USCG El Faro Investigation Report


#104

IIRC, they did look into exactly that but nothing came of it.


#105

I think both the 2M & 3M did get it. I don’t see how they couldn’t have. That’s why they both came up with the southerly route through Crooked Island Passage, which would have given them tail winds.

Both of them had received Sat C updates. Both had then plotted a southerly escape route. Both had then spoken to the Master. But neither of them had felt able to insist that he needed to come and see what they were seeing.


#106

…sleepin’ like a baby…


#107

Very well put description of the sad reality.


#108

Wait… I missed that the first couple times. 2nd Mate proposed the other course. Master said, “run it.” Is there any clarification in the VDR transcript whether he meant to run his course or her suggestion? That’s a little vague for an answer, and I hope that were I the 2M that I’d have made damn sure which one he meant in that situation.


#109

Yes, both the 3rd and 2nd mates seemed to get that the amount of risk was unacceptable. But the captain believed that the ship was going to pass south of the eye and get good speed from the tail winds. What the third mate said was the eye was going to be 22 miles away at 0400.

This message was not sufficient, this is what the 3/m said to the watch AB:

well he seems to think that we’ll be south of it by then so the winds won’t be an issue.

IIRC the 2/M did not plot the SAT-C position but got the update off the XM radio. At one point the 2/M said something about expecting the wind to back.

2M 03:24:49.9
I think it’s shifting. cause that weather report say tha uhh – west - southwest wind which we were not getting but I think its starting to shift west and now its coming back around. we’re gunna start getting it on the starboard side.

When the capt came up at 0400 he still expected the wind to shift

but) our forecast had it comin’ around to starboard.
CAPT?
04:14:38.0 the wind?
CM 04:14:39.1 right.
CAPT 04:14:39.4 it will eventually.

It appears that no one on ship understood where the ship was in relationship to the eye.

It seems likely that had the message to the captain specifically contradicted his understanding it would have been more effective. For example: Captain the eye is forecast to cross our track in front of us and we are going to enter the dangerous semi-circle and the wind has been veering not backing, the eye is on our stbd bow, we are not going to pass south of it… And/Or we are going to get head winds, not tail winds.


#111

Re-reading the transcript, rather than just the Report summary, I think you are right. Even when the 2M hands over to the CM there is no real urgency. Not even a mention that she had unsuccessfully advised the Master to change course to the south.


#112

Good practice would have been for the captain to make his plan clear to all the mates which evidently did not happen. When the third mate came up to the bridge at 2000 hrs he tried to tell the captain that he had heard on the Weather Channel TV that the system had strengthen but the capt and c/m had already laid out the plan. Instead of explaining the plan the captain shut the 3 mate down and told him to follow the waypoints.


#113

In my years at sea I have often thought that the Classification Societies should be at arms length from the shipowner and be directly employed by the insurer. The shipowner buys insurance not the classification society.
I was for a time employed as master by a German shipowner where bean counters were thin on the ground and there was experienced people in the office. The Safety Management System was run properly by an ex master with years of experience and the audit was carried out by a seperate Classification Society than the vessel’s class.
I was never questioned about my actions to avoid Typhoons in my many voyages to Korea, China and Singapore even though they upset the scheduling.
I maintained scrupulous records for the charterers detailing the situation and the where and why my decisions were made.
Record keeping that is accurate and complete is vitally important from the first day a young officer stands a watch and it helps build on experience that will stand them in good stead throughout their career.


#114

Most charterers today employ ‘weather routeing services’. They do a fairly good job of advising the Master on avoiding bad weather. In addition, they employ statistical techniques to calculate mathematically the degree of under-performance of a vessel during the voyage. That helps to resolve claims and counter-claims between the owner and the charterer. There have been cases where a Master has decided to take a route different from those advised by routeing services’ and the courts have not taken to such deviations kindly.


#115

Exactly!


#116

It doesn’t seem plausible that TOTE management was putting pressure on the ship masters to maintain schedule to the point where the level of risk being taken by masters is far in excess of industry norms. More likely what TOTE is saying is true, that the weather routing is left entirely to each ship captain with no guidance from the company.

It’s not just the El Faro, consider the case of the El Yunque, a ship in such poor shape the the Coast Guard forced TOTE to scrap it. In the same tropical cyclone that sank the El Faro the El Yunque took took a direct route from a San Juan to Jacksonville and reported encountering a 100 kt wind gust. The captain said “luckily” the gust was from dead ahead.

When planning an encounter with a tropical system without guidance from shoreside management, each captain is going to plan the encounter in accordance with evolving company norms, his own tolerance for risk, his (misplaced) confidence in his ship and his (mis)understanding of the nature of tropical cyclones.

The hands off approach of the company, combined with the companies inability to properly evaluate senior deck officers, along with competition for jobs on new ships may have lead to a creation of a high-risk culture amongst the captains and mates.

Within this culture, no direct pressure from the company would be required to explain the TOTE captain’s proclivity for taking on risks which would be considered excessive by industry standards.


#117

Not to mention the captain getting into trouble for detouring for weather previously when the company decided after the fact it wasn’t justified.


#118

Exactly. Davidson was at least implicitly pressured by TOTE to take the direct route in order to keep his job and/or be appointed to one of the new ships. The USCG has let TOTE skate on this.

What Davidson was thinking is obvious: “this is nuts. I should be taking the Old Bahama Channel, like I did last time, but those idiots in the office Will fire me if I do. I want one of those new ships. If this is what I have to do to get one, so be it. We can make it; this hurricane is no worse than winter weather in the Gulf of Alaska.”


#119

Was this verified? I thought what I saw on this was speculation.


#120

I’m thinking along the same lines but what I’m saying is that the bar was being set by the other ships/ captains, not shoreside. Shoreside lacked the expertise to know what was safe or not safe. If the other captains’ are cutting it close Davidson can’t afford not to as well. A race to the bottom.


#121

of course the USCG is letting TOTE off on this matter and it is not raised in the least in the final report. The thing is however that an office can pressure a master to take a certain route and it is very difficult for the master to say BS, I ain’t gong that way. I have been pressured myself to go straight across the Gulf of Alaska to Dutch Harbor at a time of year when I knew that I would get to Dutch in the same amount of time going up the inside to Cape Spencer, then to Whale Pass and finally down the Peninsula. Something I had done a dozen times before but could not convince the owners that it was in their interest for me to go that route. Of course we got plastered for three days by a strong gale somewhere south of the Shumagins and had to heave to so in the end nothing was saved by going straight across.

Now, with regards to Davidson…there is no amount of pressure any company can place on a master with professional integrity to force him to risk the very survival of his ship and her people and why I have said many times here that the ultimate cause for the ship’s loss was the final decision made by Davidson to proceed at around 2300 on the track as planned and not to have said to himself, “we don’t know for certain where the center of this hurricane is nor know its track well enough to keep driving towards it”. The failure of Davidson not to slow down to say 10kts at 2300 to give them margin was THE final fatal decision. As it was, the EL FARO got too close and was drawn into the maelstrom with the resultant flooding then the loss of propulsion after the alteration of the heading.

So why did Davidson not feel that fear? Why was he still so certain that the ship was going to pass south the center of circulation? Why did he not feel any hesitation that the ship might not survive? After all she was old and he certainly knew there was compromised watertight integrity? Giving into the office at the time of departure from Jacksonville can be excused but not slowing the ship down and remaining behind San Salvador CANNOT! Once the EL FARO went past that final point they were in for a hideous and needless ordeal which they might have survived but obviously didn’t. FATALLY FLAWED DECISION MAKING ON THE MASTER’S PART IS WHAT KILLED THEM ALL!

I cannot help but be reminded of this scene from the Hunt for Red October when I think of that Davidson did to his ship and crew


#122

Tote’s violations found by the Coast Guard are cost-cutting measures or errors of neglect. Work/rest violations, cutting port mates, pushing ships out of port before checking stability. Poor enforcement of an inadequate SMS, failure to properly inspect the hull etc.

Tote had no operations department, to TOTE, running ships was matter of hiring port engineers to keep the plant running on the ships and collecting/dispersing money.

It may have made sense to push those ships on the Alaska run where a high percentage of the voyages are going to be impacted by heavy weather. The JAX/SJU run is not in Alaskans waters, the weather on that run is almost always good.

On what percentage of trips a year is the schedule impacted by topical cyclones? TOTE watched it bottom line closely. It doesn’t make sense that TOTE would have devoted resources, time and attention to making sure that the ships took high risks on a couple trips a year to stay on schedule.


#123

I think Tote runs a decent operation in Alaska, but the Jacksonville operation isn’t much better than TAL.

I think the quality of management at Foss has declined too, just my impression. I’ve lost respect for Saltchuk.


#124

Thank You (I don’t know your name),
Between you, JOHN, Alumni of Fort Schuyler, and MANY other Mariners. I will be capable of responding to the USCG Commandant. This group of professional Maritine professionals provided me with incite to communicate effectively with the USCG Commandant.
THANK YOU All!
Frank Pusatere