The accident happened simply because everyone made a small mistake

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The article is a bit long, but it’s very informative to read. In front of the Brazilian shipping company Marítima Shunyuan, there stands a stone that is 5 meters high and 2 meters wide, covered in dense inscriptions in Portuguese. When the Pakistani port official leading the tour gently read the text above from beginning to end in English, all the visitors fell silent. It’s a sobering true story about responsibility. The text listed below is what is engraved on the stone. “By the time the rescue ship sent by Brazil’s Marítima Shipping Company arrived at the site of the incident, the Atlantic Navigator ship had disappeared; the 21 crew members were missing, and only a life raft on the sea surface was emitting distress signals in Morse code at regular intervals. The rescuers stared at the calm sea in confusion, unable to understand what could have happened in such a favorable sailing condition to cause the sinking of this state-of-the-art ship. At that moment, someone noticed a sealed bottle tied underneath the radio. When the bottle was opened, there was a note inside with 21 different handwriting styles, which read: Richard I: On March 21st, I bought a table lamp at Oakland Port on my own, intending to use it for lighting while writing letters to my wife. Second Officer Thurman, I saw Richard returning to the ship with a table lamp; he said that the base of the lamp was light, and that it needed to be kept from falling over when the ship moved, but he didn’t interfere. Third Officer Patti: The ship left port on the afternoon of March 21st. I noticed a problem with the life raft launcher, so I tied the life raft to a rack. Davis II: During the departure inspection, it was found that the door closer in the crew area was damaged, so the door was secured with wire. ; Second Officer Antel: When I checked the fire-fighting equipment, I found that the fire hydrants in the sailor’s area were rusty. I thought there were a few days left before arriving at the port, so I would replace them then. Captain McKay: At the time of departure, I was busy with work and did not review the safety inspection reports from the deck and engine departments. Blacksmith Daniel: On the morning of March 23, the fire alarms in Richard and Suller’s rooms went off repeatedly. After Walter and I went in, we didn’t see any flames; we concluded that the detector had given a false alarm. We removed it and gave it to Whitman, asking for a replacement. Chief Engineer Whitman: I said those who are busy will give them to you in a moment. Waiter Sconey: Go to Richard’s room at 1 p.m. on March 23 to find him; he wasn’t there, so I sat there for a while and turned on his desk lamp. Chief Officer Kemp: At 1:30 p.m. on March 23, I took Suler and Robert on a safety inspection; I did not enter Richard and Suler’s rooms, and said, “Go ahead and check your own rooms.” Su Le Yishui: I smiled, didn’t enter the room either, and followed Kempu. Robert I: I didn’t go into the room either; I followed Suller. Mechanical and Electrical Engineer Cohen: I noticed a tripping at 2 p.m. on March 23; since this had happened before, I didn’t give it much thought, simply reopened the switch without investigating the cause. Third engineer Masin: Feeling that the air quality was poor, he first called the kitchen to confirm there were no issues, and then had the cabin’s ventilation valves opened. Chef Shi Ruo: When I answered Marcin’s call, I joked, What’s the problem here? You still haven’t come to help us cook. Then he asked Usu, ‘Is it safe here?’ Second chef Wusula: I replied that I also felt the air quality was poor, but since I thought we were in a safe place, I continued cooking. Mechanic Nupo: After receiving Masin’s call, I opened the ventilation valves. Administrator Daismon: At 2:30 p.m., I gathered everyone who wasn’t on duty to help in the kitchen to prepare food; we’ll have a meal together in the evening. Doctor Morris: I’m not doing any house calls. Electrician Holin: He ran into the restaurant while I was on duty at night. Finally, words from Captain McKeam: When the fire was discovered at 7:30 p.m., Richard and Suller’s rooms had already been engulfed in flames; things were in a terrible state. We were unable to control the fire, which kept getting worse until the entire ship was on fire. Each of us made a small mistake that led to a catastrophic error resulting in the loss of the ship and lives. ” After reading this final note, none of the rescuers said a word; there was a deathly silence on the sea, and it seemed as though they could clearly see the entire sequence of events that had taken place. At 1 p.m. on March 23rd, waiter Skorney turned on a lamp in Richard’s room and then left. At 2 p.m., the swaying of the ship caused by the waves led to a table lamp falling onto the ship; the lamp and its bulb were broken, and the resulting short circuit ignited the materials surrounding it. Mechanical engineer Cohen \"didn’t think much about it and closed the valve.\" At that moment, the burning material set the wires on fire. Since this was a \"state-of-the-art ship,\" its lighting system relied on wires that were arranged in a dense network throughout the entire ship. As a result, the sparks from the fires spread immediately throughout the ship’s wiring. Since the wires were usually hidden inside decorative materials, and for fire prevention reasons, these decorative materials had to be highly flame-retardant; it would take some time before a fire could start. By then, however, all the wires in the ship had already caught fire, which is why many crew members \"felt that the air quality was poor.\" At that time, the third engineer, Masin, called the kitchen to confirm that there were no problems, and he also had the crew open the ventilation valves. We knew that the fire started in Richard’s room; Richard’s room was located below the deck, and there was an open flame in that room. Although the wires in other rooms were on fire, no open flames could be seen in those rooms yet. Due to the large amount of air being introduced through the ventilation systems, the oxygen level increased significantly, which caused the fire in Richard’s room to intensify. Many other rooms also developed open flames. The fire broke out at 2 p.m., and at 2:30 p.m., as the fire was spreading, the supervisor, Damon, \"called everyone who wasn’t on duty to the kitchen to help cook for a dinner party\", thereby giving up the opportunity to monitor the various fire sites and extinguish the fires promptly. At 7:30 p.m., when people from various positions reported to Captain McKay that a fire had broken out on the ship and he learned that the main source of the fire was in Richard’s cabin, he issued his first order: close off the passages in the sailors’ quarters to prevent the fire from spreading to the deck! When a few crew members arrived at the door leading to the crew area, they found that Davis had already tied the door to the ship’s hull with wire; thick smoke and intense flames were rapidly spreading through that door and toward the deck. Upon learning that the fire couldn’t be contained, the captain gave a second order: Open the fire hydrants in the crew quarters and put out the fire right there! Several crew members rushed back into the inferno. Enduring the pungent fumes and intense heat, they made their way to the fire hydrant in the crew quarters. Despite exerting all their strength, they couldn’t turn the rusted valve. After holding on for several dozen seconds, they had no choice but to flee from the flames and report the situation to the captain. At this point, the captain kept receiving reports of fires in various parts of the ship; the fire spread throughout the vessel and grew worse by the moment. Then the captain issued a third order: lower the lifeboats and abandon the ship to save one’s life! More than 20 crew members were covered in flames; the smell of burning hair and skin could be detected even from a short distance. Although all of them were severely injured, several crew members around the captain still faithfully carried out his orders. But, good heavens, it was only when they reached the side of the ship where the life raft was supposed to be released that they realized, due to a problem with the release mechanism, the life raft had been firmly tied to a frame by the third officer, Patti, before the ship set sail; it was impossible to drop the life raft into the sea. One can imagine that the entire ship was already on fire. There was no time to go down to the cabin to get a fire axe or pliers, and entering the cabin again would mean certain death from the raging flames. The fire in the bottom hold grew worse and caused the diesel tanks to explode; the diesel that splashed around further fueled the fire. Desperate crew members ran around the ship in panic. At that moment, the ship suddenly tilted to the right. The experienced captain realized that this was due to seawater pouring in as a result of the fire in the right bottom hold. Realizing there was nothing more that could be done, he issued his fourth and final order as captain: to throw the life radio and notes written in 21 different handwriting styles into the vast ocean. Soon, the entire ship sank to the bottom of the Atlantic Ocean, along with its 21 crew members, accompanied by the hostile screeching sounds of water and fire. In determining the cause of this beach accident, it was found that the 21 crew members of the “CircumAtlantic” made serious mistakes in 20 critical details, thereby triggering this catastrophe. Detail one: Richard, in violation of the ship’s safety rules, brought a table lamp aboard, which became the catalyst for the accident – it was as if he had brought a time bomb on board. Detail two: Although Second Officer Thurman pointed out that \"the base of this table lamp is light, so be careful not to let it fall over when the ship shakes,\" he did not stop him from bringing it aboard, thereby violating the regulations regarding mutual supervision to ensure safety – failing to take action when a danger was present. Thurman’s indulgence toward Richard ruined the entire ship, as well as 21 crew members including the captain – and of course himself as well. Detail three: On the afternoon of March 21, Third Officer Patti discovered a problem with the life raft launcher; failing to comply with the regulations regarding the maintenance of safety equipment, she did not repair it immediately. Instead, she tied the life raft to a rack. As a result, 55 hours later, when all the crew members tried to use the life raft to escape, they were unable to release it, thus losing their last chance of survival. As it turned out later, Patty not only tied the life raft to the frame, but also tied the lives of 21 crew members to the ship. Detail four: During the departure inspection, Davies found that the door closer in the crew area was damaged; he tied the door tightly to the ship’s hull using wire. According to safety regulations, the door closer should be replaced immediately, as the doors in the crew area serve to prevent smoke, fire, and even water from entering – they represent the last line of defense in case of an accident. Since this door no longer served as a barrier, it could not stop the fire dragon in the event of a fire, thus failing to buy time for firefighting and evacuation. Detail five: When the second engineer Antel discovered that the fire hydrants in the crew area were rusted and failed to fix the problem in time, it became impossible to use water to extinguish the fire in that area. Antel had thought, \"There are a few days left before reaching the port; I can change then.\" He never imagined that his negligence would prevent the Atlantic Circle from reaching the port, as well as preventing him from doing so himself. Detail six: The biggest mistake was that Captain McKay also had extremely poor safety awareness; he casually disregarded safety inspection procedures. At the time of departure, “he did not review the safety inspection reports from the deck and engine departments.” Had he strictly followed the procedures and reviewed those reports, had he promptly fixed the malfunction in the life raft launcher, had he promptly resolved the issue with the door closers in the sailors’ quarters, and had he promptly addressed the problem with the fire hydrants there, it would at least have been possible to contain the fire to some extent. Furthermore, more broadly speaking, errors made by crew members in all other aspects are directly related to the captain’s usual attitude toward safety oversight and management. McKim’s reason for not reviewing the safety report was \"being busy with work.\" 55 hours after the ship set sail, Captain McKim and 20 crew members sank to the bottom of the sea along with the Atlantic Circumnavigation, and this time he was free forever. Detail seven: Four hours before the fire broke out, mechanic Daniel noticed that the fire alarm sensor in Richard’s room was giving false alarms, so he removed the sensor without replacing it with a new one in time. As a result, when the room caught fire four hours later, there was no sensor to trigger an alarm, which delayed the efforts to extinguish the fire. Detail eight: Chief engineer Whitman, being busy with other tasks, failed to provide Daniel with a new sensor in time, nor did he follow up on the matter, resulting in a management gap that put the entire ship at risk. Detail nine: At 1 p.m. on the 23rd, waiter Skoni was in Richard’s room. He completely forgot about the safety rule of turning off lights when leaving a room; he had no awareness whatsoever regarding the risk of electrical fires. Instead, he “casually turned on his desk lamp.” What Skoni casually switched on wasn’t merely a desk lamp—it was the door to hell for the entire ship. This disaster could have been avoided if the Scornians had turned off the table lamp or unplugged its power cord when leaving the room. Detail ten: Half an hour before the fire broke out, during his safety inspection, Chief Officer Kemp did not enter Richard and Suler’s rooms; he simply told Richard and Suler, who were with him, to go check their own rooms. As one of the key management officers on the ship, Kemp abandoned the security inspection duties assigned to him by the captain, nor did he supervise Richard and Suler as they checked their rooms. Half an hour later, this uninspected room turned out to be the origin of the fire. Detail eleven: Isu Sule failed to carry out the instructions of Chief Officer Kump, nor did he inspect the room that was about to catch fire. Had a routine inspection been conducted and the table lamp switch turned off, this disaster could have been avoided. Detail twelve: Robert also failed to carry out the first mate’s instructions and did not check the rooms. The last chance to hedge against risks simply slipped away. Detail thirteen: When a trip occurs at 2 p.m., if the mechanical and electrical supervisor Cohen conducts a thorough investigation of the cause, he can also identify the desk lamp that has caused a short circuit, thereby eliminating the danger. However, he \"thought nothing of it and closed the switch,\" which caused a large-scale fire. Detail fourteen: When the third engineer, Ma Xing, sensed that the air quality was poor, he checked with the kitchen and found no problems. Instead of reporting this to the first officer Kemp – who was clearly the ship’s safety officer – he had the engine room open the ventilation compartments, which accelerated the spread of the open flame. Detail fifteen: The head chef, Shi Ruo, also lacked a sense of safety; after confirming that there was no fire in the kitchen, he did not urge the third engineer Ma Xing or the first officer Kemp to check other parts of the ship, but instead asked others to help with cooking. Detail sixteen: The second cook, Ursula, also “felt that the air quality was poor,” but thought the kitchen was safe, so she continued cooking without warning any of the crew members, nor did she report to the chief officer or the captain to ask for an investigation into the cause of the poor air quality. Detail seventeen: The mechanic Nupo must have also smelled the burnt smell throughout the ship, but instead of suggesting that someone conduct an inspection, he opened the ventilation valves, which in effect meant turning on the blowers in the area where the fire was. Detail eighteen: At 2:15 p.m., when the fire was spreading and the smell of burning filled the entire ship, steward Damon failed to raise any alarm. Instead of sending those who were not on duty to investigate the cause of the poor air quality, he gathered all such people in the kitchen to help with cooking. / Detail nineteen: If Dr. Morris had insisted on carrying out his routine inspections, he would have been able to detect not only the fire in Richard’s room but also smoke coming from many other cabins. Yet this last opportunity to discover the fire was lost. Detail twenty: Electrician Holin was on duty that night; if he had stayed at his post and continued with his inspections, he would have noticed that the wires were on fire. By cutting off the power supply early, it might have been possible to buy some time to extinguish the fire. In reality, however, Holin “went into the restaurant while on duty.” From an analysis of these 20 details, it is clear that the crew aboard the Titanic had extremely poor safety awareness, that the systems in place were ineffective, that job responsibilities were not fulfilled, and that operational standards were not met. It must be said that Captain McKayem is a rather incompetent captain. It seems, then, that a fire and sinking are inevitable, while safe navigation is accidental; if the \"Transatlantic\" ship did not catch fire and sink on March 23rd, it is inevitable that it will catch fire and sink on × month 23rd as well. “The sum of 20 minor errors on the Ring Atlantic led to the ship and its 21 crew members sinking to the bottom of the sea.