Cockpit Resource Management (CRM) was begun in 1979 as a result of a NASA workshop. One of the key elements was to make sure that co-pilots would be more responsive to warning/advising the pilot. In the case of Air France Flight 447, they didn’t even get to that stage, with two co-pilots, both of whom tried to control the plane. Instead of working together, they actually worked against each other.The situation got worse when the Captain entered the cockpit, with neither co-pilot filling him in on the sequence of events and vital readings which might have allowed the Captain to quickly assess the situation.
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There’s a common image of a red and white sign for Area 51 you can find
There’s a common image of a red and white sign for Area 51 you can find
The Worst Maritime Disaster in US History
The Rule of Seven:
Every catastrophe has 7 events.
Six Cascade Events leading to the
final event, the Catastrophe. At
least one of the Cascade Events
involves human error. Thus most
catastrophes can be avoided.
“If we arrive safe at Cairo (IL) it would be
the greatest trip ever made on the western
waters, as there were more people on board
than were ever carried on one boat on the
Mississippi River!” William J. Gambrel, first
clerk & part owner of the steamship Sultana.
On 27 April 1865, three of four boilers on
board the Sultana exploded, killing
approximately 1,800. This was a greater loss
of life than the Titanic. Most of those killed
were Union soldiers who were former
prisoners of war returning home.
This occurred on the Mississippi River,
roughly eight miles north of Memphis in the
middle of the night.
21 April 1965: Sultana departs New Orleans
24 April 1865: Sultana arrives at Vicksburg;
boiler is ‘repaired’. The boat is overloaded,
mostly with former Union POWs
26 April 1865: Sultana docks at Memphis
27 April 1865: Sultana explodes
Faulty and Hasty Repairs on a boiler.
The Sultana departed New Orleans with a faulty boiler, but
continued for two days until reaching Vicksburg. Instead of replacing
it, which would take too long, the Captain over-rode the engineer’s
protests and ordered him to patch it.
His reason: Lack of funds for a replacement and fear of losing out on
the lucrative government contract for transporting soldiers home
out of Vicksburg.
(interestingly, the Sultana also brought the first word up-river of
Lesson: Greed Leads to Speed which Kills.
Most of the passengers were in poor physical health and unable
to deal with a catastrophe, especially on water.
The majority of those who boarded the Sultana were former
POWs from Andersonville and Cahaba. They’d survived horrific
conditions, and then most had walked all the way to the
Mississippi to get transportation home.
A number had to be carried on board on stretchers.
LESSON: Physical Condition is a factor not only in survival but
The Sultana was grossly overloaded.
With a legal capacity of 376, it is estimated there were
roughly 2,400 people on board the Sultana.
The ship’s owners received $5 for every enlisted man
carried and $10 for every officer.
And the ship’s captain made an under the table deal to
kick back to the Quartermaster who determining how
many passengers were loaded at a rate of $1.15 for every
Another steamship, Lady Gay, was larger than Sultana
but left Vicksburg without a single soldier because its
Captain would not participate in the kickback scheme.
LESSON: The lure of ‘easy money’ and the kick back scheme
set the stage for disaster. Regulations, concern for safety, and
common sense all disappeared. Each soldier was viewed as
cash, not a human being. The Quartermaster violated Army
Traveling up-river, and against the spring flood, put more
strain on the engines than normal and made the top-heavy
boat more liable to lean when turning.
It was spring and the Mississippi was surging, which required
more steam to navigate. The river also has many turns. In fact,
the location of the wreck was recently discovered; in a field two
miles from today’s current river course.
It was while navigating a cluster of islands nicknamed “Hen and
Chickens” that the damaged boiler exploded.
When the boat leaned, water flowed from the upside boilers to
the downside. This made the upside boilers very hot without
water to be heated into steam.
LESSON: Cascade events pile up. Combine a hastily patched
boiler, an overloaded boat, extra power needed to navigate
upstream, turns with a top-heavy hull (because it was overloaded
and most passengers were on deck) and we have a recipe for
Technically the country was still at war & there is the
possibility the explosion was the result of sabotage.
While most people think the Civil War ended at Appomattox
on 9 April, it officially ended on 9 May 1865; after the Sultana
Agents were known to use ‘coal torpedoes’. These were
artillery shells fashioned to look like pieces of coal and
painted black. Loaded onto the steamships during refueling,
they exploded when shoveled into the boiler.
Years after the war, on his deathbed, a former Confederate
agent, confessed to planting a coal torpedo on the Sultana.
History withholds judgement on this.
Lesson: Even if this was what happened, the loss of life
would have been much less if the preceding Cascade Events
weren’t already present.
The explosion occurred at night with no other boats in the
immediate vicinity to help with rescue.
Almost every possible catastrophe is made worse if it occurs in
the dark. The ship departed at midnight. While the Sultana was
on a river, with the shore on either side, most of those on
board didn’t know how to swim.
For many who survived the initial explosion, they faced a
terrible choice: be consumed by fire on board the sinking ship;
or jump into the water. A similar choice would be forced on
people on 9-11.
Even some who survived in the water initially, succumbed to
hypothermia before rescue could arrive.
LESSON: Catastrophes rarely happen at opportune times.
The boilers explode. Approximately 1,800 crew and
Given the patch job on the boiler, the over-loading, the
river, the timing, etc. it was almost inevitable disaster
would occur (as the quote at the beginning of this
presentation indicates). The Captain believed they would
“dodge the bullet”; which is hoping for a Delusion Event
rather than a Catastrophe.
A Delusion Event is when a Catastrophe is avoided only by
luck; but it makes one more confident this will always be
the case. Delusion Events inevitably lead to Catastrophes.
LESSON: Greed is an incubator for catastrophe.
Whether it’s cutting costs or trying to make a profit.
Regulations are there for a reason. Sadly, the
Quartermaster who took the kickbacks had been
arrested earlier in the war for taking bribes, but never
court-martialed. He was from Illinois, where his
brother was Secretary of State and intervened to get
Lincoln to personally write a letter, keeping the
Quartermaster from being court-martialed.
Ultimately, no one was held responsible for the
1. Have a Special Ops preparation mindset
2. Focus by utilizing both big picture & detail thinkers
3. Conduct Special Forces Area Studies
4. Use the Special Forces CARVER formula
5. Have a “10th man”
6. Conduct After Action Reviews
7. Write and USE Standing Operating Procedures (SOPs)
Shit Doesn’t Just Happen: The Gift of Failure
Are you interested in a presentation about various catastrophes and
how the cascade events could have been prevented?
Events covered range from human-machine interface, to leadership,
to communication, cost-cutting, engineering, group think,
perseverance, systematic failure, and more?
Catastrophes are cascade events culminating in disastrous chaos.
War is chaos. Special Forces is the most elite unit trained for a variety
of combat situations.
What makes Special Forces elite is our mindset and preparation.
Are you interested in a presentation on how to use Special Forces
tactics, techniques and mental attitude to help your organization
anticipate and prevent potential catastrophes?
Please email firstname.lastname@example.org
Bob Mayer is a NY Times Bestselling author, graduate of West Point, former Green
Beret (including commanding an A-Team) and the feeder of two Yellow Labs, most
famously Cool Gus. He’s had over 70 books published including the #1 series Area 51,
Atlantis and The Green Berets. Born in the Bronx, having traveled the world (usually
not tourist spots), he now lives peacefully with his wife, and said labs.
Bob has presented for over a thousand organizations both in the United States and
internationally, including keynote presentations, all day workshops, and multi-day
seminars. He has taught organizations ranging from Maui Writers to San Diego State
University, to the University of Georgia, to the Romance Writers of America National
Convention, to Boston SWAT, the CIA, the Royal Danish Navy Frogman Corps, Fortune
500 companies, IT Teams in Silicon Valley, National Guard units, Ohio State University
Nursing Program, Army Reserves, and many others. He has done interviews/consulted
for the Wall Street Journal, NY Times front page, Forbes, Sports Illustrated, PBS, NPR,
the Discovery Channel, the SyFy channel and local cable shows.