The Sultana disaster was the worst maritime disaster in U.S. history. On April 27, 1865, three boilers exploded on the steamship Sultana on the Mississippi River near Memphis, killing around 1,800 people, mostly Union soldiers returning home from Confederate prisoner-of-war camps. The disaster was the result of a series of cascading events, including faulty and hastily repaired boilers, an overloaded ship in poor condition carrying around 2,400 people, strain on the engines from navigating upstream against flood waters, and the physical conditions of the passengers from their time as POWs. While some speculate sabotage may have played a role, the preceding events had already set the stage for catastrophe. No one

1. The Worst Maritime Disaster
In U.S. History Occurred
On A River

2. 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

3. “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 Sultana
The Greatest Maritime Disaster in
United States History

4. 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.
THE FACTS

5. 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 departs Memphis and
then explodes
THE TIMELINE

6. 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 from Vicksburg.
(interestingly, the Sultana also brought the first word
up-river of Lincoln’s assassination)
Cascade 1

7. Lesson: Greed Leads to Speed which Kills.
Steamship Boilers

8. 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
transportation home.
A number had to be carried on board on
stretchers.
Cascade 2

9. Cascade 2

10. LESSON: Physical Condition is a factor not only in
survival but in the will to live. Andersonville is the
worst Civil War location I’ve ever visited. You can
literally feel the ground crying out in pain.

11. 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.
Cascade 3

12. 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.

13. 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
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
overheat without water to be made into steam.
Cascade 4

14. 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.

15. 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.
Cascade 5

16. 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.

17. 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.
Cascade 6

18. LESSON: Catastrophes rarely happen at opportune
times.

19. The boilers explode. Approximately 1,800 crew and
passengers die.
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.
Final Event

20. 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
Sultana catastrophe.
Final Event

22. Seven Ways to Prevent Catastrophes
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)

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