NTSB El Faro Report Meeting


#162

How’s this for a possible scenario of the captain’s mind set: “TOTE got pissed when I deviated from the normal route to avoid weather in the past. Now they’re denying me command of a new ship possibly because of it. I’ll ram through this thing and if we lose a few container and a few car fenders get bent down in the hold that’s too bad. I’ll be looking for a new job anyway so fuck’em.”


#163

Let me introduce myself first ; raised in a seaside town being on small fishing and pleasure boats acquired healty respect for sea. 11 years in navy, 3 years as XO, 4 years as CO on guided missile fast patrol boats. 27 years on merchantmen which 5 years on general cargo/bulk carriers as deck officer/chief officer, 22 years as master unlimited on handy/handymax/panamax size bulk carriers.

Such service behind me I came to conclusion that one has to have some “prime directives” to survive such as ;

1- preserve life,
2- preserve licence,
3- preserve job.

To preserve life one can not delegate one’s own responsibilty to stay alive to some shore forecasting facility and resign to comfort of ignorance. I believe what happened here.

Armed with the knowledge of how tricky is the nature of these revolving storms, one has to be on his toes. Wind direction and pressure change being foremost tools to avoid a catastrophe one has to heed warnings.

my two kurus.


#164

While I agree with your priorities in regards to preserving life, license and job in that order, what the hell are two kurus worth? Like a tenth of a penny?


#165

The kurus is 1/100 of a Turkish lira. Two kurus today are 0.52 US cents.


#166

The main point of the Andy Chase article is that role played by the failure to use a formal process for decision making and not having the crew on the same page, same as the El Faro. There are procedures that can be used to accomplish this, the lesson learned is to use those procedures.

I don’t believe I called this loss “an error”. There are three major strands in this loss, crew errors, ship not seaworthy, failure of company SMS.

When I say error I mean to say to look at each fact and compare it against what I consider standard practice.

For example it a fact (AFAIK) that Joaquin was not plotted methodical on a paper chart. In my experience this is standard practice shipboard, as is a cross-check with other sources, so I call it an error.

Another example is the scuttle left open, standard practice is to maintain watertight integrity, another error.

It’s also a fact that the mate’s used whats called “mitigated speech”, but I don’t see that as an error as that is the standard on ships, at least in my experience.

As far as blame, I have tried not to attribute those errors to anyone as I don’t really know.

After the outcome is clear, any attribution of error is a social and psychological judgment process, not a narrow, purely technical or objective analysis.
•Richard Cook and David Woods


#167

But an over-reliance on procedures has its own flaws.

Procedures are great for assembly line workers. But higher level leaders can’t possibly have a procedure for every scenario.


#168

Yes, I see your point and agree in general. Not just follow a simple procedure of course. But for example the crew should have been required to have a formal paper plot based on SAT-C reports.

Also the avoidance plan could have been laid out in a more formal manner, in the night orders for example. "Plan to pass no less than x miles from the center outside the x kt wind field. - Plot SAT C positions every 6 hrs. Winds expected to shift… and so on.

Something that when what is expected does not happen the mates can call with a specfic message, things are not unfolding as expected.


#169

I find it scary that a sister ship, but with another company is still in service, 45 years old FFS.


#170

Sister ship yes but different company, management, and very likely condition. In any case its replacement is under construction.


#171

Perhaps we could add:

Driver was facing the wrong way, looking for something on the backseat - Absent from the bridge
Failed to see the on-coming vehicle flashing its lights at him - Didn’t heed the warnings of his mates

If they’d only followed the 2M’s advice to head south through the Crooked Island Passage once they had passed Rum Cay, likely none of the rest of the failings would have mattered much


#172

Yes, in better condition but the replacements for that class of ship should be reaching the end of THEIR lives about now. Engine wise they were hardly cutting edge when built and not exactly the easiest vessel to keep good watertight, lots of ventilation trunks, ramps, lots of space on the main deck for water to accumulate.


#173

We have to assume that Davidson understood he was responsible for the safety of the ship so the only conclusion is he must have believed the ship was safe. How could that be so? Very strong confidence that his understanding of the situation, based on the BVS program was correct, very low confidence in what the mates were telling him. Perhaps he was thinking his mates were underestimating his skills and/or experience in heavy weather.

What other explanation can there be?


#174

We know plenty of systematic blunders were committed long before that ship and crew sailed for the last time.
If attributing blame results in changes that improve survivability in a disaster at sea, I’m all for it. You can’t deny that there’s plenty to go around in this case and the clues are hard to miss.
In the last moments, the one thing the people on that ship didn’t have, the one thing that might have saved their lives was an enclosed lifeboat.
It’s too bad the CG can’t see that fact worthy of a rule change.


#175

It’s obvious that his balls were bigger than his brain and the use of common sense was out of the question.


#176

His balls were bigger than his willingness lose his job at Tote by taking a safer route. He was so pissed off about the position Tote was putting him in, that it clouded his judgment.

Given the Hurricane, the only safe route departing Jacksonville was the Old Bahama Channel —- which would have added half a day to the voyage.


#177

Davidson, the crew, the company and Davidson’s peers all had a high opinion of his skills and experience before. Now, after, it’s obvious that common sense was out the window.

This seem like a problem for mariners like you or I. How are we different than the “before” Davidson? Are we going to have to sail into a hurricane and lose a ship to discover we were mistaken?


#178

It is VERY difficult to predict how people will react in a critical situation.
Some who looks cool and collected in most situations MAY panic if they get in a real emergency.
Others that behave like a featherbrain in their daily life turns into heros when in a critical situation.

I worked with a fellow that fitted the last description and could never make up his mind. He was OIM on a drilling rig in West Africa which I visited regularly as Rig Mover.

Some years later the same rig got caught in a storm in the North Sea while under tow. Things started to go badly wrong to where the rig eventually capsized and sunk.

He was credited of taking all the right decisions and ensured that all the people on board got off in an orderly fashion by jumping off the stern and get picked up by the Standby boat, before leaving himself.
He was honoured with a medal for his bravery under serve distress.


#179

You seem to be missing the point. The discussion is with regards to routing decisions which were routine situations, not emergencies.


#180

Another hypothetical: If the “before” Davidson took the same route, but with a newer ship that wasn’t an old POS, and the ship made it through the storm but had some damaged cargo, mild damage to the ship…would everybody still be blaming him?

As far as we can tell, this man was not on a suicide mission. So we must assume he had the safety of the crew and ship in his mind when making the route decision.

Is it fair for Capt Davidson to also assume that the El Faro was seaworthy and safe for the passage? We now all know the ship was a rusty old POS that should’ve been scrapped years ago.

I just feel that one of the main root causes of this disaster is that the El Faro was not seaworthy due to age and condition. Why are these old junkers still at sailing in the US Flag fleet?


#181

Davidson and Tote had to know that EL FARO was an old junker. They had just been getting away with so much for so long — a good run of luck —- that they had grown to expect that she was good enough.