-year White Star Line veteran and was chosen to command the Titanic due to his experience in international navigation, specifically this plot.

On the evening of April 14, 1912, the weather was perfect. It was clear, cold, and the sea was flat calm however, visibility was limited to ¼ mile due to there being a new moon and the only illumination was from starlight.

t6

At 11:35 p.m., the Titanic approached a point 375 nautical miles south-southeast of Newfoundland where the cold Labrador current from the north met the warmer Gulf current from the south. This location was well known for being the edge of pack ice and was notorious for icebergs which calf or break-off from their parent shelf.

Captain Smith had inspected the bridge at approximately 9:30 p.m. According to testimony from the surviving helmsman, Captain Smith discussed the potential of icebergs although none were yet seen. Smith directed the helmsman to maintain course and to raise him if conditions changed. The Captain left the bridge, retiring to his quarters. He was no longer involved in mastering the ship until after the collision.

t38Testimony from the Titanic’s helmsman, Robert Hitchens who was at the wheel during the iceberg collision, records that the Titanic was at 75 propeller revolutions per minute which calculated to 22.5 nautical miles per hour, just short of its maximum design speed of 80 revolutions or 24 knots. The helmsman also testified the Titanic was actually speeding up when it struck the iceberg as it was White Star chairman and managing director, Bruce Ismay’s, intention to run the rest of the route to New York at full speed, arrive early, and prove the Titanic’s superior performance. Ismay survived the disaster and testified at the inquiries that this speed increase was approved by Captain Smith and the helmsman was operating under his Captain’s direction.

The Titanic was built long before radar became the main nighttime navigational aid. The watch depended on a crew member in the forward crow’s-nest who stared through the dark for obstacles. Other ships were not a concern as they were brightly lit and the only threat to the Titanic was an iceberg.

t2From the dim, Titanic’s watchman saw the shape of an iceberg materialize. It was estimated at ten times the Titanic’s size above water, which equates to a total mass of one hundred Titanics. The watchman alerted the bridge that an iceberg was at the front right, or starboard side, and to alter course.

Testimony shows that confusion may have caused a mistake being made in relaying a course change from the bridge to the steerage located at the ship’s stern. It appears the rudder might have been swung in the wrong direction and they accidently turned into the iceberg. It’s reported that when the helmsman realized the error, he ordered all engines in full reverse. Screw and rudder ships cannot steer in reverse. They can only back up in a straight line but it was too late.

Stopping the Titanic was impossible. It was speeding ahead far too fast to brake within a 1/4 mile, which is 440 yards. Without a speed reduction, covering 440 yards at 22.5 nautical miles per hour would take 36 seconds. Testimony from the inquiries recorded that during the eight-day sea trials, the Titanic was tested from full-ahead at 22 knots to full-stop. This took 3 minutes and 15 seconds and the deceleration covered 850 yards.

t39The Titanic sideswiped the iceberg on its starboard front, exchanging a phenomenal amount of energy. It immediately began taking on water that filled the ship’s six forward hull compartments. Water cascaded over the tops of the bulkheads in a domino effect and, as the weight of the water pulled the bow down, more water ingressed. This caused the stern to rise above the waterline. With the rear third of the ship losing buoyancy and the weight from her propellers being in the air, the stress on the ship’s midpoint caused a fracture. The ship split in two and quickly sank to the bottom. It was 2:20 a.m. on April 15, 1912 — two hours and twenty minutes after the iceberg collision.

Warning and Life Saving Attempts

Captain Smith came to the bridge shortly after the collision. Again, survivor testimony is conflicting and Smith did not live to give his version of what took place in mustering the crew and passengers for safe abandonment.

t36Without any doubt, there was complete confusion — some said utter chaos — in abandoning ship. The voyage had been so hastily pushed that the crew had no specific training or conducted any drills in lifesaving on the Titanic , being unfamiliar with the lifeboats and their davit lowering mechanisms.

Compounding this was a decision by White Star management to equip the Titanic with only half the necessary lifeboats to handle the number of people onboard. The reasons are long established. White Star felt a full complement of lifeboats would give the ship an unattractive, cluttered look. They also clearly had a false confidence the lifeboats would never be needed.

It’s well documented that many lifeboats discharged from the Titanic weren’t filled to capacity. Partly at fault was a “women and children first” mentality, but the primary reason is that no one person took charge of the operation. Testimony is clear that Captain Smith was involved during the lifeboat discharges but there’s no record of what charge he actually took. Some accounts tell of the Captain remaining on the bridge and going down with the ship, as the old mariner’s line goes.

t34Another well-documented issue was the failure of the ocean liner Californian to come to Titanic’s rescue. The Californian was within visual view of the Titanic. In fact, the crew of the Californian had sent the Titanic repeated messages warning of icebergs and the Californian had stopped for the night because of limited visibility and high risk of iceberg collision. These messages were improperly addressed and were never relayed to the bridge of the Titanic.

Further, the crew of the Californian had seen Titanic’s distress flares but the Californian’s Captain refused to respond. This was a major issue brought up at both official inquiries and a reasonable explanation from Californian’s Captain was never resolved.

Eventually, the ocean liner Carpathia responded. It, too, sent the Titanic iceberg warnings before the collision. The inquiries drilled down into the message relay flaws. They discovered the wireless operators on board the Titanic weren’t crewmembers nor directed by White Star. They were employees of the Marconi Telegraph Company privately contracted in a for-profit role to deliver all messages to and from the Titanic. In the few hours before the iceberg collision, the Titanic was within range of an on-shore relay station and this gave them a short window to pass high-priority messages for wealthy passengers. Navigation warning messages to the Titanic were given low or no priority.

t40Hearing testimony recorded that shortly after dark, as early as 7:00 p.m., the Titanic was sent at least five iceberg warnings. There’s no record these were passed on to the ship’s bridge nor the Captain. The Marconi operator aboard the Titanic survived to testify there’d been a severe backlog of paying customer messages and he was being “interrupted” by incoming navigational alerts. The warnings were set aside as they were not addressed “MSG” which means “Master Service Gram”. By policy, MSG messages required the Captain’s personal action whereas non-marked messages were delivered when time permitted.

Finding the Titanic — Design and Damage

Although the Titanic was the largest ship of its time, there was nothing technologically new about its design, materials, or method of construction. The hull was built of large steel plates, some as large as 6 feet by 30 feet and between 1 and 1 ½ inches thick. The technology at the time was to rivet the sections together where today, modern ships are welded at their seams.

t17Riveting a ship’s seams was an entire trade on its own — almost an art. There were two types of rivets used on the Titanic. Rivets in the mid-section of the hull, where stresses from lateral wave forces were greatest, were made of steel and triple-riveted while those in the bow and stern were composed of cheaper iron. The bow and the stern endured less force when under normal operation and only required double riveting by design. Further, with the mid-section of the Titanic being straight and flat, these rivets were installed with hydraulic presses where the curved plates at the ship’s ends had to be hand riveted. That involved setting rivets in place while white hot and hand-hammering them closed.

Anyone who’s watched the movie “Titanic” knows the ship was designed with sixteen “watertight” compartments, separated by fifteen bulkheads that had doors which could be shut off in the event the hull was compromised anywhere along these sections. The “watertight” design only applied below or at the waterline, leaving the entire hull open above the top of these bulkheads.

The bulkheads were the fatal design cause of the Titanic’s sinking but they weren’t the root cause of the disaster.

The ship’s architect, Thomas Andrews, was aware that flooding of more than four compartments would create a “mathematical certainty” that the bulkheads would overflow and cause the ship to sink. Testimony records that Andrews informed Captain Smith of this right after he realized the extent of flooding. This triggered the abandon ship order.

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Over the years following the sinking and before the Titanic’s wreckage was discovered, most historians and naval experts assumed the ship suffered a continuous gash in the hull below the waterline and across all six compartments. There was one dissenter, though, who surmised it only took a small amount of opening in each compartment to let in 34,000 tons of water and that was enough to compromise the ship.

Edward Wilding was a naval architect and co-designer of the Titanic who testified at the American inquiry. He calculated that as little as 12 square feet of opening in the hull would have been enough to let in that much water in the amount of time the Titanic remained afloat. Wilding stated his opinion that there was not a long gash, rather it was a “series of steps of comparatively short length, an aggregate of small holes” that were punctured in the hull. Wilding went as far to speculate that the force of the collision probably caused a number of rivets to “pop or let go” and it was “leaks at the ruptured seams” that let in seawater.

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In September, 1985, the Titanic’s wreckage was found by a deep sea expedition led by Dr. Bob Ballard. It was in 12,500 feet of water and its debris field covered 2,000 yards. Her hull was in two separate main pieces with her bow nosed into 35 feet of muddy bottom. Since then, a number of dives have been made on the Titanic including one which used a ground penetrating sonar that mapped the section of the bow that was under the mud.

The sonar readings clearly showed six separate openings in the forward six hull compartments. They were narrow, horizontal slits in various spots, not at all in one continuous line like the gash theory held. The sonar map was analyzed by naval architects at Bedford & Hackett who calculated the total area exposed by the slits was 12.6 square feet—almost the exact figure proposed by Edward Wilding in 1912.

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The architects also stated the rivets were clearly at fault and they’d failed from the impact. The rivets either sheared off on the outer heads or simply fractured and were released by the impact’s force. Immediately, many experts questioned why only a few rivets in a few seemingly random places failed and not most all along the area of impact.

In one of the dives, a large piece of the Titanic’s forward hull was recovered. This led to a forensic study on the plate steel and rivet composition by metallurgists Jennifer McCarty and Tim Foecke which they documented in their book “What Really Sank The Titanic”. Drs. McCarty and Foecke established a number of the Titanic’s iron rivets had an unacceptable amount of slag in their chemical makeup, contrary to what the ship’s design specified. The metallurgists concluded when the inferior, weak rivets were exposed in below-zero Fahrenheit water temperature on the night of the sinking, they were brittle and shattered from the collision force.

t14The metallurgists went further in their investigation. They found during the rush to complete the Titanic on time, the builders purposely resorted to inferior metal than specified by the designers. The builders were also faced with a critical shortage of skilled riveting labor. This led to a compounded error of inferior rivets being installed by inferior tradesmen that likely explains the randomness of failed areas.

Today, the failed rivet theory stands as the most logical explanation for the mechanical cause of the Titanic disaster but this still doesn’t get at the root cause of the tragedy.

At the core of Root Cause Analysis is the question “Why?”. This form of accident investigation forces the question “Why did this happen?” to be asked over and over until you cannot ask anymore “Whys?”. In Titanic’s case, this path leads to answering the root cause — the fatal flaw in why over 1,500 innocent people lost their lives.

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The two official investigations back in 1912 started with a conclusion — the Titanic hit an iceberg and sank. They made somewhat of an attempt to answer why that happened without attaching too much blame. The result was not so much as getting to the root cause but to try and make some good come from the disaster and ensure there was less chance of it happening again.

That is a good thing and, to repeat, it led to improving world marine safety through SOLAS. But that still doesn’t get to identifying the fatal flaw in what really sank the Titanic.

Think Reliability identified five root causes of the Titanic disaster:

1. Iceberg warnings were ignored.

2. The iceberg wasn’t seen until too late.

3. The Titanic was traveling too fast for visual conditions and couldn’t avoid colliding with the iceberg.

4. The rivets failed, compromising the hull’s integrity and letting in enough water to exceed the design buoyancy.

5. Insufficient lifesaving procedures and equipment were in place.

While these five reasons are the prime contributors to why the accident and tremendous loss of life happened, they still don’t arrive at the true, single root cause — the fatal flaw in what caused the Titanic tragedy.

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Finding the fatal flaw requires answering ‘Why” to each of these five points.

1. Why were the iceberg warnings ignored?

The answer is a systematic failure of communication operating on the Titanic. There was ample reason to suspect icebergs might be in the Titanic’s path. Any competent captain would be aware of hazards like this and would liaise with other ships along the route for warning information. Navigational communication was not a priority under Captain Smith’s command.

2. Why was the iceberg not seen until too late?

There’s another simple answer here. Night visibility was poor as there was limited light. Testimony from the surviving crewmembers consistently estimated the visibility range to be no more than ¼ mile. Eyesight, combined with compass readings, were the only forms of navigation in 1912. The Titanic was going too fast for the crew to react because Captain Smith allowed his ship to exceed a safe speed for navigation conditions.

3. Why was the Titanic traveling too fast for navigation conditions?

Without question, Captain Smith was under pressure from Bruce Ismay to bring the Titanic into New York earlier than scheduled. While this would never have set a speed record for the route, it certainly would reflect positively on the White Star Line and its business futures. Captain Smith succumbed to unreasonable pressure and allowed his ship to be operated unsafely.

4. Why did the rivets fail?

While Captain Smith had no input into the construction of the Titanic, he certainly knew its design limits. The Titanic was built as an ocean liner, not a battleship or an icebreaker. Captain Smith knew how dangerous an iceberg collision could be yet he still risked his ship being operated in unsafe conditions.

5. Why were there insufficient lifesaving equipment and procedures in place?

The fault began with White Star’s failure to provide the proper amount of lifeboats as well as rushing the Titanic into service before the crew was properly trained in drills and equipment operation. Captain Smith was aware of this. Despite, he allowed the Titanic to sail unprepared.

t18At the root of each of question lies irresponsibility of the Titanic’s captain. It’s long held in marine law that a ship’s captain is ultimately responsible for the safety of the vessel, the crew, and the passengers.

Captain Smith had full authority over every stage in the Titanic’s disaster and he failed on each point. Clearly, Captain Smith is the fatal flaw that caused the Titanic tragedy.

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Note: Garry Rodgers holds a Transport Canada Marine Captain Certification which includes training in Ship Stability, Navigation, SOLAS and Marine Emergency Duties. Garry’s also trained in Think Reliability Root Cause Mapping.