NTSB El Faro Report Meeting


#21

I believe he was quoting a finding of the NTSB to that effect. Hence the number 56 and the word “Finding…”.


#22

ABS was not mentioned once by name in the report but the remark number 20 under’ Recommendations’ is rather deadly for them, with this in your pocket you can better close shop.

Review and implement training of Coast Guard inspectors and accredited classification society surveyors to ensure that they are properly qualified and supported to perform effective, accurate, and transparent vessel inspections, meeting all statutory and regulatory requirements.

One item, as an example, springs to mind was the lady surveyor testing the boilers…

In my opinion a serious omission in the report is the fact that no mention at all is made about the psychological testing of senior officers and especially captains which I think, like in the aircraft industry, is necessary and rather essential for the safety of a ship.


#23

I agree that the mate’s were sufficiently aggressive. They both seemed like experienced and skilled mariners with good sea sense.

Having said that there was a problem with the language the mates used to communicate with the captain. Mostly this is because the captain failed to set up clear parameters or call trigger points. BRM training should drill into the mate’s heads how to send a assertive message to a superior without being overly aggressive or seeming insubordinate.


#24

I stand corrected and apologize.


#25

MY GOD! so many failures by so many people or parties…all of which were avoidable if only due caution were exercised. This was no Act of God…this was an utterly needless sinking!


#26

I think that the mates did everything that they should have done with the information that they had. It is some years ago now that we had a computer on the bridge which in addition to chart correction tracings and Notice to Mariners also printed out weather information with graphics and a daily news paper of about 8 pages. It had its own modem.
The emails I received in my office were of an administrative nature and I forwarded these as an when required.
It seems the master and mates were not on the same page.


#27

Yes this was the NTSB’s finding not mine so “facts, figures and verifiable experiences” must be sought there.

I thought it was significant because while all the findings should inform us of what went wrong on this ship in this case, some illuminate larger area of concerns. In climbing “the ladder of abstraction” as we humans are wont to do, we go from the dampers/ducts/plenums on El Faro are in poor condition to, why are they in poor condition, to lack of inspection, maintenance and oversight.

Many other ships use this program and so many other ships may also be “operating in substandard” condition. Actually they say “likely to be” not “may be”. That’s quite something to consider if you’re sailing on one and have been wrangling with the office over some repairs that should be done, or inspections being deferred. If your logic was “well that rotten structure can’t be that bad because surely the surveyor would have found it/noted it” it seems you could be wrong.

Not necessarily because of the experience or integrity of the inspector but because this “program” perhaps allows each party to shirk responsibility actively or by small sins of omission.

There’s a big difference between making/having a program and successfully implementing one. Well meaning people put something on paper but in practice it can crumble for lack of resources, unintended consequences or misunderstanding the likely motives and actions of the parties involved. People sea lawyer the MOU’s and agreements, look for the no friction way and the owners stay happy and the ships material condition may suffer.


#28

I am not in any way trying to say this is the fault of the mates. From a technical point of view and lessons learned ect the second mate’s message is not an effective one considering the ship was headed for the dangerous side of the eye of a force three hurricane.

(uh) I just wanted * * * (runs) south (of the) (island)* * * (old Bahama/weather) channel * * * we’ll be meeting the storm. umm fox news just said it’s up to category * * *. yeah– yes (that’s what I heard) * * *. it isn’t lookin’ good right now .– right now my uh– trackline I have zero-two hundred– alter course
straight south and then (we’ll) * go through all these * shallow areas. umm (and the next) course change (will/gunna) be (through the Bahamas) and then (just gunna) turn * * *.

okay.
DCA16MM001
Voyage Data Rec

Better first to get the captain to understand that his situational awareness is very significantly in error, then try to get the captain to the bridge to look at the plot.


#29

Perhaps the mates were in shock - knowing they were headed smack into a Cat. 3. Given the interruptions and limitations of the compiled VDR, their conversations were “off”, even between each other.


#30

The important thing to remember from this report is there is rarely ONE cause of a major system failure. There are a series of seemingly small failures that ultimately add up to disastor. One can cherry pick the failures to suit ones own purpose but that doesn’t solve the ultimate end result.
It is easy to see how the crew came to believe the substandard vessel they were on was normal. The company probably believed their safety management system was adequate because no one told them it wasn’t and no ship sank before.
The USCG passed off their responsibility to ABS and vice versa. At the end of the day there was no protection to prevent this loss of life. Another word for protection is regulation. Regulation without enforcement to the point of prison terms if needed are just words on paper.
Companies from banks to ships know that the worst that can happen is the stock price may drop or some minor executive lose their job. They see no reason not to roll the dice . The employees just get caught up in the process or figure they are part of something that is beyond their control.


#31

Thank you for expressing a portion of my thoughts. Also, the “culture of safety” was truly lacking at the corporate level.
The NTSB staff investigators ( the entire team along with the Board) had a difficult time. I believe they wore their heats on their sleeves when I spoke to each one of them over the last 26 months.


#32

I think of an incident like this like the parts of a rope. The strands can be unwound and each can be traced back to a single thread.

There are two major strands here. The condition of the ship and the actions of the crew.

There are a lot of findings, plenty of yarn to unwind, threads to follow, for my part I focus on the voyage planning, weather avoidance and crew performance because that’s what I know. No purpose or cherry picking beyond that.

Of course anyone is free to comment on any other topic. I try not to comment on subjects that I have little experience and/or knowledge.

I will add that I think there should be sufficient margin of error built into the ship to allow for weather routing errors like this. One example, open/close indicators on the watertight openings are very helpful, traps errors. We sometimes have some left open from time to time and send someone round at the end of the work day if required to button up.


#33

Removed by author.


#34

There is a lot of blame and finger pointing that can be laid here. The buck ultimately stops with all of us. I urge people, especially in management positions, to study the basics of industrial and organizational psychology. It is an oft overlooked field of study and can present as very dry material at times, but will help lead to a better understanding of what makes people “tick” in the workplace, in normal times, and while under stress.

We can focus on the details of machinery condition, weather, etc but ultimately, it is the human thought process, communications and decision making that fails us.


#35

INDEED SIR! For there to be systemic change in the culture to ensure that ships are ALWAYS operated to the safest degree possible then there must be severe penalties for those in positions of power who violate that mandate. And there can be no more severe penalty than to be incarcerated. This must be held to all levels of management and not just lower level personnel. A CEO must be treated as a master as being responsible for the failures of his subordinates since the buck stops with them. With the threat of losing one’s lucrative salary, pension, stock options, etc… and then going to the big house can’t cause a man to straighten up and fly right then what can? I also say that a master too must be held to a higher standard of conduct so that if he takes responsibility for a manifestly unseaworthy ship then is becomes his baby too. Give then a good reason to say “NO FUCKING WAY am I leaving the dock with this pile!”

FURTHER, any master to refuses to take an unseaworthy ship to sea must be protected by the courts from retribution by vindictive owners. Allow a master to sue an owner for damages for injury to his professional reputation like a seaman can sue for injury to his body.


#36

I don’t know what the practice is or was on those vessels but UK flag the Third Mate was usually the Met Officer and was charged with monitoring and updating the met situation to the Master, particularly if it was a Voluntary Observing Ship.

The reasoning was the 3/Os were the most recently trained and acted as a sounding board to the Master. There were then benefits to both - the Third Mate was involved and the Master passed on his hard gained wisdom.

From the reports and transcripts there seemed to be a complete lack of information flow and cohesion of the bridge team. It maybe that the method of hiring, union halls etc mean that the officers first loyalty is to the Union, not the ship, and the Master is under extreme pressure from the ShipCo,.


#37

It does seem like the crew El Faro could have benefited from more stringent procedures for handling the weather information and a better understanding of the limitations of the BVS system. The NTSB has made recommendations in that regards.

As far as the union etc, with regards to the tempo of operations and demands on the crew, the run the El Faro was on is, in many ways, more similar to the RO/RO ferries run that serve the English cross-channel operaton than a deep-sea operation.

Did the investigation into the Herald of Free Enterprise disaster look into role disloyal union crew members may have played in that sinking and loss of life?


#38

There was something in the air between the Second Mate and the Chief Officer. This is what I wrote in my review of the accident:

“Had the bow doors been closed there would have been no problem and the ship would have gone to sea, still discharging the No 14 deep tank and the watchkeepers would have taken up their roles on the bridge while it made its way towards Dover, but since the doors were open what actually happened before the loss was of considerable interest to the investigators. They established that it was the job of the Assistant Boatswain to close the bow doors, and that he had in fact been asleep and the tannoy had not awakened him. Down in the vehicle deck the Second Officer had been in charge of the loading, but had been informally relieved by the Chief Officer, and despite some quite close questioning there seemed to be something undiscovered in this situation. The Second Officer said that had he been left to complete his job he would have made sure that the Assistant Boatswain was at the door ready to close it, but since he had been relieved by the Chief Officer he had gone aft to his station. The Chief Officer who had formal instructions to be on the bridge 15 minutes before departure said that he had seen someone approaching the door and thought it was the man assigned to the task, and so had left to carry out his next job.”

And in twenty years sailing on British ships I felt that the people I sailed with were loyal to the ship - whether union members or not.


#39

This is just like the STCW training program that we all go through in the USA with the silly classes. On paper, it sounds great. In practice, many of the classes are a complete joke…BRM and ERRM to give examples.

I’ve posed this question a few times, but never got a solid reply. If the El Faro was a newer ship (5-10 years old), instead of an old piece of junk, would it have survived the exact same path into the hurricane?

And isn’t it even more alarming that the El Faro wasn’t scheduled to be scrapped, it was going to take up a route in Alaska?

Disasters usually have a chain of events. But ultimately, there is usually a root cause the initiates the chain. Yes, the captain ran the ship into a storm…but I rekn’ some of the experienced men on this forum have been in similar or worse weather.


#40

This is from the VDR transcript - Around 2000 hrs: First the C/M and captain discuss the weather and change the route to stay further from the center. Then the 3/m arrives in the wheelhouse and the capt tells the C/M and 3/M to do watch change. Once the 3/m has relieved the C/M and the capt tells the third mate to let the new route sink in:

Capt (to the 3/M): give you a (minute/moment) to digest that. * * *. (make sure / you let me
know) if you see anything out of the ordinary to be concerned about.

Then the 3/M brings up the fact the the forecast is changing.

3/M to capt" I just hope it’s not worse than what this is saying because that’s
Weather Underground [weather related website -
www.weatherunderground.com] is– saying it’s a lot. they’re sayin’ it’s–
more like eighty-five– not fifty * wind.

Capt: did you (notice/minus) the wind on the ship.

3/M tries to redirect back to the Weather Underground info:

3/M but what they’re sayin’ they’re– they’re saying this is much more powerful than this is saying
right now. * * so it’s more powerful here– then maybe it’s more powerful
here.

At that point apparently the C/M directs the 3/M attention back to the new waypoints that he and the Capt have laid out.

CM (waypoints) printed here and they’re listed in there * the track.

Third mate drops the subject of the forecast:

3/M okay very well. I understand.

Capt: …we’ll be passing clear on the backside of it. just keep steamin’ our
speed is tremendous right now. the faster we’re goin’ the better. this will
put the wind on the stern a little bit more– it’s givin’ us a push.

3/M okay.