El Faro NTSB Document Release 13 Dec, 2016

New El Faro thread for a discussion given latestNTSB release.

Earl posted this on the other tread.

[QUOTE=Earl Boebert;193285]
There was another set of documents released by NTSB, the Meteorology Group Factual Report: http://dms.ntsb.gov/pubdms/search/hitlist.cfm?sort=0&order=1&CurrentPage=1&EndRow=15&StartRow=1&docketID=58116&txtSearchT=Meteorology
I have only skimmed it, but at first glance it appears very thorough. Like c.captain, I do not feel it appropriate to offer comments on the contents of that report at this time.
Earl
Edit: To save people time I have archived the whole report and the Appendices (35, one file for each) into a single zip file and uploaded it to my site: http://bit.ly/2hxBp49[/QUOTE]

This is from the NTSB release on Engineering

According to the 1973 ABS rules for building and classing steel
1
vessels, the lubricating oil system of the main engine was to be “so arranged that it would function
2
satisfactorily when the vessel is permanently inclined to an angle of 15˚ athwartship and 3 5˚ fore and af

Lube oil was mentioned in the trascript.

The alternate chief engineer (a supernumerary) came up to the bridge and discussed lube oil levels with the master. "[You hit] the low pressure alarm on the lube oil . . . level of the engine . . .” he said

NTSB summary of transcript:

The following is a summary of the characterization of the bridge audio transcript.

The bridge audio recording began about 5:37 a.m., Sept. 30, 2015, roughly eight hours after the El Faro departed Jacksonville, Florida.

The first recorded conversation about the forecasted weather was captured the morning of Sept. 30, between the captain and chief mate, who agreed on a course diversion they believed would keep them sufficiently clear of the eye of Hurricane Joaquin. There were multiple conversations regarding weather and route planning throughout the day and evening of Sept. 30.

The captain departed the bridge at about 8 p.m. Sept. 30, and returned at about 4:10 a.m. Oct 1. At about 4:37 a.m. the chief mate received a phone call from the chief engineer regarding the vessel’s list and engine oil levels. This appears to be the first recorded conversation about these issues. The information was related to the captain. The alternate chief engineer is heard stating at about 5:12 a.m. that he’s never seen the ship with such a list.

At about 5:43 a.m. the captain takes a phone call and indicates there is a problem in the number three hold of the ship and sends the chief mate to investigate. They discuss suspected flooding over UHF radio, which appears to be the first recorded conversation about a flooding condition on the ship .

The captain indicates at about 6:13 a.m. that the ship lost propulsion. Numerous conversations are heard throughout the remainder of the recording about the ship’s flooding condition, attempts to rectify the ship’s list and attempts to regain propulsion.

The second mate began formatting a GMDSS distress message at about 6:32 a.m. as directed by the captain. At 7:07 a.m. the captain notified Tote Service’s designated shoreside representative of the critical situation and that he was preparing to send an electronic distress signal. The captain instructed the second mate to send the distress message at about 7:13 a.m. The captain gave the command to sound the ship’s general alarm at about 7:27 a.m. and about two minutes later the second mate exclaimed there were containers in the water and the captain gave the command to sound the abandon ship alarm. About four minutes later the captain relayed over the UHF radio to put the life rafts in the water.

The bridge audio recording ended at about 7:40 a.m. Oct. 1, 2015, with the captain and one of the helmsmen still present on the bridge.

I have archived and uploaded the remaining NTSB documents.

Engineering (13 mb): http://bit.ly/2gF9NIi

Electronic (VDR, tracks, etc. 9 mb): http://bit.ly/2gP7sxL

Earl

Edit: I did not download the sonar and subsea material as these appear to have been released earlier and put up on this site.

Since the article linking to the NTSB reports won’t always pop up on the gCaptain home page, here are the links to the NTSB site:

All documents:
http://dms.ntsb.gov/pubdms/search/hitlist.cfm?docketID=58116&CFID=798287&CFTOKEN=11b57a8a59ea12bf-23BC0E89-EAD5-43A3-629B00FA448F7D8B

VDR Transcript:
http://dms.ntsb.gov/pubdms/search/document.cfm?docID=447547&docketID=58116&mkey=92109

Should either of those links stop working, the NTSB Accident ID is DCA16MM001

This is from the transcript, the fire main as a possible source of the water ingress.

CM 07:14:54.1 07:14:56.2
I think that water level’s rising captain.
CAPT 07:14:56.2 07:14:58.
(okay). do you know where it’s comin’ from?
CM 07:14:58.1 07:15:05.9

  • (at) first the chief said something hit the fire main. got it ruptured. hard.
    CAPT 07:15:05.6 07:15:07.3
    um there’s no way to secure that?
    CM 07:15:08.2 07:15:21.6
    we don’t know if they’ve (seen/still have) any pressure on the fire main or not. don’t know where s’sea– between the sea suction and the hull or what uh but anything I say is a guess.

The engineering report has a photo of the emergency fire pump in #3 hold. It’s isolated from the sea by a valve operated by a reach rod. Given the location and layout it looks like it’s possible the entire pipe and valve could have been damaged by shifting cargo.

To me the most telling part of the transcript is page 269, when at 23:14 the 3M on watch calls the Captain (in his cabin) and tells him that according to the latest weather report, the Faro would pass within 22 miles of the eye at CPA, with winds well over 100 knots. He suggested altering course to the south to avoid the worst of it, and Captain Davidson said no. He didn’t even come on the bridge to look at the Sat-C printout or verify his mate’s plotting. Suggests lack of judgment to me.

That is a very likely explanation.

[QUOTE=starbored;193333]To me the most telling part of the transcript is page 269, when at 23:14 the 3M on watch calls the Captain (in his cabin) and tells him that according to the latest weather report, the Faro would pass within 22 miles of the eye at CPA, with winds well over 100 knots. He suggested altering course to the south to avoid the worst of it, and Captain Davidson said no. He didn’t even come on the bridge to look at the Sat-C printout or verify his mate’s plotting. Suggests lack of judgment to me.[/QUOTE]

Indeed, lack of judgement and abundance of confidence. This factor is probably superior in the contributing causes in my opinion. In this forum, there have been occasions, usually castigating Chouestt and the AIVIQ towing the KULLUK in winter across the GOA without “Alaska experience”. The master mentioned Alaska a bunch. He mentioned ‘good steel’ on a vessel historically (past and future) engaged in Alaska runs. He was confident, perhaps overconfident in his estimation of heavy weather effects on his passage with an “Alaska” ship. He dealt with reversals according to his confidence. Flooding? Change course, dewater, counter flood… working the problems. Even when the vessel was lost he was confident, no abandonment, stick with the ship (not for the company, smart, the heavy steel shelter is better than any raft or boat–cause it never works out in Alaska williwaws for the crabbers and their rafts, or more properly, ‘kites’ once popped in such conditions). He stayed confident, dealt with problems, had his crew ready and not once did he stop thinking he had a move to make even with an AB who had given up.

From the transcript looks like the sequence may have been this:

  • Cargo breaks loose in #3 hold rupturing the fire main causing flooding in #3 hold.
  • Crew discovers flooding and an open scuttle. The scuttle is believed to be the source of the flooding The scuttle is closed
  • Crew takes measures to reduce the list, maneuvering to put wind on opposite side, pumping holds, counter-ballasting
  • Flooding continues until list reaches 15 degrees or more, the limit of the lube oil system and loss of lube oil pressure cause the propulsion to shut down.
  • Engine crew temporally restores propulsion
  • Final loss of propulsion
  • Flooding continues.

[QUOTE=Kennebec Captain;193351]From the transcript looks like the sequence may have been this:

  • Cargo breaks loose in #3 hold rupturing the fire main causing flooding in #3 hold.
  • Crew discovers flooding and an open scuttle. The scuttle is believed to be the source of the flooding The scuttle is closed
  • Crew takes measures to reduce the list, maneuvering to put wind on opposite side, pumping holds, counter-ballasting
  • Flooding continues until list reaches 15 degrees or more, the limit of the lube oil system and loss of lube oil pressure cause the propulsion to shut down.
  • Engine crew temporally restores propulsion
  • Final loss of propulsion
  • Flooding continues.[/QUOTE]

I’m not sure your initial statement is correct, unless I missed some conclusive comment about witnessing the failure of the seawater piping to the E-pump in 3 by the crew. If so, can I trouble you for the timestamp?

Some flooding may have occurred before (the scuttle was noted, perhaps the vents and inadequate closures previously debated) which may enabled failure of lashing/cargo securing, which could then possibly lead to damage to the E-pump seawater piping or appendages–looking at the photo, imagining cargo and water, might have been battering the seavalve and reach rod to impact the flanges, leading of course to more flooding past the capacity of bilge pumping.

The issue though, of whether flooding from these sources was a cause of lashing failure, or because of lashing failure, both have a common precursor----excessive rolling and sea state, wind so it may be moot. Such effects are also related to freeboard, vessel construction and arrangements. But as those are fixed arrangements to be considered in assessing voyages, and anticipated environmental conditions, the variable of roll and course in a seaway (and estimation of impacts) is perhaps more significant and a human factor consideration based not just on voyage planning and guidance like stability plans and such, but also ongoing evidence of senses and practice of rounds and presence arrangement of bilge alarms.

[QUOTE=Jamesbrown;193353]I’m not sure your initial statement is correct, unless I missed some conclusive comment about witnessing the failure of the seawater piping to the E-pump in 3 by the crew. If so, can I trouble you for the timestamp?
[/QUOTE]

I’m not sure it’s correct either, I didn’t intend to convey a high level of confidence.

To my mind that the sole or main sorce of the flooding was the scuttle never really made sense. Seems like too much water for an open deck scuttle.

As far a conclusive comment, seems we are dealing more with weighing the probabilities of various scenarios.

As far as a time stamp, there is this

CM 07:14:54.1 07:14:56.2
I think that water level’s rising captain.
CAPT 07:14:56.2 07:14:58.
(okay). do you know where it’s comin’ from?
CM 07:14:58.1 07:15:05.9

  • (at) first the chief said something hit the fire main. got it ruptured. hard.
    CAPT 07:15:05.6 07:15:07.3
    um there’s no way to secure that?
    CM 07:15:08.2 07:15:21.6
    we don’t know if they’ve (seen/still have) any pressure on the fire main or not. don’t know where s’sea– between the sea suction and the hull or what uh but anything I say is a guess.

This was after the scuttle was secured, the crew seems to believe up till this point the source of flooding had been stopped, (CM: I think that water level’s rising captain) - seems like new information to cm and capt. Also seems like they were having a hard time sorting out wind heel and flooding heel.

[QUOTE=Kennebec Captain;193355]I’m not sure it’s correct either, I didn’t intend to convey a high level of confidence.

To my mind that the sole or main sorce of the flooding was the scuttle never really made sense. Seems like too much water for an open deck scuttle.

As far a conclusive comment, seems we are dealing more with weighing the probabilities of various scenarios.

As far as a time stamp, there is this

This was after the scuttle was secured, the crew seems to believe up till this point the source of flooding had been stopped, (CM: I think that water level’s rising captain) - seems like new information to cm and capt. Also seems like they were having a hard time sorting out wind heel and flooding heel.[/QUOTE]

CM notes it as a guess. Seawater piping source requires cargo shifting damage. 0605 CM reports he doesn’t see cars broke free. Not conclusive, speculation. I think ventilation can be flooding there as well as engineeoom as noted… also might be worth exploring the ballast shifting to/from ramp tanks. In the back and forth maybe the engineering crew was distracted? The main prop casualty was ongoing. What if that hour of ballast shifting had unintended consequence to hold three?

[QUOTE=Kennebec Captain;193355]I’m not sure it’s correct either, I didn’t intend to convey a high level of confidence.

To my mind that the sole or main sorce of the flooding was the scuttle never really made sense. Seems like too much water for an open deck scuttle.

As far a conclusive comment, seems we are dealing more with weighing the probabilities of various scenarios.

As far as a time stamp, there is this

This was after the scuttle was secured, the crew seems to believe up till this point the source of flooding had been stopped, (CM: I think that water level’s rising captain) - seems like new information to cm and capt. Also seems like they were having a hard time sorting out wind heel and flooding heel.[/QUOTE]

I tend to agree with K.C… The scuttle as the main source of flooding just doesn’t make sense. A number of bad things can happen running hard in heavy weather. At night it is worse as often it goes unnoticed until too late. Damaged piping from shifting cargo is very possible as is a hull breach due to fracture or puncture (again shifting cargo). I will add this can happen to a new ship as well as one a bit long on the tooth. I had to deal with hull framing and plate damage on a newbuild still in its guarantee period due to a captain not slowing down in a North Pacific winter storm.

The scuttle being popped open or blown open or left open might have been speculation since the comments were not conclusive. I heard something about firemain rupture on a cargo deck when shifting cargo struck a section of firemain- does anyone know if they had a wet or dry firemain?

I would love to know if the vent duct openings were above the problematic lube oil pumps- could they have lost one or both lube oil pumps due to seawater intrusion causing electrical damage? The gravity tank wasn’t going to give them the required pressure to restart the HP/LP turbines- the gravity tank is only there to protect the journal bearings during a shutdown. So…if they lost main eng (turbines) to loss of sump level or lubo press it would be a real bitch to get that back on a pitching/rolling ship, and if seawater was pouring in may have been impossible.

So many questions. And my heart still breaks for the crew.

Does anyone need the link for the docket? http://dms.ntsb.gov/pubdms/search/projList.cfm?ntsbnum=DCA16MM001

[QUOTE=Jamesbrown;193357]CM notes it as a guess. Seawater piping source requires cargo shifting damage. 0605 CM reports he doesn’t see cars broke free. Not conclusive, speculation. I think ventilation can be flooding there as well as engineeoom as noted… also might be worth exploring the ballast shifting to/from ramp tanks. In the back and forth maybe the engineering crew was distracted? The main prop casualty was ongoing. What if that hour of ballast shifting had unintended consequence to hold three?[/QUOTE]

No, not a guess on the C/M part. Here it is again:

CM 07:14:54.1 07:14:56.2
I think that water level’s rising captain.
CAPT 07:14:56.2 07:14:58.
(okay). do you know where it’s comin’ from?
CM 07:14:58.1 07:15:05.9

  • (at) first the chief said something hit the fire main. got it ruptured. hard.
    CAPT 07:15:05.6 07:15:07.3
    um there’s no way to secure that?
    CM 07:15:08.2 07:15:21.6
    we don’t know if they’ve (seen/still have) any pressure on the fire main or not. don’t know where s’sea– between the sea suction and the hull or what uh but anything I say is a guess.

The “guess” is the answer to the question “is there any way to secure that?”

And yes, again, absoluely not conclusive. Not pure speculation however, call it an educated guess, an application of Occam’s razor, the simplest explanation that fits (most of?) the known facts.

I’ve been on RO/RO about 20 years, loose cargo can do a surprising amount of damage. When I saw that photo of the emergency fire main… Not much there to stop a heavy piece of fast moving cargo, steel gets torn up.

Of course it could be ballast vent pipes, hull breach?? But the C/E says the fire main was ruptured. That’s about as solid piece of information as it gets in this case. Any other source of the requred volume seems less likely.

And again, just my observations, YMMV.

I have two questions in regard vessel stability.

  1. Why did it take a call from the ECR for the bridge to realize there was a stability concern (i.e. the list)?

  2. What tools (e.g. stability computer or worksheets) and information (e.g. damage stability booklet) were available to understand and rectify the stability issue? Is there any indiction that these tools/information where utilized?

[QUOTE=john;193384]I have two questions in regard vessel stability.

  1. Why did it take a call from the ECR for the bridge to realize there was a stability concern (i.e. the list)?

  2. What tools (e.g. stability computer or worksheets) and information (e.g. damage stability booklet) were available to understand and rectify the stability issue? Is there any indiction that these tools/information where utilized?[/QUOTE]

Great questions gCaptain.

[QUOTE=DeepSeaDiver;193422]Great questions gCapt

[QUOTE=john;193384]I have two questions in regard vessel stability.

  1. Why did it take a call from the ECR for the bridge to realize there was a stability concern (i.e. the list)?

  2. What tools (e.g. stability computer or worksheets) and information (e.g. damage stability booklet) were available to understand and rectify the stability issue? Is there any indiction that these tools/information where utilized?[/QUOTE]

  1. I would say that the list would be stability concern if it was close to deck edge submersion. The machinery limits would likely come sooner. The engineers were trying to solve their problems and they needed the list reduced.

Seems that the crew, in particular the C/M was properly focused on getting the water pumped out and inspecting the holds. Better to concentrate on that rather than consult stablity books or whatever.

Tough subject, strong eng dept and the chief mate was a good man.