Is The El Faro A Mystery Or A Puzzle?

Professional Mariner Forum
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In the discussion “why the gcaptain forum always gets it wrong” initiated by @Kennebec_Captain there is much talk about various incidents but no mention of a critical difference between two types of incidents… mysteries and puzzles.

The distinction was made by Gregory Treverton and highlighted by Malcolm Gladwell in a piece he wrote about Enron a few years ago.

Gladwell originally wrote:

The national-security expert Gregory Treverton has famously made a distinction between puzzles and mysteries. Osama bin Laden’s whereabouts are a puzzle. We can’t find him because we don’t have enough information. The key to the puzzle will probably come from someone close to bin Laden, and until we can find that source bin Laden will remain at large.

The problem of what would happen in Iraq after the toppling of Saddam Hussein was, by contrast, a mystery. It wasn’t a question that had a simple, factual answer. Mysteries require judgments and the assessment of uncertainty, and the hard part is not that we have too little information but that we have too much. The C.I.A. had a position on what a post-invasion Iraq would look like, and so did the Pentagon and the State Department and Colin Powell and Dick Cheney and any number of political scientists and journalists and think-tank fellows. For that matter, so did every cabdriver in Baghdad.

The distinction is not trivial…

If things go wrong with a puzzle, identifying the culprit is easy: it’s the person who withheld information. Mysteries, though, are a lot murkier: sometimes the information we’ve been given is inadequate, and sometimes we aren’t very smart about making sense of what we’ve been given, and sometimes the question itself cannot be answered. Puzzles come to satisfying conclusions. Mysteries often don’t.

So the first Question is… Is the sinking of the El Faro A Puzzle or a Mystery?

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The second questions is… why investigate mysteries if the mystery will never be solved?

Puzzles are attractive because, as Gladwell points out, they come to clean conclusions. Ironically, by these definitions, all of the Agatha Christie books are puzzles, not mysteries – they can always be solved if you just pay attention to the right information, which is all there for you.

In opening this topic for debate I would suggest that the El Faro, Marine Electric and Titanic are three examples of mysteries. This is the reason that the titanic continues to intrigue the world over a century after she sank.

The overwhelming aspect of each of these sinkings was that prudent mariners knew exactly why each of these incidents happened immediately after they occured.

1)The Titanic sank becasue she entered an area with icebergs at high speed with limited visibility or tools for detection.

  1. The marine electric sank because she was very old and tired.

  2. The el faro sank because she sailed into the eye of the storm.

Facts 1,2 and 3 were immediately know to all experienced mariners very soon after the incidents happened. Nothing in the exhaustive investigation of these incidents will ever over-ride these three basic facts.

Conversly I would suggest Kulluk (a fairly simple puzzle) and the Deepwater Horizon (a highly complex puzzle) are examples of puzzles and have since been solved.

For the sake of argument I will contend that Marine Board Investigations are wholly ineffective at solving mysteries. That is not to say they are useless… it is to say that their effectiveness is in highlighting tangental safety problems that have little to do with the initial incident.

For example. It is unlikely that closed lifeboats would have survived the eye of the hurricane yet the investigation of open vs closed lifeboats has exposed the fact that closed lifeboats are much more capable of saving lives in the margins of safe working conditions.

The central mystery of the el faro is “why did Davidson not alter course?” and I suggest this is a mystery that will never be solved but a continued investigation into the sinking will uncover tangental lessons learned and provide more opportunities to save lives.

Mysteries also have a longevity which are not inherit in puzzles. Once a puzzle is solves the community of largely looses interest in continued debate and investigation. Mysteries, however, can provide a focal point of discussion (and a common knowledge base) for years to come.

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@Earl_Boebert1 am I on the right track with this line of thinking?

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I think so. Real world analysis always deals with mysteries, because there is always missing information. Forget the “connect the dots” cliche. What you have is a jigsaw puzzle with missing pieces. You know where some of the pieces fit and you have to deduce the location of others and the shape of the missing ones. Sometimes the most important insights are gained by observing a piece that should be there but isn’t: “The curious behaviour of the dog in the night-time” (Sherlock Holmes) “If this is a consular ship where is the Ambassador?” (Darth Vader) That’s where the experience-based expertise of a place like this is so valuable.

At the end, though, you are still left with what intelligence analysts call an “assessment,” which is a polite term for “best guess.”

Cheers,

Earl

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To some extent, at the heart, it will always be a mystery.

One error the forum made was looking for parts of a puzzle to solve a mystery. The email from the company telling the captain not to be late is never going to be found because almost for sure it never existed.

The best we can do is some plausible explanation given what we know about human factors and decision making errors.

We can convert some mysteries into puzzles if we use the right tools. But to someone who only has a hammer everything looks like a nail. If the tools of confirmation bias and escalation of commitment are not available it’s going to look like commercial pressure.

There is a book about solving mysteries which I highly recommend Superforecasting: The Art and Science of Prediction

“Tetlock’s thesis is that politics and human affairs are not inscrutable mysteries. Instead, they are a bit like weather forecasting, where short-term predictions are possible and reasonably accurate… The techniques and habits of mind set out in this book are a gift to anyone who has to think about what the future might bring. In other words, to everyone.”

It’s not just the mystery of the forecasts.

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Are the tools of superforecasting, confirmation bias and escalation of commitment available to the MAIB? If so, are they being used effectively? If not, why not?

From Page 12 of the Commandant’s Final Action Memo:

  1. The Coast Guard received one comment noting that NTSB had the Human Performance Factors Group included in their investigation, and that there should have been an expert witness in the field ofstudy ofdecision making. The Coast Guard does not concur with this comment. The Coast Guard disagrees that human factors were not adequately considered. The Coast Guard was a party to the NTSB investigation and participated in all phases of that process. There was a great deal of information shared between the two investigations, and the analysis of human factors played a critical part in the MBI and the ROI.

In fact Zukunft took many of the comments from el faro family members out of context and truncated others.

Here is the full text of the comment a family member sent to Zukunft to which #49 of the memo refers:

"I know that the NTSB had the Human Performance Factual Group include in their investigation. There should have been further analysis on cognitive basis’s . There should have been an expert witness in the field of study of decision making. Someone like Dr. Gary Klein, author of the book “Sources of Power”.”

Zukunft has completely erased the specific request for “cognitive bias” analysis and, as per the rest… Zukunft provides a vapid generalization: “was a great deal of information shared”.

So the el faro is a mystery that with the tools of Superforecasting could be seen as a puzzle… but, considering the USCG is not using those tools, it remains a mystery… yet they act as if it were a puzzle?

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I haven’t got time to dig it out right now, but the TOTE VP of human resources was on the Human Factors Group. Imagine how candid an employee is going to be when their VP of HR is sitting on the other side of the table, especially in today’s economy.

As I mentioned way back when, going back to 1998 I could not find maritime investigations by NTSB that included a Person In Interest in the investigation team except for when an oddball vessel was involved; the ones I remember were a DUKW and a RIB.

Earl

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I’m not on solid ground here but it seems to me the more human factors are taken into account in this analysts the more it becomes apparent that Tote’s lack of oversight was a huge and very significant error.

By not providing oversight Tote created an “every captain for himself” environment in which captains could take on more risk without supervision to compensate for routing errors.

The report does says this:

A further possible explanation of the captain’s actions is what is known as confirmation
bias. That is the tendency of a person to search for, interpret, favor, and recall information in a way that confirms his or her beliefs or hypotheses while giving less attention to information that contradicts those beliefs (Plous 1993). Once the captain made his decision to continue on the planned route, he was not swayed by information that contradicted his plan, including his officers’ suggestions of route changes to avoid the storm. The captain was also unwilling to change course even though weather forecasts led the officers to believe they would come within 22 nm of the hurricane’s eye.

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That’s my point… I’m certainly not either, nor is anyone on this forum (with the possible exception of @Earl_Boebert1) but I feel like we are light years ahead of the USCG… which is why an expert needs to look at the evidence.

Agreed

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There is a bias against people closest to the event. Did the NTSB take that into account or do they take advantage of the fact the the biases in the report will match the bias in the report’s readers?

The Dull End Of The System Creates The Fault Tolerance But Avoids Blame

. Our innate sense of causality biases us to fix blame based on temporal sequence (Michotte, 1946/1963): if A immediately precedes B, then A caused B. The people in the “dull” end, the authorities, designers and managers, are more remote in space and time to the negative outcome and seem less directly connected. Their role as causal agents is not as intuitive.

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I would lean towards puzzle more than mystery when looking at the myriad factors that came together to cause the disaster. The mystery lies in the individual decisions and reasoning behind actions undertaken by those involved both onboard and on land.

When you read through any NTSB report, primarily those on air crashes, there is always an exhaustive review of aircraft maintenance, flight conditions, crew and ground controller work assignments and schedules, weather conditions etc. that I didn’t see as much of with this investigation. It may be an apples to oranges comparison since the subject matter is so different, but it certainly seemed like this report focused on the crew, the weather and then the vessel condition, and that inherently left several puzzle pieces out of the mix.

The mystery of the Captain’s though process and BRM has been well documented, but for me the one item that remains glaringly unexplored is the role of the engineering crew on the vessel. Did the Chief make mention of the low oil sump levels to the Captain at any point? Was he consulted at all on the intended routing since he had a boiler down? I’d like to think so, but without any records its impossible to know for sure.

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This is all just a fancy way of saying we are ‘looking for a needle in a haystack’ and we ‘can’t see the forrest for the trees.’ But I guess that doesn’t sell books and impress the neighbors.

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To tell you the truth, I’m no fan of Gladwell but, be that as it may, I think he’s onto something here.

In some investigations no amount of digging will bring us closer to the truth.

In others investigations are necessary for us to understand what happened.

The question is… should we investigate these two broad rypes of incidents the same way?

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Yes, important questions but they are all impossible to answer… which makes ut a mystery. No amount of data we can collect and puzzle together at rhis point will answer those questions.

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With regards to the low oil, it is a mystery but I can frame it up a bit. One time I warned the chief about 24 hrs before that we were going to hit heavy weather. The chief was a good chief but he prepared the engine room by making sure every thing was secured.

We took a couple big rolls and the main engine tripped out on low oil pressure. Afterwards the chief added some more oil.

It was a good chief, I think likely in most cases adding oil before heavy weather has to be on a heavy weather check list or it won’t get done because it doesn’t come to mind.

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Really, a boiler down, when did that happen? I suggest you go back and reread whatever you thought you read to get that bit of news.

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