Tag Archives: Deaths

MOUNT EVEREST — WORLD’S HIGHEST AND MOST DEADLY OPEN GRAVEYARD

Mount Everest is the world’s tallest peak. At 29,029 feet—8,848 meters—Everest looms in the Himalayan sky at the border of Tibet and Nepal. Its massive height makes Everest the holy grail of mountaineering. Since conquered by humans in 1953, Mount Everest has been summited over 7,000 times by nearly 4,000 adventurers. But 292 died during this treacherous climb and 200 of their bodies can’t be recovered. They still remain—lying open on the rocks, ice and snow of this high, deadly graveyard.

Most climbers killed on Mount Everest perish in the Death Zone. It’s that dangerous place in the stratosphere above 8,000 meters (26,247 feet) where the air is so thin that oxygen levels are insufficient to support human life. In the Death Zone, there’s less than one-third of life-sustaining oxygen than at sea level. Human beings simply aren’t designed to go where an Airbus A380 cruises. That prolonged oxygen deficiency quickly guarantees death.

Every mountaineer prepares for high-altitude climbs knowing the perils associated with a lack of oxygen. But they still go there. We’ll discuss their motivation but first, let’s examine what physiologically happens when a climber suffers Acute Mountain Sickness (AMS). Several things occur.

Without sufficient oxygen, your lungs can’t oxygenate red blood cells. That’s vital for delivering hemoglobin-rich blood through pulmonary and tissue capillaries. This supports mitochondria in your cells. Without oxygenated blood, your cells slowly die and complications set in. You’ll develop High Altitude Pulmonary Edema (HAPE) as well as High Altitude Cerebral Edema (HACE). Your lungs and brain will bleed and fill with fluid. It’s like suffocating and suffering a traumatic brain injury at the same time.

Some climbers experience HAPE and HACE quickly. In others, it comes on slowly. But the symptoms and effects are the same with all. First to come are a shortage of breath accompanied by nausea and a headache. Vision blurs. Judgment is impaired. Extremities become cold and painful. Confusion and disorientation follow. Finally, the climber becomes exhausted and lays down to die.

Although HACE and HAPE are primary contributors to death, the actual mechanism is the cessation of brain function due to cerebral hemorrhage or cardiac arrest. It might be a chicken or egg situation but one thing’s for sure—AMS is impossible to treat without restoring oxygen. That means taking the ill climber to lower elevations or supplying them with an artificial oxygen supply.

This is far more difficult than it sounds. The Death Zone on Everest sits in that 2,782 foot (848 meters) range between Camp IV—the last point of human habitation—and the summit. In the Death Zone, you’re on your own if something goes wrong. There’s simply no way to pack an unconscious or disoriented climber down. It’s not at all practical to rescue them with auxiliary oxygen. That’s why nearly all the deaths occur in that small stretch on that big mountain. And that’s why their bodies stay exposed in that deadly zone.

There are so many open dead bodies in the high reaches of Mount Everest—they’ve taken on names of their own. Ghoulishly, active climbers pass by frozen and mummified corpses of fallen comrades. They step around them and over them in tight places like the Hillary Step and the Lhotse face. They look down on the open graveyard called Rainbow Valley named for brightly-colored mountaineering suits still cladding dozens of dead strewn about the crevasse.

Certain bodies are assigned names—gruesome as it seems. Green Boots is a landmark. He’s called that because of neon green climbing boots still on his outstretched feet while the rest of him lays frozen in the fetal position under a limestone outcrop. The area is so narrow anyone summiting Everest on the northeast route must step over his green boots on their way up. And on their way down.

Sitting Man is another famous corpse. There’s a sad story behind him. This unfortunate soul fell ill to AMS after courageously making the top. On his way down, this British climber progressively fell into the fate of HACE and HAPE. He was with fellow climbers who left him alone to succumb from a lack of oxygen and exposure to elements. Mountaineers from other international parties passed up and down beside Sitting Man. Everyone saw this man sitting in peril as he slowly passed on. But no one assisted because on Everest—in the Death Zone—you’re on your own when something goes wrong.

A woman climber from America became known as Sleeping Beauty from her immortal climbing accident. She’d separated from her climbing partner during a descent in bad weather. Disoriented, she stopped in the Death Zone, waiting too long. Her body stays stretched on her back alongside the trail where her brown hair waves in the wind and her lifeless eyes stare openly up at the heavens.

The most famous dead body still lying open in Everest’s lofty graveyard is George Mallory. He’s been there since 1924 when Mallory and Andrew Irvine died in the Death Zone. History records that Sir Edmund Hillary and Sherpa guide, Tenzing Norgay, are officially credited with being the first people to reach Everest’s summit in 1953 but there’s good reason to believe that 29 years earlier, Mallory and Irvine beat them to it.

Unfortunately, neither Irvine nor Mallory returned to tell the tale. They stayed near the summit and perished into eternity until one day in 1999, a group of experienced mountain adventurers stumbled upon George Mallory’s mummified cadaver lying face down on an open rock slide near the Death Zone. It appears he fell during his descent. Mallory was still in recognizable condition and his effects were mostly intact. His camera was never found. That might have contained confirming summit photos but something else was missing. Mallory promised he’d leave his wife’s photo on top of Mount Everest. His wallet was in his pocket and contained all documents except for the photo of his wife.

Since Hillary and Norgay summited in 1953, Everest has been a Mecca for mountaineers. There is so much demand for climbing positions that the governments of China (representing Tibet) and Nepal restrict permits. Still, there’s an overcrowding of space in this lucrative business. Climbers come from all over the world to compete for conditions on Mount Everest. And yearly, about 7.6 percent of them die. That figure grows each year.

Although most Everest climbing deaths happen in the Death Zone, there are many fatal accidents in the lower reaches. It’s partly due that assaults on Everest normally take place in 5 stages. This is a proven strategy. Practically every guided group follows this pattern.

  • Stage 1 is Basecamp. It’s at 5,270 meters (17,290 feet) and groups spend days if not weeks here preparing to ascend. Part of the reason is to acclimatize their bodies to compensate for the lower oxygen levels already found at this height. Acclimatization is hugely effective in delaying the effects of acute mountain sickness.
  • Stage 2 reaches Camp I. This elevation is 6,035 meters (19,799 feet). Climbers sometimes spend a few days further acclimatizing at Camp I before pushing on.
  • Stage 3 is called Camp II. Now they’re at 6,474 meters (21,240 feet) where the air is really starting to thin. Most climbers bivouac overnight and move up.
  • Stage 4 is Camp III at 7,158 meters (23,484 feet). There’s no time to waste in this oxygen depleted place. It’s a spot to rest, eat and hydrate.
  • Stage 5 is the last stop before summiting. Camp IV is at 7906 meters (25,938 feet). It’s just 94 meters (309 feet) short of the Death Zone. Here climbers spend little time as possible. They’re waiting for a weather or time window—making a break for the top.

 

Descending Everest doesn’t take the same stops. Depending on climate conditions as well as the climber’s physical state, they make multiple descent camps in one day. But descending has problems with pressurization. Descents made too fast brings on physical symptoms similar to acute mountain sickness. Quick, uncontrolled descents cause bad judgment leading to accidental death.

Despite the perils of AMS, HACE and HAPE, these contributors only account for a small amount of direct causes of death on Mount Everest. Statistics indicate accidents are by far the leading cause of Everest’s climbing deaths.

  • 29 percent are due to avalanches.
  • 27 percent are other causes like wind shear and equipment failure.
  • 23 percent are from falls.
  • 11 percent are the result of exposure and freezing.
  • 10 percent are directly related to acute mountain sickness.

So with the high odds of being killed on Mount Everest and bodies being left exposed in this high and open graveyard, why do so many adventurers want to risk their lives taking chances in the Death Zone?

That’s tough to answer. Each climber has personal reasons. Some are natural risk takers and thrill seekers. They want to push their envelope. For some, it’s all about ego and bragging rights. Some might be naïve. They simply don’t know what they’re getting into. If you have the money, you can buy a ticket up Everest.

Some dedicated climbers are motivated by business. Local Sherpas depend on guiding novice Everest guests. They’re well-paid, their local economy thrives on the mountain and they’ve been doing it for years. That’s why the greatest percentage—by far—of victim nationality is Nepalese. Most of them die in accidents, not AMS, as their physiology makes them much better suited to functioning in high-altitude environments.

Then some mountaineers are motivated by a macabre sense of brushing the face of death. They may have personal fears to conquer—something to prove to themselves or others. Perhaps they don’t think it’ll happen to them. Being surrounded by danger is a fix. It’s something an adrenaline junkie craves. Maybe for a few, they enjoy being suicidal. Climbing Everest is like loading one round in a revolver, spinning the cylinder, putting the barrel in your mouth and pulling the trigger. If you survive, then climbing Mount Everest was probably a good idea.

But maybe the real reason why people climb mountains like Everest was best summed by George Mallory himself. Asked why he wanted to do it, Mallory said, “Because it’s there.”

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.

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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.

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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.

FENTANYL—HEROIN’S DEADLY LITTLE SISTER

F20Imagine a serial killer causing 256 deaths in your town—within the first four months of this year. Your place would panic. Your doors would be locked. Windows barred. Your streets would be bare with the cops falling flat-out to find the fiend. Does this sound like a far-fetched plot for the next best-seller? Nope. It’s real. It’s happening right here at home and the killer is known. Her name is Fentanyl. She’s heroin’s deadly little sister.

British Columbians, in Canada, are among the world’s most prolific illicit drug consumers and the B.C. Coroners Service just released some figures. They’re projecting over 800 drug overdose deaths for 2016. Maybe a thousand. Most will involve fentanyl.

Who is this lethal lady? Where does she come from? And why is she suddenly so popular?

F12Fentanyl is a high-potency, rapid-onset synthetic opioid drug prescribed for the treatment of chronic pain. It was developed in the 1950’s as an intravenous anesthetic for surgery and evolved into a breakthrough cancer pain treatment in the form of tablets, lozenges, lollipops, and patches. It’s legal and readily available with a prescription and is listed on the U.S., Canadian, and U.K. Schedules as a controlled drug.

Like heroin and morphine, fentanyl works by binding to the body’s opiate receptors and driving up dopamine levels in the brain’s reward areas, producing a state of euphoria and intense relaxation. That’s all and well when used in moderation and highly effective when properly prescribed.

001But fentanyl is 100 times more potent than morphine and 50 times stronger than pharmaceutical grade, 100% pure heroin. It’s also far more available on the street than heroin and the reason is profit. One kilogram of heroin sells in Vancouver for $60,000—if you could find one. One kilo of fentanyl powder goes for $125,000 and is readily available. Not hard to figure out what’s going on.

But with fentanyl being so powerful, the inevitable deaths tag along. The mechanism of death by fentanyl overdose is the same as heroin in that the central nervous system is depressed and respiratory failure occurs. Fentanyl is much quicker than heroin, though. One street source was quoted, “With fentanyl you just hit the ground. Light’s out, that’s it. They don’t know there’s fentanyl in their fix till it’s too late.”

F22The toxicity of all drugs is rated on an LD50 scale, whereas the Lethal Dose of 50 percent of humans occurs at a certain scale which is proportionate to body mass. Fentanyl’s LD50 rating is .03 mcg/kg (micrograms per kilogram). Given that a microgram is .001 of a milligram, this equals an average 70 kilogram (155 pound) person requiring 2.1 mgs of fentanyl to kill them. Some, already tolerant to opioids, require more. Some, with no tolerance, require less. Especially if mixed with other drugs or alcohol.

So why the sudden rise in the availability of fentanyl?

There’ll always be the demand. The answer’s in the supply and the reason’s found on the internet. The digital drug highway. The internet has done to drugs what Amazon has done for books.

F23Ten years ago, when heroin was so popular, it was available from a natural product through a complex delivery system which requires a chain from the country of source—China, Afghanistan, and Vietnam to name a few—through international couriers, middle-men, and street dealers before it ever reached the end-user. The junkie in the alley.

The process of profit required “stepping-on” or “cutting” at every level and, by the time the drug reached the consumer, it was of low purity and the chances of an accidental overdose were slim.

Today’s plentiful purity is what’s killing the customers and it’s not about to change.

002Now you can go online and order any amount of fentanyl—a synthetic and easily mass-produced opioid—you want, as long as your money goes through. Visa, Mastercard, Paypal, and Bitcoin are fine and UPS will deliver it right to your door. Presto, you’re in the illicit drug business.

Don’t believe me?

Well, I tried it out.

I started Google-searching “where to buy fentanyl online without a prescription” and snooped around. Then I hooked-up with a few shadowy and shady, sinister people through email. It’s easy to get information when you’re anonymous and they think you have money. They steered me to the Silk Road Online Pharmacy—the Walmart of internet black market pharmaceuticals. It’s in Karachi, Pakistan. Click here.

F14

I paged through a menu of everything from Molly to Ecstacy to Pure MDMA to Phentermine to LSD to Viagara to Pregnyl to Humatrope. The site is nicely organized in departments with pretty much everything you could be surreptitiously looking for—men’s & women’s health, weight loss, pain-killers, things for ADD/ADHD, stuff for highs, shit for lows, a great selection of steroids, plus lots and lots of research chemicals and powders.

Then I found what I wanted.

Abstral.

F31Abstral is a brand name for a formulation of fentanyl citrate (the salt produced by combining the chemical base for fentanyl with citric acid) and is available as a sublingual tablet—one you dissolve under your tongue and is absorbed in your buccal mucosa to provide rapid analgesia. And it comes with this warning:

F16

Silk Road Pharmacy sells Abstral in two strengths: 400 mcg and 800 mcg. I chose the stronger. There’s more bang for the buck.

F30

They also have a minimum order of 50 tablets so, being a first-time customer, I selected the lesser and clicked “Buy” on my cart. That took me to the checkout page where, for $300.00 plus fifty bucks for shipping and handling, the deal was done through my Mastercard. A client-needs agent by the name of Asha Ali guaranteed delivery to North America within two weeks. He even gave me his email at contact@silkroad.pharmacy.com if there’s a problem.

F32

So, getting back to the not-so-hypothetical Fentanyl serial killer, this is what I’ve calculated. I have 50 – 800 microgram tabs of Abstral on the way. That’s a total of 40 milligrams. If it takes 2.1 mg to kill the average person, then I’ve got enough to do in nineteen people. Fifteen to be sure. Ten at the absolute least.

F33Now, I don’t have anything against anyone in particular so I propose to do this randomly.

What I’ve got in mind is cruising the coffee shops downtown. There’s Starbucks at the mall. The Vault on the corner. Serious Coffee in the conference center. Perkins up the street. And there’s got to be twenty restaurants with three blocks. It’ll be so easy to grind up my e-mail pills and sprinkle the fentanyl powder into momentarily unattended lattes. I might even lace sugar packets.

Hey! Imagine the bars where they’re drinking.

F35Talk about a return on the dollar. That’s under twenty-five bucks a death—the price of five coffees at Starbucks—three beers and a burger at The Palace. The chances of getting caught are practically nil. Random stranger-to-stranger killings are the hardest to solve and the easiest to get away with. Just ask the Chicago Tylenol Poisoner.

Anyway, I have a couple weeks before my precious pills get here—a couple weeks plotting serial kills with fentanyl poisoning. It’s my next novel.

And I’m planning a plot with a random twist that you’ll never see coming… in Deadly Little Sister.