El Faro NTSB Human Factors Factual Report


#1

El Faro NTSB Human Factors Factual Report

Report includes: Crew qualifications, training, crew evaluations, shoreside support, company organization, Safety Management System.


#2

This is new information from Davison’s previous employer.

Investigators requested from the captain’s previous employer a copy of his performance evaluations (and related material) for the last 2 years of employment, any disciplinary reports, and his letter of resignation.

Although the company provided no performance evaluations, investigators found documentation related to his performance, including two letters of warning and a letter describing a meeting between the captain and management in which they discussed the following four areas: overtime for cargo operations; concern of unprofessional or disparaging remarks to nonvessel personnel by vessel officers; perception of master disassociating himself from daily activities; and perception of disharmony between master and senior officers.

During this meeting, management advised the captain that he was to be conscious of his “interactions with his senior officers and to exert efforts to dispel any perceptions of disharmony—this is not to say that the master is to everybody’s best friend, but to manage a safe and healthy working environment.”

In one letter of warning, two violations were listed in relation to the reporting of an accident. The company warned that “any further incidents of policy infractions or poor job performance would cause us to have a loss of confidence in you as master within our fleet of vessels,” resulting in further disciplinary action, up to and including termination.

A second letter of warning indicated a failure to notify management of actual or suspected cargo damage. The letter stated: “Previously you have been warned that any further incidents of policy infractions or poor job performance would cause us to have a loss of confidence in you as master within our fleet of vessels, and more severe disciplinary action, up to and including, your termination would occur.”

The captain submitted his resignation letter during the month of the second warning letter.


#3

I am still confused as to why employees of Parties In Interest were full members of an NTSB Group. I went back through the dockets of joint USCG/NTSB investigations to 1995 and the only times I saw this was when the vessel was of a specialized nature (e.g. DUKW). Perhaps someone with more experience in these kinds of investigations can shed some light on this.

Earl


#4

The Master lost Situational Awareness. See page 77.