El Faro - What was the Captain Thinking is the Wrong Question

Professional Mariner Forum
121

You’re right that the mates did exactly what would be expected of them. If things were unfolding in a way that was not expected, given their workload (in hindsight it’s easy to forget they had a watch to run) we’d expect them to feel uneasy and perhaps confused on some details. They did in fact have doubts, almost upon arrival on watch at 01/0400 the mate says: “I don’t like this”. But all three mates did the right thing, called the captain.

As for the captain not being on the bridge, that’s a mystery because from the transcripts he told the mates that he would be on the bridge most of the night.

122

[QUOTE=Lee Shore;195930]Confused 30 foot seas would likely swing a dead ship past 10 degrees to either side of the reported 15 degree list, rapidly accelerating water ingress.[/QUOTE]

I wouldn’t even know where to start in determining the range of rolling in this case. La Dage and Gemert says [I]“stability of a vessel due to flooding involve detailed and difficult calculations”[/I].

I’d be curious to see how you came up with the 10 degree roll.

123

[QUOTE=Kennebec Captain;195963]I wouldn’t even know where to start in determining the range of rolling in this case. La Dage and Gemert says [I]“stability of a vessel due to flooding involve detailed and difficult calculations”[/I].

I’d be curious to see how you came up with the 10 degree roll.[/QUOTE]

Sadly, I am incapable of performing “detailed and difficult calculations”, but like probably most of us here, I’ve been through some seriously shitty weather.
The 10 degree roll is obviously a guess. It’s a guess based on the knowledge that seas near the eyewall of a hurricane are known to be extremely chaotic, that 30 foot seas were reported, that the ship was dead in the water, and from the heart wrenching VDR recording.
Feel free to guess.

124

Anybody knows what the present status is of Captain John Loftus’ Open Letter to our friend Neubauer? Governments don’t like whistleblowers so I am curious whether they consider his open letter as valuable input into their analysis and whether anything is done with it or that it will end up in the shredder.

125

[QUOTE=Lee Shore;195964]Sadly, I am incapable of performing “detailed and difficult calculations”, but like probably most of us here, I’ve been through some seriously shitty weather.
The 10 degree roll is obviously a guess. It’s a guess based on the knowledge that seas near the eyewall of a hurricane are known to be extremely chaotic, that 30 foot seas were reported, that the ship was dead in the water, and from the heart wrenching VDR recording.
Feel free to guess.[/QUOTE]

If you’ve ever been in heavy weather when other ships are about you might notice that similar ships respond to the wind/sea in different ways. This is also often apparent when several ships are anchored in an exposed off-shore anchorage. When a swell is present in an off-shore anchorage some ships may roll to large angles while other ships sit quietly. Variations over time in swell height, period or direction change the responses of each ship in different ways.

Another important factor is stabilty. On the most fundamental level ship stability is about the location of weights in the ship. When a ship floods the added water may make the ship more stable because weights are added low in the ship but on the other hand the increased free surface may make it less stable.

Extrapolating experience in heavy weather aboard one ship to determine the behavior of a different, flooded ship, in different conditons is of little value and in fact likely misleading.

126

[QUOTE=Kennebec Captain;196004]If you’ve ever been in heavy weather when other ships are about you might notice that similar ships respond to the wind/sea in different ways. This is also often apparent when several ships are anchored in an exposed off-shore anchorage. When a swell is present in an off-shore anchorage some ships may roll to large angles while other ships sit quietly. Variations over time in swell height, period or direction change the responses of each ship in different ways.

Another important factor is stabilty. On the most fundamental level ship stability is about the location of weights in the ship. When a ship floods the added water may make the ship more stable because weights are added low in the ship but on the other hand the increased free surface may make it less stable.

Extrapolating experience in heavy weather aboard one ship to determine the behavior of a different, flooded ship, in different conditons is of little value and in fact likely misleading.[/QUOTE]

OK, you win. She was probably steady as a rock as she sat dead in the water in 30 foot seas, within spitting distance of the eyewall, and contrary to what the board of inquiry thinks, the loud banging reverberating from the lower decks heard on the VDR was not from cargo that had broken loose. It was actually the sound made by frustrated engineers pounding on the boilers with sledgehammers in an effort to jumpstart the plant. Feel better?

PS - I don’t disagree that different ships respond differently in similar swell conditions but get real. These were extreme conditions.

127

[QUOTE=c.captain;196012]this is getting ridiculous…not having a working anemometer did not lead the EL FARO into peril. BAD DECISION MAKING ON THE PART OF THE MASTER LED TO THE LOSS. HIS NOT BEING ON THE BRIDGE AS THE VESSEL APPROACHED THE CENTER OF CIRCULATION IS WHAT KILLED ALL OF THEM![/QUOTE]

Or - was it was the decision-making “box” where the captain found himself?

Remember the Movie “Master and Commander”? That captain had full control of his ship, his crew, his schedule and so forth. His instructions left many decisons up to his discretion. He could have sailed around the Horn or waited a few days for weather, could have sailed up the coast of S. American or back down the coast at will. It was understood the the captain alone was responsible for the success of the misson.

Not so today, over the years the decision making “box” - the area where the captain actually has control has gotten smaller and smaller. The captain on the JAX/SJU run has a very small decison making box, his range of options is limited. The captain today is essentially no more than a bus driver.

He is told what cargo to take, when to sail, critically what repairs will or will not be made and so forth. The office even, at times, decides when the captain will work and when he can sleep.

His area of responsbilty has however remained the same, still responsible for the outcome.

In this case there should have been in place a procedure to limit the captains ability to take on additional risk. For example there could have been in place a requirement that once the voyage violated the 1-2-3 rule, or something like it, the captain be required to get routing assistance.

128

[QUOTE=Kennebec Captain;196034]Or - was it was the decision-making “box” where the captain found himself?[/QUOTE]

box…shmox! the master of the EL FARO never for one second lost his ability to slow or stop the vessel’s progress as it approached Joachim. Never anywhere does a master lose that simple authority. He may be stoopid or a coward to Joe Boss but never ever has the right to keep his vessel safe taken away from him

129

[QUOTE=Kennebec Captain;196034]Or - was it was the decision-making “box” where the captain found himself?

Remember the Movie “Master and Commander”? That captain had full control of his ship, his crew, his schedule and so forth. His instructions left many decisons up to his discretion. He could have sailed around the Horn or waited a few days for weather, could have sailed up the coast of S. American or back down the coast at will. It was understood the the captain alone was responsible for the success of the misson.

Not so today, over the years the decision making “box” - the area where the captain actually has control has gotten smaller and smaller. The captain on the JAX/SJU run has a very small decison making box, his range of options is limited. The captain today is essentially no more than a bus driver.

He is told what cargo to take, when to sail, critically what repairs will or will not be made and so forth. The office even, at times, decides when the captain will work and when he can sleep.

His area of responsbilty has however remained the same, still responsible for the outcome.

In this case there should have been in place a procedure to limit the captains ability to take on additional risk. For example there could have been in place a requirement that once the voyage violated the 1-2-3 rule, or something like it, the captain be required to get routing assistance.[/QUOTE]

It has been my experience and observation that the strongest boxes are the ones we build around ourselves. I am willing to consider that the captain regarded slowing down as the equivalent of pushing the “get fired” button.

As far as authority structures go, it has also been my experience and observation that one can build a structure that maximizes the potential and effect of good decisions or one that minimizes the potential and effect of bad ones, but it is very hard to come up with a system that does both. BP was a good example. John Browne’s radical reorganization into a what was in effect a venture capitalist/hedge fund structure was spectacularly successful in generating good decisions about financial performance. The problem was that the structure stripped away all things that inhibited bad decisions about catastrophic physical risk.

Cheers,

Earl

130

Yes, something to keep in mind. Another thing is your reputation for being a skilled captain. Nothing like the joy of beating a sister ship that picked a different route on a rough winter x-pac trip. (tip: use professional weather routing)

As far as authority structures go, it has also been my experience and observation that one can build a structure that maximizes the potential and effect of good decisions or one that minimizes the potential and effect of bad ones, but it is very hard to come up with a system that does both. BP was a good example. John Browne’s radical reorganization into a what was in effect a venture capitalist/hedge fund structure was spectacularly successful is generating good decisions about financial performance. The problem was that the structure stripped away all things that inhibited bad decisions about catastrophic physical risk.

Cheers,

Earl

There is a good explanation how companies culture can change in the book "Managing the Unexpected. using the example of Washington Mutual.

131

[QUOTE=Kennebec Captain;196073]
There is a good explanation how companies culture can change in the book "Managing the Unexpected. using the example of Washington Mutual.[/QUOTE]

Another good example is in Steve Coll’s Private Empire about Exxon Mobil. Reading that, and talking to EM veterans, brought back memories of Curtis LeMay’s Air Force :slight_smile:

Cheers,

Earl

132

This is exactly what I mean. We can say in hindsight that the captain had this option or he had that option but what matters is what options the captain believed he had at the time.

From the transcript:

AB-116:15:53.9so what did you say– there could be a chance that we could turnaround?

CAPT16:15:57.6 huhhh?

AB-116:15:58.8 no. I’m just bein’ nosey.

CM16:16:00.6 this storm.

CAPT16:16:01.9 oh. no no no. we’re not gunna turn around– we’re not gunna turnaround.

CM16:16:04.7 so that’s it then.

CAPT16:16:06.9 the– the– the storm is very unpredictable– very unpredictable.

Turning around was absolutely possible and without a doubt within the captain’s authority, but, for whatever reason, the captain did not consider it an option. He’s very emphatic about that.

The captain wants to meet his goals, but stay inside the parameters of what is acceptable to him. He don’t want to turn around (take a loss then and there) but he does feel he can take on just a bit more risk.

This should be changed. There should be a hard limit (for example stay outside 34 kt wind field) on how much risk he can take without conferring with shoreside.

That close to a TC should be outside the range of possible solutions.

133

It seems to me that people who feel that their choices are restricted so much by their bosses or corporate structure or whatever that they don’t have the freedom to do their job properly and to their own standards complain to someone. A spouse, a friend, a co-worker, someone. Now, I’ve never heard a captain complain this way to an officer or crewman. I can imagine that the spouse gets an earful though, and maybe a buddy, too. Wouldn’t a captain in this situation feel frustrated by it? Wouldn’t he have expressed those feelings to someone? Wouldn’t that person have said something after the loss? Does it seem likely that he would not have been frustrated by this assumed lack of freedom? Does it seem likely that he never told anyone?

134

[QUOTE=Earl Boebert;196072]It has been my experience and observation that the strongest boxes are the ones we build around ourselves. [B]I am willing to consider that the captain regarded slowing down as the equivalent of pushing the “get fired” button.[/B]

As far as authority structures go, it has also been my experience and observation that one can build a structure that maximizes the potential and effect of good decisions or one that minimizes the potential and effect of bad ones, but it is very hard to come up with a system that does both. BP was a good example. John Browne’s radical reorganization into a what was in effect a venture capitalist/hedge fund structure was spectacularly successful in generating good decisions about financial performance. The problem was that the structure stripped away all things that inhibited bad decisions about catastrophic physical risk.

Cheers,

Earl[/QUOTE]

I would much rather “get fired” than “get dead”.

135

[QUOTE=Kennebec Captain;195947]You’re right that the mates did exactly what would be expected of them. If things were unfolding in a way that was not expected, given their workload (in hindsight it’s easy to forget they had a watch to run) we’d expect them to feel uneasy and perhaps confused on some details. They did in fact have doubts, almost upon arrival on watch at 01/0400 the mate says: “I don’t like this”. But all three mates did the right thing, called the captain.
[/QUOTE]
Its an age-old dilemma. I don’t mean to trivialize the debate, but it reminds me of this quote from Fargo:

Jeb Cheney: "You Minnesota boys don't got much in the way of backbone, now, do ya?
Hank Larsson (Ted Danson): Well, now, I wouldn't say that. Just like to think things through.
Jeb Cheney: Mm. Army?
Hank Larsson: Yes, sir. Liberated France in the great war. Not single-handedly, but I like to think they couldn't have done it without me.
Jeb Cheney: Well, then, you know it's the generals that do the thinkin' and everybody else just says, "How high?"
Hank Larsson: I'm not gonna debate the merits of top-down decision makin' with ya, Captain. 'Cept to say I had a lieutenant in the war, and h-he told Eisenhower to go to hell once, on account of his orders woulda got us all killed. And I send that man a card every Christmas-- 'cause I can."
136

[QUOTE=Emrobu;196086]It seems to me that people who feel that their choices are restricted so much by their bosses or corporate structure or whatever that they don’t have the freedom to do their job properly and to their own standards complain to someone. A spouse, a friend, a co-worker, someone. Now, I’ve never heard a captain complain this way to an officer or crewman. I can imagine that the spouse gets an earful though, and maybe a buddy, too. Wouldn’t a captain in this situation feel frustrated by it? Wouldn’t he have expressed those feelings to someone? Wouldn’t that person have said something after the loss? Does it seem likely that he would not have been frustrated by this assumed lack of freedom? Does it seem likely that he never told anyone?[/QUOTE]

The way I see it is that captains today, especially on runs like JAX/SJU, are essentially bus drivers. But there’s nothing wrong with being a bus driver! It’s actually often very interesting work.

But a problem arises if the company does not recognize they are essentially a bus company.

For example with busses, if a snow storm hits, an each individual bus driver doesn’t make the decision to divert around a steep hill made slippery by snow. Instead the driver has to report to the bus dispatcher that the hill is getting slippery and someone in authority has to cancel service on that route.

Otherwise each bus driver will decide on his own whether to tackle the hill or not. Each driver will have a different appetite for risk. Imagine if each driver has to report that he believes he lacks the skill to tackle the hill but not if he believes he can handle it. Drivers with less experience in snow may have more confidence.

In this case with TOTE evidently the captain believed there was an unstated requirement to get permisson to divert but there is not a requirement, stated or not, to notify the company when more risk is taken.

The cost/risk evaluation system is biased to take on more risk.

137

I have been a bus driver. A bus driver is obligated to drive for conditions and take all precautions to preserve the life of her passengers and the people who are sharing the road with her. Bus driving is prudence, prudence, prudence, care, patience and prudence. You have to know the condition of your coach, tires, engine,safety equipment, inspect it every day, know the road conditions, even know your passengers. You have to know who to call and when. When I drove, I was in a city a mile and a half above sea level. We had more weather than the buses could handle some winter nights. I think your bus driver analogy is great, but I don’t think it makes the point that you’re trying to make.

138

[QUOTE=Emrobu;196105]I have been a bus driver. A bus driver is obligated to drive for conditions and take all precautions to preserve the life of her passengers and the people who are sharing the road with her. Bus driving is prudence, prudence, prudence, care, patience and prudence. You have to know the condition of your coach, tires, engine,safety equipment, inspect it every day, know the road conditions, even know your passengers. You have to know who to call and when. When I drove, I was in a city a mile and a half above sea level. We had more weather than the buses could handle some winter nights. I think your bus driver analogy is great, but I don’t think it makes the point that you’re trying to make.[/QUOTE]

I have been a ship captain. A ship captain is obligated to sail for conditions and take all precautions to preserve the life of her passengers and crew and to avoid collision with other vessels Commanding a ship is prudence, prudence, prudence, care, patience and prudence. You have to know the condition of your hull, propeller , engine,safety equipment, inspect it every day, know the sea conditions, even know your crew. You have to know who to call and when. I sail world-wide, always at sea level. We had heavy weather some winter nights.

Ship captains today are like bus drivers, the full implications of that fact are not appreciated. In this case a bus driver would not (I assume) be allowed to take a more dangerous route on her own. The same should be true of ship captains.

139

And that’s been the problem all along: no adult supervision from outside of the “bubble.” Either management knew what was going on and was fine with it (and perhaps were putting pressure on the skipper to play dodgeball with Joaquin to meet the stupid schedule), or they were paying no attention at all to how their vessel was being operated in a high/risk environment.

Either way, by omission or commission, they had their hand fully in the steaming turd and own most of it. These things don’t just “happen,” as in “shit happens.”

Bus drivers, indeed.

140

[QUOTE=captjacksparrow;196116]And that’s been the problem all along: no adult supervision from outside of the “bubble.” Either management knew what was going on and was fine with it (and perhaps were putting pressure on the skipper to play dodgeball with Joaquin to meet the stupid schedule), or they were paying no attention at all to how their vessel was being operated in a high/risk environment.

Either way, by omission or commission, they had their hand fully in the steaming turd and own most of it. These things don’t just “happen,” as in “shit happens.”

Bus drivers, indeed.[/QUOTE]

In this case the right move was Old Bahama Channel, giving the company the resultant ETA. The wrong move (without hindsight) is the direct route with an inaccurate ETA and then having to back-track.

Once the wrong move has been made the captain has two choices, tell the company he can’t read a weather map and go around, losing time and blowing his ETA or take a gamble with a TC. If he gets through without damage, like the El Yuque, he doesn’t own the error.

That’s the pressure, to make the right move, every time.