USCG El Faro Investigation Report


Great book! Here a link:


I wouldn’t put too much faith in the NTSB report. The TOTE VP of Human Resources was on the Human Performance task group (or whatever it is they call them – I haven’t time right now to look it up.) Anyhow, this caught my eye and I went back through NTSB dockets to 1998 for marine accidents and found only two in which a representative of a PII was actually part of the investigation. One of these (IIRC) was a RIB accident and the other a DUKW, so the people there were presumably chosen for knowledge of the vessels. NTSB testimony is not sworn, and they interviewed people like the friends of the Second Mate and a neighbor of the Captain. I wonder what it was like for TOTE employees to be interviewed when the person in charge of hiring and firing for your employer is sitting on the investigation side of the table. Actually, I don’t.

“Human error is a symptom, not a cause.” – Prof. Nancy Leveson



I’m amazed the NTSB can’t see that conflict.


There were others. IIRC, both ABS and Herbert Engineering had people on task groups, but you should check the docket to make sure. And then there was the strange resignation/retirement of the head of the investigation.



I notice that we are once more referencing the Marine Electric disaster, and why not, because the findings from its investigation are appropriate. Being a Brit I had never heard about it before, but prompted by earlier references on this forum I read the report and wrote an article about it on my website. For those who might be wondering why it is important today I attach my concluding paragraph:

‘The report goes into considerable detail about the effectiveness of the various inspections and it is obvious that the investigators thought that the Coast Guard inspectors could have done a better job and that that ABS were less than independent, since they were being paid by the shipowners – as class still are – and therefore if the owners did not like what they did it would be an option for them to change to another class society – as they still can. This they said would result in a conflict of interests. However, interestingly for those studying the event today, the Coast Guard Admiral who signed off on the report disagreeed with this conclusion and stated that ABS were a fine expert independent body who would not be influenced by the source of their renumeration, even if individual surveyors had failed in their duty. ABS were of course carrying out inspection activities on behalf of the Coast Guard, as they still do, and it appeared from the Admiral’s conclusions that he was keen to play down the problems with this distribution of responsibilities. Similar difficulties were evident in the inspections of the Deepwater Horizon (See “A Catalogue of Disasters”). It is worth saying that today (2017) class societies promote themselves as champions of safety, while at the same time refusing to accept any level of liability for any failings of any sort on the part of their surveyors or any other of their employees, and attempts by various organisations and authorities to take them to court in the aftemath of marine disasters have generally been unsuccessful.’


Cannot believe this can happen in the USA.

If what you are saying is true then the Master risked not only his own life but that of his crew too.

No job is more important than one’s own life.


Your comment implies that a master or chief with no intention of going back to sea who takes a DPA position is somehow less reliable or conscientious about the safety or needs of those afloat. Think about that for a moment …

The best people for the DPA job are those with years of at sea experience who fully understand the nuances of “office” influence on operational decision making because they experienced that influence or pressure on the job and when it may or may not have determined the course of their own career.

Someone who intends to go back to sea is most likely going to be a junior or mid career individual with far less management experience or a lower license, someone who is the most likely to succumb to management pressure to drink the corporate Kool-Aid.

Give me an older and wiser chief or master who has had all the seatime he wants and has more interest in doing the DPA job well than making sure his boss gives him a chief or master’s job when he’s tired of office work.


No, my comment implies there are good masters and chiefs and there are not so good ones. More importantly there are great companies and there are companies with such poor corporate culture they even bring the best Maters and chiefs to their knees. If a company is strong arming a Chief into making bad choices offshore, bringing him ashore is unlikely to stop the behavior.

I was also playing devil’s advocate. If we are going to regulate substandard operators then it is important to think about problems from their perspective. We need to find the loopholes.

One question we have to ask is what are the companies we most respect doing about these problems?


Then the phrase "… who have no intention of going back to sea … " was just filler? Inserting that phrase really does imply that those people are somehow less likely to put safety first.

There is no need to imply that there are good and bad masters and chiefs, we all know that for a fact but if that needed reinforcement it should have been stated directly rather than imply that others are unreliable or less than acceptable. As a chief and former DPA with no intention of returning to sea I found that comment offensive.

The concept is fine, the execution needs to be tuned and the authority of the DPA should be made very clear to all shoreside management and the authority of the DPA fully supported by company as well as CG policy and process. The concept often fails because it is too often seen as a figurehead position.


I agree, the system is fine and very much needed, since there is a deplorable lack of actual nautical knowledge in many Shipowning and Shipmanagement companies.
Appointment as DPA is frequently assigned to whoever is least able to carry the burden and least able to help with advise from own knowledge and experience in an emergency. (I.e. whoever is least able to protest against being on call 24/7)

Since we are complaining about shore staff; I have noticed a lack of knowledge and practical experience, most critically in the Marine Offshore business. Frequently I’ve found that even the Operations department are staffed with people with little or no experience from the type of operations the vessels under their charge are conducting. Knowledge of bulkers, tankers or Naval vessels does not equate to any understanding of Offshore Marine Operations.


Not a filler… it was in response to c.captain who said “DPA one which MUST be held by a licensed master or chief. Make their license be at risk if they fail to perform their sworn duty to upholding the mandates of the ISM Code.”

I was simply pointing out that if person takes a DPA job at a company company that frequently violates the law… threatening to take away their license is unlikely to persuade them to acting properly.


I agree most people will cave to internal pressure maybe not at first but as they get comfortable with the job. I also believe the coast guard and ABS have given vessel operators to much freedom when it comes to inspection and reporting.

Would a third party option work for filling the DPA position? this position needs to not have internal pressure. Company culture doesn’t change easily if at all look at BP as a good example I would be curious to see if they have changed following the spill or has enough time and economic pressure brought back old behavior.


§ 1.01-20 Officer in Charge, Marine Inspection.

(a) Officers in Charge, Marine Inspection (OCMI), have been designated and delegated to perform, within each OCMI’s jurisdiction, the following functions: Inspection of vessels in order to determine that they comply with the applicable laws, rules, and regulations relating to safe construction, equipment, manning, and operation and that they are in a seaworthy condition for the services in which they are operated;

The Coast guard is “ultimately responsible” for the seaworthiness of US flag vessels yet MBI chair Captain Neubeuer points the finger at Captain Davidson, says that the El Faro Captain is “ultimately responsible” for safe navigation of the ship. Neubeuer also points at Tote as being responsible for the ship’s safe operation. Neubeuer says the ABS failed to meet performance standards.

As far as the Coast Guard’s responsibility that U.S. ships be seaworth, Capt Neubeuer says about the wastage of the vents: “The problem with those areas is that they were hard to access, and it was missed by not only TOTE, but by the ABBS and the Coast Guard.”

In other words the coast Guard failed at their responsibilities because finding corrosion on the cargo hold vents is really difficult.


Do you know (or can you guess) why none of the crew or their union representatives, other than the Master, had PII representation? It seems that almost shouldn’t have been an option.


Do you know (or can you guess) why none of the crew or their union representatives, other than the Master, had PII representation? It seems that almost shouldn’t have been an option.

No, but I find it impossible to avoid the impression that both the Coast Guard and the NTSB efforts were heavily biased toward organizational interests. I really recommend that people who are interested take the trouble to dig into the docket and read some of the interviews and how they were conducted. The “examination” of the stability software would have shocked me if I weren’t well past the age where anything shocks me anymore :frowning:



YES! Mandate under the law what professional credentials must be held by any DPA and further add to the law penalties against any company who willfully disregards any DPA’s efforts to ensure full compliance with the ISM Code. Put the DPA in the position of being held liable for failing to perform but also make the DPA potentially a hero if he tries but is ignored provided he fully documents all the trail of reporting from the master to him and from him onto higher management. A highly professional DPA will see who is the problem and if he is not afraid of retribution then he can act per his experience and knowledge.

Additionally, the ISM needs to be strengthened to protect masters against retribution by management if he takes actions which he deems are necessary to protect the ship but which management tries to overrule. Should Davidson have known that if he were fired for heaving to before getting too close to the center of circulation that he would have been able to go to court and file a civil suit against management for violating his sworn duty then would be have possibly acted with more caution that evening before the EL FARO went past San Salvador? If he knew that a court would treat his claim as bona fide with the onus on the operator to prove otherwise would he have felt he could not be harmed? Make penalties such that should a master be fired and potentially prevented further employment elsewhere that they be large enough for the person to be able to live for many years (ie. millions in damages). The lawyers would love to take such cases and companies would be very, very worried about how much it would cost them in a suit if they fire a master for doing the right thing!

Now the simple matter here in the loss of the EL FARO is if the master challenged the storm because he was afraid of being fired or if he was simply ignorant to the risk? I say here is was both because of his past statements that this was just another day in the Gulf of Alaska. He didn’t go Old Bahamas Channel to please his bosses but he did not slow or heave to sooner because he did not have fear for the ship should it enter the storm’s center. I believe he never considered the potential consequences of what might occur hence why he slept that night and ignored his mates when they advised slowing. HE WAS A VERY POOR EXCUSE FOR A MASTER FOR BEING AS OLD AND EXPERIENCED AS HE WAS AND YES, HE WAS THE ULTIMATE RESPONSIBLE CAUSE OF HIS OWN DEATH AS WELL AS 32 OTHER SOULS!


Radical idea…why not separate the inspection from the CG and go back to the :Steamboat Inspection Service" model? Experienced senior officers are offered a position and they have no one to answer to but the Chief in DC? No one knows ships better than experienced mariners. Why did the Marine Electric investigation lead to chages? Dom Calicchio, a man who KNEW the job and had actually done it. Was he also a strong willed individual? Absolutely, and he had the long term best interests of mariners in mind. When you dig into that sad tale you will see alarming parallels with the El Faro…hand washing of who was responsible, soft peddling the governments role…the difference is that CAPT Calicchio refused to knuckle under to political pressure from his superiors.

More random thoughts and my apologies for tossing bits and pieces out as these ideas pop into my head but this whole affair makes me sick. "…finding corrosion is ‘really difficult’ " COME ON! A mariner who has served on a ship knows where the problems are likely to occur and will not let a bit of rust, dirt, and scuzz on their pretty blue coveralls stop them from checking. There is always pressure to get through a survey or inspection but when you are done what is nice to hear is “So, is there anything ELSE we should check?” What that means to me is “Hey, Cap…I am done with my checklist but is there anything else you have submitted for repair that the office hasn’t arranged for? What can I do to help?”

Let’s be honest, most of us have submitted repairs that are delayed or pushed back. We KNOW they need to be done but unless the hammer of ABS of USCG comes down, they will not be done when we would prefer. We should always avail ourselves of open ended questions by inspectors and surveyors. The issue is too few of them ask that type of question anymore.

I am fortunate to work for a decent company that, on the whole, is very responsive to the Masters and Chiefs. The problem is that I feel I am in the minority of the current US fleet. If I am wrong, please correct me.


Yes, or at least mandate that all US ships use the ACP via ABS, no other class society. At least then ABS can act without worry of being fired for DNV.


It would be easier just to make the rule that the same class society has to be used for the life of the vessel. I’ve seen inspectors from both ABS and DNV manipulated by the C/E so I don’t have much faith in either one being better than the other.


I wasn’t saying ABS was better, I just picked them to inspect all American ships because they’re an American company.