El Faro - An Overview


#1

Months ago, I made a timeline with essential (my view) data from official sources, to understand the way into this disaster. Updated and completed with my personal remarks, it follows:

All times EDT.
Times of the NAVTEX are from the docket listing, some minutes later than arrival on the bridge.

05:15 on Sep 30 NAVTEX: Tropical Storm Joaquin will become Hurricane this morning.
Moving SW; next night expected to be at 24.7°/-74.5°, 35 NM North of San Salvador Island.

06:00 - Change of course, more southerly, nearer to the Bahamas islands.

Obviously, they have seen that Joaquin did not perform as foreseen at departure time.
If they have seen the latest NAVTEX… they did not read it.
Captain and CM prepared the new route. CM tried to speak about the Old Bahama Channel, but the captain’s interest seemed to be the ETA, with Joaquin just as a nuisance.

12:13 NAVTEX: Hurricane Joaquin expected to be next night at 24.1°/-74.0°, 22 NM east of San Salvador Island, moving SW, strengthening.

At this time, El Faro is at the northern limit of the Little Bahama Bank, free to go W to the Florida Straits.

14:15 - USCG aircraft on VHF16: Hurricane Warning for Central Bahamas (Salvador, Rum Cay…) and Hurricane Watch for Northern Bahamas (Abaco…). Repeated at 14:38.

Capt and 2M said “wow… an aircraft”, but they confounded ‘Watch for Abaco’, where they were, with ‘Warning for Salvador’, where they went to, Maybe they ‘read’ what they hoped for: Joaquin turns North…

17:00 - 2M and AB-2 had a long discussion about the SAT-C weather for 02:00 “…that’s where we should be and that’s where the hurricane’s gunna be. [sound of giggling.]”
17:12 – CM joined the discussion…”fascinating…”
17:30 – Captain on bridge, informed by CM… will wait for new BVS weather…

17:35 NAVTEX: Joaquin moving SW and strengthening, estimated position on morning, Oct 1, 23.9°/-74.5°.

This expected position of Joaquin is at the southern tip of San Salvador Island !

18:00 - Latitude Hole in the Wall, El Faro at 25.9°/-75°, the last possibility to escape to the Florida Straits, taking the New Providence Channels.

Not used. From now on, the choice was limited to the most or the least horrible route.

19:00+ Captain and CM planned route for the night

19:59 - Captain left the bridge for the night.
Route for the night: Pass San Salvador on its West side, then straight to a point off San Juan !
BVS download from 17:00 – Joaquin’s position at 02:00 = 24.3°/-73.6°

This is 55 NM ENE of the expected NAVTEX position received at 17:35.
For later hours, BVS did not see Joaquin going south of San Salvador
Vive le Bon Voyage, and its lovely colored charts!

23:02 - BVS sent mail to El Faro: Forecast is ready for download.

If downloaded, it would have shown Joaquin going a bit south of San Salvador…

23:05 - After long weather discussions between 3M and AB-3, 3M called the captain and asked to verify his own estimation of being on a collision course with Joaquin.
To AB-3: “he seems to think that we’ll be south of it by then– so the winds won’t be an issue”

23:16 NAVTEX: Joaquin now at 23.8°/-73.1°, moving SW 220°, strengthening.

At this time El Faro is NW of Salvador, at 24.5°/-75.1°, course SE 150°, Joaquin is at 120 NM, bearing 111°.

01:00 on Oct 01 - El Faro West of Salvador Island

01:20 - El Faro position between South San Salvador and Rum Cay, before course change.
After long discussions 2M <> AB-2, 2M calls the Captain on the phone:
We would run into Joaquin’s center, I want to change the plan and go straight South.
To AB-2: he wants to hold on the planned course.

She proposed to escape through the Crooked Island Channel and then join the Old Bahama Channel. A minor route extension of about 80 NM.
With the info they had on the bridge, this was not THE safe route, there was none, but it was the least horrible one.

01:30 - South of Salvador Island, new (planned) course 116°, direct to N off San Juan

…and on collision course with Joaquin.
They chose the most horrible solution.

03:44 - CM on bridge

04:09 - Captain on bridge
CM turned off the sound of the permanent off course alarm.

They are in survival mode now!

04:45 - from BVS’ server log: El Faro finally downloaded the 23:02 forecast.

I did not mention the other BVS downloads: they were always outdated and false…

05:18 NAVTEX: Joaquin now at 23.4°/-73.7° moving WSW at 4 knots, intensifying.

This estimated position and El Faro’s AIS position would be 9 NM apart!

05:43 - Water ingress detected (the scuttle).

06:13 - El Faro lost propulsion…

07:35:45 - Last AIS data received
07:39:41 - End of VDR recording


What books are you reading or have finished lately
El Faro Resources
#2

This post is a work in progress

NTSB Public Meeting of December 12, 2017 (preliminary report)

El Faro VDR Transcript

United States Coast Guard Marine Board of Investigation Report

Marine Board of Investigation Hearing 1 Day 1 Transcript

16 February 2016

WIT: Phillip Morrell - Vice President of Marine Operations Commercial.


Hearing 1 Day 2 Transcript

17 February 2016

WIT: Philip H. Greene - President of Tote Services Incorporated.

Hearing 1 Day 3

18 February 2016

Capt Loftfield - Capt of El Yunque page 1- page 37

Second mate Baird - previous voyage 2nd Mate of El Faro p 37 - p 103

Capt Loftfield p 38 to End

Hearing 1 Day 4

19 February 2016

WIT: Jim Fisker- Andersen, Port Engineer, Tote Services Incorporated. Begin to p 89

Mr. Berrios - Second Officer aboard Isla Bella on Tote Maritime.p 90 to p 136

Tony Callaway with PORTUS. (shore side cargo loading / lashing ) P 136 to end

Hearing 1 Day 5

20 February 2016

Mr. Johnathan Lawrence, Tote Services Incorporated, Manager of Safety and Operations. - Designated Person Ashore (DPA) Begin to p -110

Ronald Rodriguez, terminal manager p-110 to p168
Mr. Donald Matthews, Marine Operations Manager. p-169 to end

Hearing 1 Day 6

22 February 2016

Captain John Warner Mauger Commanding Officer of the Coast Guard’s Marine Safety Center. Begin to p 109

Captain Kyle McAvoy, Chief of the Office of commercial vesselcompliance at Coast Guard Headquarters. P 109 to end

Hearing 1 Day 7

23 February 2016

Mr. James Robinson, former Chief Engineer of the El Faro. Begin to p 109

Walker able seaman maintenance p 109 to p 138

Captain Todd Coggeshall, the Seventh Coast Guard District Director of Inciden Management. p-139 to end

Hearing 1 Day 8

24 February 2016

Matthew Cadmon unit controller and situation unit controller for the Coast Guard Seventh District in Miami Florida. Begin to p 57

57 to 130 VDR experts

Vagts Chief Mate Isla Bella p 130 to end

Hearing 1 Day 9

25 February 2016

Torres, former Chief Mate on the El Faro Begin to p 88

Beisner Sector Jacksonville as a Marine Inspection Apprentice and also Port State Control Branch Chief. P 89 to p 109

Mr. Luke Laakso, Walashek boiler inspector P 110 to end

Hearing 1 Day 10

26 February 2016
Louis Charles O’Donnell, Assistant Chief Surveyor of the Americas Division for ABS. Begin to p 118

Mr. Tim Neeson, Port Engineer, Tote Services Incorporated. p 119 to End

VDR Transcipts

El Faro Marine Board of Investigation Document Library

Main page

Docket page


#3

The first time I looked up the term “information” on Wikipedia it said something along the lines was that it was what was required to change the “state” … seems like they were saying to flip something from “1” to “0” If a message doesn’t change the state, then it’s not information. (?)

In a computer it take 1.2 volts to flip from 0 to 1. For human it is much more, it might take 440 volts and 30 amps (that’ll learn ya)and depends on many things. For one who the message is coming from etc.

So the captain of El Faro has a mental model of what’s happening. To change his mental model he needs information. But he is going to reject a message that doesn’t conform to his prior beliefs.

The captain actively wants to reject a message that doesn’t conform to his belief.

Overall it’s a mistake to focus too much on one particular event, the whole picture is important but…

Having said that, take the 2/m message to the captain at 0120, why does he reject that message? I have to guess but:

#1 reason - doesn’t fit what I "know’ for sure.

  • 2/m has never been to Alaska, doesn’t know real bad weather
  • 2/m doesn’t know what the ship can take
    -2/m easily rattled by a something she heard on the XM radio

At this point, that captain needs more than a message, he needs information.

For example, from the 2/m to the capt: _According to your night orders (there actually were none) you expect max 50 kt winds on the stbd beam, but I am right now getting 70 kts wind on the port beam and it not backing as you expect, it’s veering and getting worse, barometer is dropping like a stone. According to my plot, carried out as per your instructions, we are heading for the eye wall, dangerous side. _

And I’m not guessing about wind. It’s a 10 minute average reading from a digital marine grade anemometer and a split second before I took the reading it had been calibrated by top members of the state AND federal Department of Weights and Measures… to be dead on balls accurate! *

*My Cousin Vinny.


#4

#5

It works down to doing a cross-check.

1.verify (figures or information) by using an alternative source or method.

How is having the captain using the BVS weather program any different the a new third mate with his head stuck in an ECDIS? The difference is hopefully someone is keeping an eye on the new third mate and will set him right.