NTSB El Faro Accident Report


#1

Final report released.

https://www.ntsb.gov/investigations/AccidentReports/Reports/MAR1701.pdf


#2

Chairman Robert L. Sumwalt’s remarks (Page 256)

Communication is a two-way street; if someone isn’t getting the message, the person attempting to communicate must alter his/her communication style to ensure the message is truly understood and addressed.

Yes someone finally gets it!!

Wait no… he clearly does not get it because…. he only mentions the interaction between the Captain and crew in his statement. There is NOTHING in his remarks discusses the equally important “two-way street” of communication between the Captain with 3rd parties including Tote, Weather Routers, ABS, USCG, etc, etc, etc.

giphy


#3

From the report:

Actively promoting BRM was the ultimate responsibility of the company. TOTE’s SMS stated that the captain was responsible for providing onboard BRM training to the crew every quarter, in accordance with a training addendum to the SMS. However, the most recent version of the training addendum (dated August 2015) did not include a section on BRM, though a version dated February 2013 did. In fact, the section on BRM was marked as deleted on the contents page of the August 2015 addendum. The document control list indicated that El Faro had received the
newest training addendum. Logs of safety training meetings held during the first two quarters of 2015 contained no reference to BRM as a training topic. TOTE was required by its SMS to ensure that quarterly BRM training was conducted aboard El Faro and that BRM principles were addressed in the captain’s standing orders. Investigators found no evidence that TOTE management implemented BRM aboard El Faro. Thus, the NTSB concludes that the company’s failure to ensure the implementation of BRM contributed to the sinking.


#4

Oh I understand and, to be clear, the NTSB does make this point in the report AND the NTSB does not let Tote of the hook in the report.

BUT and this is important. The Chairman’s Letter, which is appended to the report on page 256, serves to highlight what is most important. And words “Tote, ABS, USCG, etc” are NOT included in the Chairman’s letter.

Further, the congressmen and senators and administrators who write the law and provide oversight of the USCG do not have the technical expertise to understand all the recommendations. The Chairman’s Letter serves to provide the broad strokes of understanding for those people (and, in reality, it’s all that many of them will read)

There are dozens of recommendations and everyone here understands that not all of them will be followed up with. But what is highlighted by the Chairman will be looked at further.

@Kennebec_Captain While everything you mention in this post is true and important NONE of it is contained in the all important Chairman’s letter. And that has me :face_with_symbols_over_mouth:


#5

Ex TOTE Master here. Worked 30 years for TOTE, 17 as Master. I was Master of the El Faro when she was the Northern Lights.
Regarding your comments on the BRM onboard training and lack of TOTE follow through.
I find this incredible, as during my many years at TOTE, their oversight and implementation of the SMS was excellent. In fact, BRM onboard training always seemed to be something the audit checked specifically.
My own opinion…as TOTE’s new ORCA class vessels came online and displaced the older ships off to the PR run, many felt that these vessels and crews had the status of the B team. Don’t get me wrong, I’m not criticizing the officers or crew, this was just the perception or opinion within the fleet.
As a result, was there a lack of attention to detail and duty, both onboard and ashore, in this case?
BRM training should have been held and when it wasn’t, TOTE should have caught it in their audits of the SMS.
Davidson and his opposite were responsible for this onboard training, and Davidson should have been listening to his officers input.


#6

I have edited my post to show that it was a copy and paste from NTSB’s report.


#7

I certainly have the impression that Tote Alaska was the A Team, and that everything about Tote Jacksonville, from the price fixing criminal conviction onward, was the F Troop.

It seems like the only thingthat the two companies or divisions shared was the Tote name, and Jacksonville eagerly taking Alaska’s cast off worn out ships. I do get the impression that Tote Alaska became infected by Jacksonville’s problems.


#8

It wouldn’t surprise me if the on-board culture on the Alaska run compared to JAX/SJU would be very different just from the fact of the different weather on the two runs.


#9

Recent Ex TOTE mate, with 8 years as Master for Maersk here. My experience with TOTE corporate, mirror’s CaptainRon1. Furthermore, the command structure of the vessel I sailed on encouraged input from the mates. Is that the case on all TOTE vessels? How difficult is it to “check-the-box” and say “training was provided”?
All AMO deck officers I know, have taken the BRM course at Dania. Trust me, we have been BRM’d to death. The problem is in the execution of BRM. What is the course of action if the Master isn’t listening? If the El Faro Master was being obstinate, then it’s incumbent upon the rest of the mates to speak up. It appears this didn’t happen.

What I find astonishing from following the El Faro case, is the finger pointing to corporate. TOTE Corporate certainly could have spent more money on maintenance, and the level of maintenance may have made a bad situation worse, but Davidson had an obligation to keep the vessel safe. He didn’t.

It wasn’t JAX’s fault that Davidson steered for the hurricane; he’s the guy who didn’t go up to the bridge at 2300 when the 3/M called. Had he gone up when the 3/M called, and again when the 2/M called, perhaps this would not of happened.

I know I’m old and cranky, but I can’t help but think what I would do if I knew the Master was steering a ship into a hurricane. Y’know, if the old man isn’t going to come up to the bridge when I call him for imminent danger, I’ll call the Chief Mate. And if he fails to come up, I’d take matters into my own hand, and make the turn away from the hurricane. By the time he wakes up, the ship is out of danger. Yes, I’ll be packing my sea bag when the ship hits port, but at least the ship would hit port.

However, I also realize that my sea experience is deep, and sometimes the mates on watch are not as experienced. But in the VDR recording, wasn’t there a mention they were heading towards an intercept with the hurricane? There is no way I’ll permit that to happen. For you 3rd and 2nd’s out there, LEARN about HURRICANES, and always have a contingency plan if the Master fails to show up.

Since I’ve retired after 23 years of sailing, it is clear to me that over-regulation and stupid regulations (alternative compliance vs USCG inspection) have made this occupation very difficult. I long for the days when a successful voyage was measured by five metrics: Not touching bottom, not touching another vessel, no cargo in the water, and no injuries. Now it’s ALL ABOUT micro-managing.

We have to get back to basics. Ship drivers need to be seamen first, then corporate pawns. Become “master ship handlers”, not just an observer of ECDIS, AIS, and all the other electronic distractions.


#10

Did they cover mitigated speech?


#11

Listen I agree with your post besides this little detail. You say you sailed Master for another company and I’m sure that you would be aghast, much like I would, if you ignored a late night call from the bridge. Hell in heavy weather I’m usually on the bridge asking the mates why they didn’t call me sooner. This taking matters into your own hands is dangerous business in my opinion. You may have a couple decades of experience but to insinuate to other junior officers that it would be advisable to chart your own course without the approval of the Master is not a good idea.

The El Faro was a tragedy that could have been avoided but if every mate I trusted with the conn of the ship couldn’t be trusted to follow the voyage plan or my night orders because at some point they thought hey knew better, I couldn’t run my ship or sleep at all. Everything else you mentioned was spot on in my opinion but this little tidbit scares me to death. I’ve had plenty of mates that are older than me with more sea time, but that does not make them the Master. Davidson should have done the right thing, that is not up for argument, but I could see far worse situations arising during the course of normal operations if anyone thought they could just deviate from the plan without the masters knowledge or permission. I’m just saying


#12

Y’know, I’m with you on the “danger”. However, the contingency here was “master’s malfeasance”, not just a brain polyp from a mate who wanted to go rogue.
Oh the times I’d have a 3rd who was, shall we say, “not gifted”. And sometimes a 2nd. Heck, as I write this, there was one C/M. . .But when I had mates who had brains, I’d play the “what if” game with them, to get their brains engaged. “What would you do if you were the only surviving deck officer? How would you get the ship out of danger?” I’d also teach/train/grill them on hurricane avoidance using a plotting sheet/maneuvering board to figure out CPA on the storm. My experience was quite enlightening (both ways, geniuses and dullards. LOL).

For normal operations, as you mentioned, I’m with you, brother. But we are talking about a “Caine Mutiny” moment - The master is psychologically “locked-up” and impotent, and we have to save the ship.


#13

No. What they did instill is the requirement to be absolutely clear with what one is communicating; to be succinct. Apparently it is too subtle for me.


#14

In that case they were doing worse then wasting everyone’s time. They were making people think they understood BRM when in fact they didn’t cover important basics.


#15

Perhaps. Or perhaps not. There is a problem with “free will”. Humans, are gifted/cursed with it. I’m going to switch gears a bit, and offer two examples of “cursed free will”.

  1. EVANS/MELBOURNE collision: OOD/JOOD did not call the captain as required by his night orders when the formation course changed. They knew of the order to call, but chose not to.
  2. FITZ/ACX CRYSTAL collision: OOD/JOOD did not call the captain, as required by his night orders, when unable to achieve desired CPA with several vessels just prior to the collision. (Same as #1, they knew but chose not to call)

BRM can be pounded into us, but if it’s not implemented routinely. . .it’s just another feel-good course that’s required. Documenting training on a spreadsheet doesn’t help, except for the pin-heads in the office. And BRM really does not address a circumstance when the master is called about imminent danger, and doesn’t come to the wheelhouse.


#16

If you have taken many courses in BRM and avoiding mitigated speech wasn’t covered it was worse than a waste of time. It is exactly communicating about imminent danger.


#17

There shouldn’t be a need to deviate from SMS.

That beidge had a satellite phone and if the DP didn’t take his call the USCG would have.

Let’s also not forget one critical fact that’s been painted over in all the reports. They could have used that phone to call BonVoyage (the company that owned it DID have pro weather routers on staff) or NOAA. They also could have called a professor of weather at their academy or even a salty old sea captain freind who mentored them early in their career.

If there is a disparity of information, and the problem is not IMMEDIATE, I’ve found that it’s usually a good idea to let your your fingers do the walking.


#18

John, I agree. But in my experience, the company’s SMS, not the concept of an SMS, is something written for the bean-counters, not for the end user on the ship. And the idiom, “When you’re up to your ass in alligators, its hard to remember your original intention was to drain the swamp” is very accurate when crisis hits. I’m all for a Safety Management System. But when the printed edition occupies two 4" Binders, not including another 4" binder for forms, the document becomes functionally unworkable. I long for the days when one company I worked for had a SMS that fit into a 1/2" binder. We already have enough regulations and instructions to follow between the CFR’s, SOLAS, and MARPOL. We are drowning in documentation.

When out at sea in the past 23 years, I am from the old school, where communications with the office wasn’t immediate. So that meant that the mariners had to develop a breath and depth of skills. With the increase of internet access and band-width at sea, there is too much email traffic now between the ships and corporate, that distract the vessel crew from ordinary tasks.

When I sailed Master, in my first couple of voyages my standing orders were concise, and probably filled only two pages. My opening line was, “Conduct yourself within the dictates of your license”, followed by “call me if in doubt-and if you don’t know if you are in doubt, CALL ME”, followed by “call me in sufficient time that I can help you-not in time to be a witness to a marine incident”. As I look back now - it was too cerebral.
After sailing with a few knuckleheads, on different voyages, my standing orders grew to about 12 pages, as I tried to cover contingencies that had surfaced and when “operate within the dictates of your license” failed. [On a positive note, no groundings, no paint scraping, to product in the water.] I could not imagine writing in my standing orders, my instructions on what to do if I don’t come to the bridge when called. However, since El Faro, I’d start page 13, and I’d make certain that the MOW knew the dialing string for the SATPHONE, and the phone numbers.


#19

For many years I works 18:00-06:00 as Chief Mate and one of the more frustrating and frequent conversations I had with watch officers would go something like this.

2M: I’m concerned about problem x, can you take a look?
CM: sure
2M: Well xxx is crossing yyy and we have this other problem over hear… so I want to turn to xxx here
CM: Looks like a good option. Well done.
2M: I’m not so sure. I am concerned that xx will happen. Does that concern you?
Cm: Nope
2M: Well thats good, if you’re not worried then I won’t worry
CM: I’m not the watchstander, I just showed up to get a cup of coffee 3 minutes ago
2M: so I’m confused, is my plan good or am I doing something wrong?
CM: Both!
2M: how’s that possible?
CM: I think the plans great but I’m not the captain. Your orders are to call him if you are concerned.
2m: But it’s 3am and you’ve done this run way more times than the captain has.
CM: that’s not the point. If I am wrong and you are right I’m not going to be up here to help you… I’m going to be down charging rhe fire main.
2M: so what do I do
CM: call the captain
2M: no, I see your point now, everythings good
CM: nope. Call the captain or I will.
2M: you said the traffic situation didn’t concern you, why would you call him?
CM: because if you don’t follow our #1 standing I will be concerned
2M: you’re putting me in a real shitty situation here Mate. The old man’s going to be pissed at me
CM: he may or may not get pissed but I promise any anger won’t be directed at you. You asked my opinion and I said wake the old man… you are following my direct order. I’m the one to blame…
2M: Well I like working with you and just don’t want to throw you under the bus like that. I’ll call but not mention you.
CM: If you gell the straigt truth is not throwing anyone under the buss. It’s the truth. Throwing someone under the buss is embellishing the story with words like “hey capt everythings cool but that idiot mate made me call you” or just rolling your eyes when telling the facts.

Call him, stick to the facts thenhang up the phone
2M: OK


#20

Dear God.