Tag Archives: Accident

THE FATAL FLAW THAT SUNK THE TITANIC

The 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 issue (without the iceberg, there was no problem), 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.

The 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 fatal flaw—the root 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.

One 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. They failed to identify the real cause of the Titanic tragedy.

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.

Think Reliability developed 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.

The 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 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.

Some 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.

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.

Testimony 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.

From 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 ¼ 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.

The 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.

Without 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.

Another 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.

Hearing 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.

Riveting 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.

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 rivets to “pop or let go” and it was “leaks at the ruptured seams” that let in seawater.

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, many 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.

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 many 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.

The 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.

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 that sunk the Titanic.

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 Edward 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 number 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.

At 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 Edward Smith is the fatal flaw that sunk the Titanic.

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Note: Writer Garry Rodgers holds a 60 Ton Transport Canada Marine Captain Certification which includes accredited training in Ship Design & Stability, Navigation, Communication, SOLAS, and Marine Emergency Duties. Garry is also formally trained in Think Reliability Root Cause Mapping.

ELISA LAM’S GHASTLY DEATH AT THE NOTORIOUS CECIL HOTEL IN L.A.

On February 19, 2013, Elisa Lam was found dead inside a 1,000-gallon water cistern on top of the notorious Cecil Hotel in the Skid Row District of downtown Los Angeles. Elisa, age 21, was reported missing 19 days earlier and was last seen in an elevator in the 14-story, 700-room hotel where she’d been staying. The L.A. Coroner ruled Elisa’s death an accident compounded by bizarre behavior caused by her previously diagnosed bipolar disorder. Her ghastly death was one more in a long series of outrageous events at The Cecil. As an LAPD officer put it, “The place is haunted. Tell me in which room a death hasn’t occurred.”

Elisa Lam’s bizarre death circumstances caught worldwide attention. Over the years, it’s developed an internet cult where outlandish theories are tossed about like a ghoulish parlor game. Some speculate on a paranormal event. Some speculate Elisa was part of a black-web Asian practice called the elevator game. There’s been so much macabre interest in the “Dead Lady in the Hotel Water Tank” case that in 2021 Netflix produced a 4-part series on it titled Crime Scene: The Vanishing at the Cecil Hotel.

There are two distinct stories in the Elisa Lam death case, and they merge in the end. One is the truly terrifying, final moments of Elisa’s death. The other is the horrible history of the hotel that housed at least two serial killers including the Night Stalker himself, Richard Ramirez. Let’s start with examining Elisa’s case facts and then look at the craziness confined in a haunted hotel.

The Death Investigation

Elisa Lam was born in Hong Kong and immigrated to Vancouver, Canada with her parents and sister. Elisa was a bright young lady and had been enrolled in the University of British Columbia. She ran several popular blogs and was a budding writer. However, Elisa suffered from depression and was clinically diagnosed with bipolar disorder. She was prescribed the usual medications—Lamotrigine, Quetiapine, Venlafaxine, and Bupropion (Wellbutrin). Although she’d been hospitalized for a psychotic event, Elisa had no background of suicidal tendencies.

In early January 2013, Elisa took a post-Christmas sabbatical from her studies. She traveled alone via Amtrak and busses to Southern California, first to San Diego and then arriving in Los Angeles on January 26. Why she picked the Cecil Hotel is not known. Probably because The Cecil had been rebranded as Stay on Main (address 640 S. Main Street) to clean up its image as the worst lodging in the worst region of L.A. Bottomline—as a designated hostel, the price was now right.

Elisa initially roomed with two other young women. This quickly ended because of her behavior—giving entry passwords to the others and locking them out as well as leaving strange notes on their beds. Hotel staff moved Elisa to a single room where she could be alone. Then there was an episode in late January at a film studio (taping of Conan O’Brien) where Elisa was removed by security for disruptive behavior.

Elisa was last seen in person on January 31 in the hotel lobby. She’d kept in daily touch with her parents and sister. When she failed to connect on February 2, Elisa’s folks filed a missing persons report with LAPD.

Investigators checked the hotel’s video file and were satisfied Eliza never left the building through the main doors or fire escapes. What they did find was footage from February 1 where Elisa was alone in an elevator. In the 2-minute reel, Elisa portrayed seriously disturbed behavior. The video was released to the public before Elisa’s body was found, and it went viral, being viewed 33 million times on YouTube.

Before reading on, you must watch the clip to appreciate Elisa’s mental state. A picture is worth a thousand words and a video is priceless.

On February 19, a hotel maintenance worker responded to guest complaints that their water smelled bad, was a funny color, and the pressure was low. He checked the hotel’s four cisterns that were roof mounted to accommodate gravity pressure. These cisterns were steel tanks measuring 8 feet high and 4 feet in diameter. Access was through a removable upper hatch that could easily be removed by one person.

The worker found the lid open on the northeast tank. He looked inside and saw Elisa’s bloated and decomposing body floating face up on the surface—the water level being approximately 2 feet down from the top or 6 feet from the bottom and no way that 5-foot, 6-inch Elisa could have stood on the tank floor with her head in the air.

The L.A. Fire Department drained the tank and cut it open as removing Elisa’s body through the upper portal was impossible. Elisa was naked and her saturated clothes lay loose on the tank floor along with her watch and her hotel room key card. Inside her room, the rest of her belongings remained including her money, identification, and medications.

Elisa was autopsied on February 21. Aside from a ¼ inch round abrasion on her left knee, there was no sign of physical trauma. Her cause of death was clear—drowning. “Both pleural cavities contain dark brown fluid; 300 cc on the right and 200 cc on the left.”

Her toxicology testing was not so clear. Her advancing state of decomposition—being dead approximately 21 days by autopsy time—left little blood in her heart or major arteries to examine. The toxicology report (considering blood, bile, and liver tissue) was conclusive that no normal street drugs were present in her system, i.e. cocaine, opiates, amphetamines, and even THC. Traces of her prescriptions—Lamotrigine, Quetiapine, Venlafaxine, and Bupropion (Wellbutrin)—were identified but the quantity was not sufficient to make a proportional analysis.

It was the pill count in Elisa’s room that was telling. She’d had her prescriptions refilled in Vancouver on January 11, 2013, and what remained was a leading indicator as to what might have triggered a psychotic episode that led Elisa to willingly crawl inside a water tank.

Lamotrigine (anti-seizure meds)                60 issued       70 remaining

Quetiapine (bipolar/mood meds)              30 issued       20 remaining

Venlafaxine (anti-depression meds)         60 issued       64 remaining

Wellbutrin (anti-depression meds)            60 issued       57 remaining

The autopsy report’s conclusion is careful about speaking to Elisa’s undermedication:

Opinion: The decedent died as a result of drowning. A complete autopsy examination showed no evidence of trauma, and toxicology studies did not show acute drug or alcohol intoxication. Decedent had a history of bipolar disorder for which she was prescribed medication. Toxicology studies were performed for the presence of these drugs. However, quantitation in the blood was not performed due to the limited sample availability. Therefore, interpretation is limited. Police investigation did not show evidence of foul play. A full review of the circumstances of the case and appropriate consultation do not support intent to harm oneself. The manner of death is classified as accident.

Something to note in the autopsy report is Elisa’s death classification was listed as Undertermined upon conclusion of her physical examination on February 21. On June 18, the classification was changed to Accident. This was after the tox results came back and there was no sign of any overdose or poisoning. There is nothing to read into the change—this is routine to change a conclusion upon receiving further evidence or absence of evidence.

Despite internet sleuths pontificating about conspiracy theories from a serial killer loose in the hotel to a poltergeist practicing the paranormal, it’s clear from the official investigation that Elisa went into some sort of psychotic event and intentionally—on her own—entered the insecure, water-filled cistern. With no way out and only treading water to temporarily survive, she succumbed to drowning. It must have been a ghastly way to go.

The Cecil Hotel

In reading up on the Cecil Hotel’s history, I found quotes like these describing its past:

“Insanity within its walls. A hotbed of death.”
“Guests ranging from drug dealers to prostitutes to rapists.”
“A lot of safety issues. Thousands of 911 calls to there, normally three a day.”
“If you didn’t watch yourself, you might be flying out the window without wings.”
“The most infamous building in horror lore.”
“Unparalleled reputation for the macabre.”
“A meeting place for junkies, runaways, and criminals where they played in violence and death.”
“Murders, and suicides, and unexplained paranormal events.”
“The most dangerous place in Los Angeles, especially above the seventh floor.”
“A place where serial killers go to let their hair down.”

Yes, serial killers.

At the height of his spree, Night Stalker Richard Ramirez stayed on The Cecil’s top floor. Staff and residents would see Ramirez stash his bloodied clothing in the hotel’s trash receptacle and then walk through the lobby in his underwear or sometimes naked. No one reported Ramirez because, back then, who was to say what was normal or abnormal at the Cecil Hotel.

Another Cecil resident serial killer, although less known than the Night Stalker, was Jack Unterweger. He had a different distinguishment, though. Unterweger was an international serial killer who started his murderous career in Austria before moving shop to LA. His MO was to pick up prostitutes and strangle them with their own bras.

Getting back to The Cecil’s history. It was built in the Roaring Twenties as a luxury, but affordable, hotel. Centrally located in the Skid Row area of Los Angeles, The Cecil was perfectly positioned to suffer decline in the Great Depression then dilapidate into a festered urban sore through the later part of the twentieth century and into the early 2000s.

Just a side note on Skid Row. Skid Row is now an urban language term for any rundown part of a city where rubbies reside. LA’s Skid Row is an officially-listed civic region just like SoHo is in Manhattan or the French Quarter is in New Orleans. But LA’s Skid Row set the gold standard for a pit of poverty that made the Skid Row term a household name for the destitute and down-in-the-dumps. At one time, approximately 10,000 homeless people occupied a 4-mile radius around The Cecil.

By 2013, when Elisa Lam died at The Cecil, the hotel had improved. It was renamed, rebranded you could say, into the Stay on Main and billed as an affordable housing complex. Despite renovations and staff improvements, the Cecil Hotel remained lacking on one vital level.

Safety.

And this is where the stories of Elisa Lam’s death and the Cecil Hotel’s history merge.

I’m sure Elisa Lam chose the Stay on Main (the old Cecil Hotel) because of the location and the price. Can’t argue with that logic when you’re a traveling youth. But other things were going on in Elisa’s life which, to me, seem typical of a bipolar person experiencing their manic and adventuresome stage. That’s reducing or quitting their meds because they don’t think they feel the need at the time.

You can see in watching the now-famous Elevator Video that Elisa was in mental distress. She appeared paranoid, as if someone was out there wanting to harm her. It’s a classic case of psychosis. Somehow from the elevator Elisa made her way to the roof and the tank where she died.

Here’s where the hotel part enters. Elisa had to pass through two barriers to experience her demise. First—getting onto the roof. Second—getting into the tank. Both points should have been locked barriers and impossible for a young lady like Elisa to penetrate.

I’m not sure about the roof access method. I’ve been in a lot of hotels over the years, and I’ve never noticed one that has a public elevator portal to the roof. P for Parkade, yes, but not R for Roof on the buttons. She must have taken the stairway and that, in any case, should have been locked and not accessible with her room key card that was found in the death tank.

The Death Tank

The United States Occupational Safety and Health Administration (OSHA) clearly defines the cistern or water tank on top of the hotel a “Confined Space”. OSHA has extremely strict rules regulating entry into confined spaces where a person could be trapped and killed. OSHA takes confined space entry so seriously that, not only does a confined space have to be clearly signed and sufficiently locked, OSHA requires a written permit for a worker to enter. That permit must outline the purpose and method of entry and also a rescue plan if things go bad.

In utter basic, OSHA deals with common sense safety procedures like preventing access to dangerous places. For example, a 14-story hotel roof and a potentially lethal water cistern. The Cecil Hotel (sorry, in 2013 the Stay on Main) was utterly negligent in allowing a psychotic young lady to get onto its roof and drown in their tank.

Both access points should have had locked barriers, and Elisa’s host failed to protect their guest’s safety. But I guess preventing things like Elisa Lam’s ghastly death at the haunted Cecil Hotel has never been part of the company culture.

DID MARILYN MONROE REALLY COMMIT SUICIDE?

No movie star lived on after death like Marilyn Monroe. She was far more than a bleached-blonde bombshell with a voluptuous frame and a lusty voice—she intuitively knew her craft. Born in poverty as Norma Jean Mortenson (aka Baker) to a mentally unstable mother, Marilyn Monroe rose to Hollywood glamor, fame, and idolization beyond what few ever reach. Tragically, by the time she died at age thirty-six, her performing career had spiraled into the same abyss that her personal relationships and head space were already in.

Marilyn Monroe was found dead in her Beverly Hills bed at 3 a.m. on Sunday, August 5, 1962. The scene (at the time) suggested nothing suspicious—no foul play or culpable act, that is—and the toxicology results from her autopsy proved she’d succumbed to a lethal dose of prescription drugs. The coroner ruled her death as “probable suicide” but, like the deaths of other uber-celebrities, many people mumbled murder. Monroe’s death was reinvestigated in 1992 by the Los Angeles District Attorney who came to the same conclusion — “probable suicide”.

“Probable” is not in the official vocabulary of today’s coroner-speak. Neither is “possibly”. Everywhere in the civilized world, coroners are mandated by legislation to rule classifications of death as being in one of five definite categories: Natural, Homicide, Accident, Suicide, or Undetermined. Now, nearly sixty years later, an impartial look at Monroe’s case facts indicate her death classification definitely was not natural and cannot conclusively be classed as an accident or a suicide.

Does that mean Marilyn Munroe’s death was actually a homicide?

On the day of her death, many people were in Marilyn Monroe’s company. None reported any immediately implied threat or perceived action from Monroe that suggested an imminent danger of suicide, nor any behavior that was outside of her already troubled mental state of manic highs and depressive lows. She’d a history of emotional instability that, today, would likely be classified as Bipolar II Disorder, and she was under the continual care of a general physician and a psychiatrist. Monroe was no stranger to prescription pharmaceuticals, specifically anti-depressants and sleeping pills, but she was a relatively light alcohol drinker.

Marilyn Monroe had a difficult year in 1961. She worked very little due to health issues. Besides her emotional imbalance and substance dependency, she underwent surgery for endometriosis (uterus ailment) and a cholecystectomy (gall bladder removal), then suffered a painful attack of sinusitis. Her stress level soared from a lawsuit with 20th Century Fox where they sued Monroe for breach of contract—her erratic behavior led to delays in filming, disputes with cast and crew, then finally a stop of production.

On Saturday morning, August 4, Marilyn Monroe met with her official photographer and discussed an upcoming Playboy deal, then kept a massage appointment, a meeting with her publicist, talked with friends on the phone, and signed for deliveries for her house renovation. She was visited by her psychiatrist, Dr. Ralph Greenson, in the late afternoon for a scheduled therapy session. Greenson left around 7 p.m. and reported no alarming behavior, however he ensured that Monroe’s housekeeper, Eunice Murray, would be staying overnight.

Marilyn Monroe retired to her bedroom around 8 p.m. The last person to have contact with Monroe was actor Peter Lawford who invited her to a Hollywood party. He reported that in their phone conversation Monroe sounded tired—sleepy—as under the influence of drugs. After their call, Lawford became alarmed and phoned back to the house where he got Murray. She assured him everything was fine with Monroe.

At 3 a.m. on Sunday morning, Eunice Murray woke and noticed light coming from under Monroe’s bedroom door. Sensing something not right, Murray tapped on the door. There was no response, so she tried the handle and found it locked, which she stated was unusual.

Now alarmed, Murray phoned Dr. Greenson who instructed her to go outside and look through the bedroom window. She did and observed Marilyn Monroe lying facedown on the bed, covered in a sheet, and clutching a telephone receiver in her right hand.

Greenson arrived at approximately 3:20 a.m., broke the window with a fireplace poker, and climbed in. Immediately, he could tell Monroe had been dead for some time and it was pointless to call an ambulance or attempt resuscitation. Greenson phoned Monroe’s physician, Dr. Hyman Engelberg, who arrived at around 3:50 a.m. Engelberg examined Monroe by removing the phone receiver and rolling her over, officially pronouncing death. At 4:25 a.m. they notified the LAPD.

The attending detective agreed with the two doctors that there was nothing to indicate foul play and the death was most likely a drug overdose. The detective photographed the scene and recorded the “pill count” of the pharmaceutical vials on Monroe’s nightstand. Dr. Engelberg noted a vial containing twenty-five capsules of the barbiturate Nembutal that he’d prescribed two days earlier was empty. Vials with other prescriptions appeared in order including one containing the sleeping sedative Chloral Hydrate.

Marilyn Monroe was autopsied on the morning of August 6 by pathologist Dr. Thomas Noguchi who would later be known as “Coroner To The Stars” for his many postmortem exams on celebrities. His original autopsy report for Marilyn Monroe is on the public record and can be downloaded.

Noguchi is very clear in his report, and in many subsequent interviews, that he found no evidence of physical trauma—specifically needle marks—on Monroe’s body. Based on his observations and those of Drs. Greenson and Engelberg regarding Monroe’s rigor, livor, algor, and palor mortis conditions, he felt reasonable to estimate her time of death between 8 and no later than 10 p.m. the previous night. Noguchi found no natural cause of death and waited for the toxicology report before forming his final conclusions.

The tox screen was done by the LA County Coroner’s laboratory and released on August 13. The results concluded Monroe’s blood contained 4.5 milligrams (percent) of Nembutal and 8.0 milligrams (percent) of Chloral Hydrate. Her liver contained 13.0 milligrams (percent) of Pentobarbital. Blood ethanol (alcohol) was absent.

Noguchi was satisfied the combination of Nembutal and Chloral Hydrate levels in Monroe was sufficiently high to cause her death through respiratory and central nervous system failure and he knew the Pentobarbital stored in her liver was simply indicative of someone who had long exposure to barbiturates and developed a “tolerance”. Noguchi certified the cause as “acute barbiturate poisoning due to ingestion of overdose” but he was reluctant to rule the classification as “suicide”. Though Noguchi was certain no evidence existed to suggest the death was an intentional homicide, he was uncomfortable with there being no clear evidence that Monroe intended to take her own life.

There were no immediate threats, no suicide note, no warning behavior, and not all the Chloral Hydrate pills were consumed, not like the Nembutal.

It might be an accidental OD, Noguchi thought, and he was troubled by the fact Monroe had been prescribed the amounts of Nembutal and Chloral Hydrate at the same time—her physician had to have known they’d be lethal if mixed a large quantity.

Noguchi was under pressure—political pressure, if you will—from the elected Chief Coroner of Los Angeles County to shut down media speculation that there might be more to Monroe’s death than a sad case of a despondent star intentionally extinguishing her light. The Chief and Noguchi reached a temporary compromise that they’d say Monroe’s death was a “probable” suicide.

Noguchi didn’t go so far as to insinuate negligence by Monroe’s caregivers might be the smoking gun, yet he requested a “psychological autopsy” to investigate Marilyn Monroe’s mental state leading to her death. Without clear evidence of an intentional suicide, the pattern of Monroe’s behavior was crucial in corroborating a suicide rule.

This statement was issued by LA County Chief Coroner Theodore J. Curphey. It’s an addendum to Noguchi’s final autopsy report:

“Following is the summary report by the Psychiatric Investigative Team which assisted me in collecting information in this case. The team was headed by Robert Litman, M.D., Norman Farberow. Ph. D., and Norman Tabachnick, M.D.:

‘Marilyn Monroe died on the night of August 4th or the early morning of August 5th, 1962. Examination by the toxicology laboratory indicates that death was due to a self-administered overdose of sedative drugs. We have been asked, as consultants, to examine the life situation of the deceased and to give an opinion of the intent of Miss Monroe when she ingested the sedative drugs which caused her death. From the data obtained, the following points are the most important and relevant:

Miss Monroe suffered from psychiatric disturbance for a long time. She experienced severe fears and frequent depressions. Mood changes were abrupt and unpredictable. Among symptoms of disorganization, sleep disturbance was prominent, for which she had been taking sedative drugs for many years. She was thus familiar with and experienced in the use of sedative drugs and well aware of their dangers.

Recently, one of the main objectives of her psychiatric treatment had been the reduction of her intake of drugs. This has been partly successful during the last two months. She was reported to be following doctor’s orders in her use of drugs; and the amount of drugs found in her home at the time of her death was not unusual.

In our investigation, we have learned that Miss Monroe had often expressed wishes to give up, to withdraw, and even to die. On more than one occasion in the past, when disappointed and depressed, she made a suicide attempt using sedative drugs. On these occasions, she had called for help and had been rescued.

From the information collected about the events on the evening of August 4th, it is our opinion that the same pattern was repeated except for the rescue. It has been our practice with similar information collected in other cases in the past to recommend a certification for such deaths as a probable suicide.

Additional clues for suicide provided by the physical evidence are:

(1) the high level of barbiturates and chloral hydrate in the blood, which, with other evidence from the autopsy, indicate the probable ingestion of a large amount of drugs in a short period of time;

(2) the completely empty bottle of Nembutal, the prescription for which was filled the day before the ingestion of drugs; and

(3) the locked door which was unusual.’

Now that the final toxicological report and that of the psychiatric consultants have been received and considered, it is my conclusion that the death of Marilyn Monroe was caused by a self-administered overdose of sedative drugs and that the mode of death is probable suicide.

– Theodore J. Curphey, M.D. Chief Medical Examiner-Coroner for the County of Los Angeles, August 13, 1962.”

There’s that word “probable” again.

In my time as a police officer and coroner, I’ve attended many drug overdose deaths. Some were clearly suicides, backed-up by recorded threats and present notes. Some were accidents by misadventure, usually mixed with alcohol. And some were undetermined—not shown to have a definite intent by the decedent to take their own life.

I’d say some of the undetermined deaths were probably suicides—if I could say it. But a coroner doesn’t have the legal option to say “probably”. There’s a long-held court ruling called the Beckon Test that states a death can only be classified as a suicide if it can be determined that the individual knew the consequences of their actions would end in death and intentionally carried them out. There is a high standard of proof required for a finding of suicide as the ruling states:

“In most legal cases the test to be satisfied is a balance of probability. But a determination of suicide can only be made where there is clear and convincing evidence. There is to be a presumption against suicide at the outset and one must be certain beyond a high degree of probability that the death was a suicide. Where one cannot be absolutely certain, the death must be classified as undetermined.”

Based on my death investigation experience, there are three points about Marilyn Monroe’s suicide ruling that bother me.

First, in all the polypharmacy overdoses I’ve seen where suicide was obvious, the deceased downed the whole darned stash. They wanted to end it all and get it done.

In Monroe’s case, Dr. Engelberg prescribed her 50 caps of 500 mg Chloral Hydrate on July 31 as a refill for a previous Chloral Hydrate order on July 25. She was taking 10 per day. At her death scene, there were still 10 Chloral Hydrate caps left in her bedside vial. 40 were gone and, at a rate of 10 per day from July 31 till August 4, the pill count is right in order.

In the toxicology world, the effects of drugs are rated on a range scale of Therapeutic, Toxic, and Lethal. In the Lethal range, the substance is given a value called LD50 where it’s expected that 50 percent of the population would be expected to die from the drug’s effect at a certain point based upon the drug’s milligram blood content per the kilogram weight of the person.

Marilyn Monroe’s autopsy report recorded her weight at 117 pounds or 53.2 kilograms. The Chloral Hydrate level in her blood was determined to be 8.0 milligrams (percent) based on her weight or 80 parts per million (ppm). Looking at my toxicology scale from my coroner days, I see that Chloral Hydrate has a Therapeutic range to 30 ppm and an LD50 value at 100 ppm, so Monroe was 20% under the Chloral Hydrate lethal bar.

Looking at her barbiturate blood content from the Nembutal, it’s recorded to be 4.5 mg (percent) or 45 ppm. My chart says the barbiturate Pentobarbital, which is what’s in Nembutal, has a Therapeutic range to 12 ppm and an LD50 at 40 ppm. So, Monroe was only 12.5 % over the average barbiturate lethal threshold, not taking into account that she was a very “tolerant” user.

However, the combination of Chloral Hydrate and Nembutal was deadly, and this had to be known by Dr. Engelberg when he ordered Monroe’s prescription. This brings me to my second point.

A physician has a professional duty of care to their patient, especially when prescribing medication to a person with Monroe’s mental history. I find it irresponsible, actually negligent, that Dr. Engelberg failed to ensure Monroe no longer had Chloral Hydrate in her possession when he issued her a prescription for 25, 1500 mg caps of Nembutal four days later, knowing her supply of Chloral Hydrate wasn’t exhausted based on her prescribed consumption.

My third point deals with the “rescue” issue.

This very much applies to the Beckon Test. Intentional overdoses as attention-getting devices are common and always rely on the person’s backup plan that someone will intervene. This was part of Monroe’s previous overdose episodes as noted in the “psychological autopsy” report. And they referenced Monroe’s locked door as being unusual.

I think the locked door issue is completely negated by the fact that Monroe was found with her telephone receiver in hand. This was stated by Eunice Murray, Dr. Greenson, Dr. Engelberg, and corroborated by the investigating detective who verified they reported this to him and suggested she was phoning for rescue—which was her pattern—but was overcome.

If I were the coroner ruling on Marilyn Monroe’s death classification, I’d be legally bound to consider how the facts apply to the category parameters.

A natural cause determination is completely eliminated by the autopsy and toxicology evidence. Monroe clearly died as the result of a drug overdose.

Despite kooky conspiracy theories that Bobby Kennedy snuck in and injected Marilyn Monroe to cover up her alleged affair with President Jack or that mobsters Jimmy Hoffa and Sam Giancana knocked her off to keep from ratting them out, no sensible person can make a case that Monroe was intentionally murdered. But a homicide ruling doesn’t just apply to murder. The definition of homicide is “the killing of a human being due to the act or omission of another”.

I believe Dr. Engelberg was professionally negligent in his duty of care to Marilyn Monroe. He had to know—certainly ought to have known—that he was treating an emotionally unstable patient with a history of suicide attempts through polypharmacy. By giving Monroe a potentially lethal amount of barbiturates and not ensuring her chloral hydrate was gone, Engelberg effectively signed her death warrant.

However negligent Engelberg may have been, though, my suspicion falls short of the burden necessary for establishing a homicide classification.

That Monroe accidently died from a self-administered overdose is a distinct probability but, again, the Coroners Act and court precedents won’t allow me the liberty to rely on probabilities regarding suicide. I have to come to a clear conclusion based on facts.

Setting aside the locked door and phone receiver in hand—these two negate each other—I must defer to one other glaring fact. There were still 10 caps of Chloral Hydrate left in her pill vial. Marilyn Monroe was a very experienced and tolerant prescription pill user. She knew exactly what she was taking, what their effects were, and she failed to down her whole darned stash which is always proof of a polypharmacy overdose suicide.

So, deferring to the Beckon Test, I have to presume against Marilyn Monroe’s suicide classification from the outset and must be satisfied beyond a high degree of probability that her death was a suicide—I must be certain—and I can’t—because no clear evidence exists that Monroe’s death was an intentional act to end her own life. It may well have been an unfortunate, un-rescued accident (which I suspect), but I can’t support that classification through the facts.

Therefore, I find Marilyn Monroe’s death classification as Undetermined.