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.
One minute 38 seconds
The Worst Maritime Disaster in US History: Sultana
The Worst Maritime
Disaster in United States
History, occurred on a
river, not the ocean.
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.
Anatomy of Catastrophe
“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.
The Greatest Maritime Disaster in
United States History
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 Lincoln’s assassination)
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.
Many who boarded the Sultana were former
POWs from Andersonville and Cahaba. They’d
survived horrific conditions, and most had walked
all the way to the Mississippi to get
A number had to be carried on board on
LESSON: Physical Condition is a factor not only in
survival but in the will to live.
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.
The captain made an under the table deal to kick
back to the Quartermaster at a rate of $1.15 for
every soldier carried. 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 regulations.
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 only recently
discovered; in a field two miles from today’s current river
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
overheat without water to be made 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 disaster.
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 explosion.
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 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. Even some
who survived in the water initially, succumbed to
hypothermia before rescue could arrive.
LESSON: Catastrophes rarely happen at opportune
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
Seven Ways to Prevent Catastrophes
1. Have a Special Ops preparation mindset
2. Focus by utilizing both big picture & detail
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
Are you interested in a presentation about various
catastrophes and how the cascade events could have been
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
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 email@example.com
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THE GREEN BERET PREPARATION AND SURVIVAL GUIDE
The guide on the left is a complete preparation and
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New York Times bestselling author, graduate of West Point
and former Green Beret. He’s had over 75 books published,
including the #1 bestselling series Green Berets, Shadow
Warriors, Time Patrol, Area 51, and Atlantis. Born in the
Bronx and having traveled the world he now lives peacefully
with his wife and dogs. Sort of.