El Faro - What was the Captain Thinking is the Wrong Question

Professional Mariner Forum
1

A better question is why was a decision making process that was so fragile and error prone being used? Traditionally we think of the person in charge, such as a captain as the person who makes decisions. But what the person in charge really does is much more than that, the person in charge decides how decisions are made.

The decision-making process used in a crisis has to be in place before the crisis.

As to the specific reason for the failure in decision making - what happens when decison makers are under stress?

(decision making in) a threatening context, the psychological stress and anxiety may induce a rigid cognitive response on the part of individuals. People tend to draw upon deeply ingrained mental models of the environment that served them well in the past. Individuals also constrict their information gathering efforts, and they revert to the comfort of well- learned practices and routines. This cognitive rigidity impairs a leader’s ability to surface and discuss a wide range of dissenting views. To make matters worse, factors at the group and organizational level complement and reinforce this inflexible and dysfunctional response to threatening problems. Consequently, organizational decision processes become characterized by restricted information processing, a constrained search for solutions, a reduction in the breadth of participants, and increased reliance on formal communication procedures. 56 - Michael Roberto HBR

2

John Boyd’s OODA loop can be a useful tool when analyzing individual responses to situations of peril. I heard him speak once. He had the charisma of someone who could start a religion – and some people will argue that he did :slight_smile: In any case, Roberto’s observation fits largely into the “Orient” step of the loop.

Cheers,

Earl

3

[QUOTE=Earl Boebert;195547]John Boyd’s OODA loop can be a useful tool when analyzing individual responses to situations of peril. I heard him speak once. He had the charisma of someone who could start a religion – and some people will argue that he did :slight_smile: In any case, Roberto’s observation fits largely into the “Orient” step of the loop.

Cheers,

Earl[/QUOTE]

Pls note the dog eared bible [I]The Mind of War - John Boyd and American Security
[/I]
](https://flic.kr/p/Soa4Mq)image by kennebeccaptain, on Flickr[/IMG]

4

[QUOTE=Kennebec Captain;195548]Pls note the dog eared bible [I]The Mind of War - John Boyd and American Security
[/I]
](https://flic.kr/p/Soa4Mq)image by kennebeccaptain, on Flickr[/IMG][/QUOTE]

Also recommended: “Science, Strategy and War: The Strategic Theory of John Boyd” by Frans P.B. Osinga.

We need to come up with a secret handshake :slight_smile:

Cheers,

Earl

5

In order to deal with (very) difficult situation or in case of emergencies on board Dutch ships the Ship’s Counsel comes into action. This Counsel analyses and discusses the problem and takes, after mutual consultations, a decision. The Counsel members are the Captain and senior deck and engineering officers. I have met this situation once which also had to do with a hurricane and partially polluted bunkers.

This Counsel is a heritage from the old days were for instance the Dutch VOC (United East Indian Company) already had such a Counsel, if necessary, in place as well as Columbus with the Santa MarĂ­a in 1482. So this is not exactly a new idea. I am sure that if such a counsel was held on the El Faro they would have taken another route. But I am afraid that the captain probably saw no need for this as he did not evaluate the situation as to be life threatening.

I am strongly in favour of a psychological exam before starting the nautical education and also before going to sea. In aviation this is already for a long time the rule. Aviation psychologists have designed methods to select people who have the abilities, mental stability and attitudes required for flying an airplane. It is all there for the taking! I am sure that a lot of accidents could be avoided in this manner and that the safety at sea would be improved very much with such exams.

6

[QUOTE=Dutchie;195551]s.

I am sure that if such a counsel was held on the El Faro they would have taken another route. But I am afraid that the captain probably saw no need for this as he did not evaluate the situation as to be life threatening.
[/QUOTE]

There are many steps short of a meeting of senior officers. The letter you linked to mentions the practice of having a chart under plexiglass for plotting hurricanes. This is standard practice on many ships. However in this case the captain seemed to be using only the BVS program.

In the U.S. all hurricane forecasts (NHC data is the information used by BVS) use data from the NHC, this is the earliest and most reliable weather information - weather programs are very convenient however the information should be checked with NHC forecasts and actual weather observations for mismatch.

Ths ship needed a explict plan to monitor. When the orginal assumptions made to make the plan change, the plan has to be reevaluated. However apparently, from the transcripts, no such plan was laid out. The captain simply came to the bridge (just before 2000 on the 30th) and laid out new waypoints to adjust for the changing forecast. However evidently no night orders were left with instructions on what paremeters to watch (ie wind speed/directions barometric pressure) or when to call in the event observations did not match what was expected or if the forecast changed unfavoarably.

7

[QUOTE=Kennebec Captain;195556]The ship needed a explict plan to monitor. When the orginal assumptions made to make the plan change, the plan has to be reevaluated. However apparently, from the transcripts, no such plan was laid out. The captain simply came to the bridge (just before 2000 on the 30th) and laid out new waypoints to adjust for the changing forecast. However evidently no night orders were left with instructions on what paremeters to watch (ie wind speed/directions barometric pressure) or when to call in the event observations did not match what was expected or if the forecast changed unfavoarably.[/QUOTE]

That is the crux of the whole thing! Their was no concern at all on his part about the precarious situation he was actually in. Homing for a hurricane and no worries. That was not true however for some of the crew members like the second mate, as shown by her e-mail to her mother, who suspected that they were in for real trouble.

It looks like a case of narrowing reality or tunnel vision, setting aside all threaths and focusing on a certain fake reality, with in this case a disastrous end result.

8

I read the VDR transcript and felt nauseous near the end. I don’t think any of us can answer what the Captain was thinking but he definitely seemed to think his experience in the Alaskan trade gave him immunity from worry about this level of weather. At each change of the watch you can read the details of a thorough discussion each time between the mates about how nervous they were and what the weather prognosis was. I was also a little shocked at his lack of worry when the flooding and list continued to get worse. Not sounding the general alarm to have all hands available seemed like a poor choice to me. Once the plant was lost I would have had all hands preparing for the worst. He didn’t appear, at least in his words from the transcript, to be overly concerned at this point. Truly a sad situation.

9

[QUOTE=DamnYankee;195585]I read the VDR transcript and felt nauseous near the end. I don’t think any of us can answer what the Captain was thinking but he definitely seemed to think his experience in the Alaskan trade gave him immunity from worry about this level of weather. At each change of the watch you can read the details of a thorough discussion each time between the mates about how nervous they were and what the weather prognosis was. I was also a little shocked at his lack of worry when the flooding and list continued to get worse. Not sounding the general alarm to have all hands available seemed like a poor choice to me. Once the plant was lost I would have had all hands preparing for the worst. He didn’t appear, at least in his words from the transcript, to be overly concerned at this point. Truly a sad situation.[/QUOTE]

Agreed. . . that (this is nothing compared to the Gulf of Alaska - paraphrased) comment kinda got to me. . . .

10

If anything, my overall feeling was the guy was eerily calm throughout the whole ordeal. I mean the guy just seemed to fear nothing. Maybe he was in shock, I don’t know. Its been a little while since I read the transcript and I don’t care to read it again, but didnt he basically wake up and come to the bridge maybe an hour or two before their deaths? I mean damn…sleeping the night away while everyone on board is terrified.

11

I haven’t followed everything super close, but the start of this tragedy seems to have a lot in common with the 747 Korean Air 801 that crashed on Guam: https://en.wikipedia.org/wiki/Korean_Air_Flight_801

The “boss” is in charge, omniscient, and can’t be questioned, debated, nor overruled.

Think about it. What avenues would any of his subordinates have to act a little more conservative in the routing of the ship?

I’m not a master and never will be. But it seems odd to me that he was not actively involved in regular updates (say 2-3 hours)…instead just sleeping?

12

Many leaders boast of remarkable track records, like Rob Hall, and employ an autocratic leadership style. Inexperienced individuals find themselves demonstrating excessive deference to those with apparent expertise in the subject at hand. Plenty of teams lack the atmosphere of mutual trust and respect that facilitates and encourages candid dialogue. Fortunately, most business decisions are not a matter of life or death.36

from: The Leadership Challenge

3M
21:22:21.6
21:22:31.7
I don’t know. I’m not gunna second guess somebody.– the guy’s been
through a lot worse than this. he’s been sailing for a long– long time–
he did it up in Alaska.
AB-3
21:22:34.9
21:22:43.7
well I’ll never have faith in the # like I used to though. [sound of quick
chuckle] captain @UNK sailed us right into one.

reading on in the transcript; AB-3 went through Hurricane Hugo on a ship - he no longer believes captains always know what they are doing.

13

I don’t wish to take this thread off topic but I remember Hurricane Hugo (as mentioned by AB-3). Our captain headed east. As the Hugo passed by we came in behind it to arrive San Juan the next morning. The power plant was off line as a result most of San Juan and that part of the island was dark. We gathered up as much cable as we could scrounge and powered the terminal and its cranes from the ship. We left that setup in place for the next ship to use until the terminal got its power back. That took several weeks.

Sorry for the out of place comment. Hurricane Hugo brings back a lot of memories.

14

My intent here was to focus on routing decisions, that is to say events before the second mate’s call to the captain at about 0200 hrs. I have no pertinent experience to comment one way or the other about non-navigation decisions made after that.

15

[QUOTE=johnny.dollar;195592]I haven’t followed everything super close, but the start of this tragedy seems to have a lot in common with the 747 Korean Air 801 that crashed on Guam: https://en.wikipedia.org/wiki/Korean_Air_Flight_801

The “boss” is in charge, omniscient, and can’t be questioned, debated, nor overruled.

Think about it. What avenues would any of his subordinates have to act a little more conservative in the routing of the ship?

I’m not a master and never will be. But it seems odd to me that he was not actively involved in regular updates (say 2-3 hours)…instead just sleeping?[/QUOTE]

In Korean culture you donot correct the boss. Korean cockpit culture was almost unarguably the primary cause of a number of accidents. Korean society is very hierarchical and respectful, and a lot of the accidents have simply come down to first officers not wanting to question the decisions of captains, given that they had basically be “insulting” them.

Historically Korean airlines have abysmal safety records, even so that the US military stopped flying their personnel in the Pacific with them. The situation changed drastically for the better since the crash of a 747, flight 8509, shortly after take off in the UK in 1999. The flight engineer gave a warning about the malfunction of an essential navigational instrument but the captain did not react. The first officer was aware of this but preferred dying above correcting the captain or taking over the control of the airplane, such is or rather was Korean cockpit culture, unarguably the primary cause of the crash.

Almost all Korean civil pilots were ex airforce pilots flying small fighter planes. Captain Park stepped out of the military as a colonel and as such in their way of thinking he could not be a first officer without loss of face but became, after the simulator training, immediately a captain.

After the findings of the cause of this last incident Korean Airlines totally changed their cockpit training where proper communication was all important as well as working as a team instead of having one leader and two zombies. As a result no incidents have taken place since 1999 and Korean Airlines is regarded now as a safe airline.

The investigation of the crash can be seen via the link. See also what is said about the culture problem at 36:45 min.

[video]https://youtu.be/6iM29fOehag[/video]

Coming back to the El Faro there are indications that there was also a certain lack of communications on the bridge between the captain and the other crew members, a reluctance to voice their concerns strongly about the developing hurricane situation.

16

[QUOTE=Slick Cam;195590]…I mean the guy just seemed to fear nothing. Maybe he was in shock, I don’t know…[/QUOTE]

I had this feeling too.

Like Schettino, after opening the Costa Concordia’s hull on a charted rock off Giglio island.
He must immediately have known what he did: He and he alone steered the ship on the rock, without any possible excuse. He personally wrecked a 500 million $ ship, with more than 4000 people on board!
After the first damage reports, his behavior became completely irrational; not silly or incompetent, just crazy.
Only the complete loss of power forbade further idiocies.
Only a favorable wind drift saved the lives of more than 99% of the people.

On El Faro, at about 6 pm, the captain did not use the last escape at the Hole in the Wall. With following forecasts of Joaquin’s track, he could well have realized that he had entered the deadly trap; enough for a tremendous shock!
Then, he went to “sleep”; maybe to escape brutal questions… and to pray.

We cannot know.
Only a mate, often sailing with the captain, could possibly hear on the VDR, if his voice and wordings were “as usual”…

17

[QUOTE=Dutchie;195615]In Korean culture you donot correct the boss. Korean cockpit culture was almost unarguably the primary cause of a number of accidents. Korean society is very hierarchical and respectful, and a lot of the accidents have simply come down to first officers not wanting to question the decisions of captains, given that they had basically be “insulting” them.

Historically Korean airlines have abysmal safety records, even so that the US military stopped flying their personnel in the Pacific with them. The situation changed drastically for the better since the crash of a 747, flight 8509, shortly after take off in the UK in 1999. The flight engineer gave a warning about the malfunction of an essential navigational instrument but the captain did not react. The first officer was aware of this but preferred dying above correcting the captain or taking over the control of the airplane, such is or rather was Korean cockpit culture, unarguably the primary cause of the crash.

Almost all Korean civil pilots were ex airforce pilots flying small fighter planes. Captain Park stepped out of the military as a colonel and as such in their way of thinking he could not be a first officer without loss of face but became, after the simulator training, immediately a captain.

After the findings of the cause of this last incident Korean Airlines totally changed their cockpit training where proper communication was all important as well as working as a team instead of having one leader and two zombies. As a result no incidents have taken place since 1999 and Korean Airlines is regarded now as a safe airline.

The investigation of the crash can be seen via the link. See also what is said about the culture problem at 36:45 min.

[video]https://youtu.be/6iM29fOehag[/video]

Coming back to the El Faro there are indications that there was also a certain lack of communications on the bridge between the captain and the other crew members, a reluctance to voice their concerns strongly about the developing hurricane situation.[/QUOTE]

In all Asian cultures this is a problem, but especially in countries where Confucian teaching is prevalent, like in Korea. It is also a problem in the Malay culture, (Malaysia, Indonesia and part of the Philippines) but for different cultural reasons.

I have referred earlier to an accident investigation I did where an otherwise well qualified and experienced Indonesian Tug Master waited too long to warn a Mooring Master on a tanker he was assisting that he was going too fast for the capabilities of an AHT. He and three others perished when the tug breached and capsized. By the time he shouted a warning it was too late.

I knew him personally and can vouch for his abilities, but also his unwillingness to do things he would see as “rude”.

I didn’t think this would be a problem in an American setting though. (If I was that Tug Master I would have shouted - in no uncertain terms - a lot earlier)

18

[QUOTE=johnny.dollar;195592]

Think about it. What avenues would any of his subordinates have to act a little more conservative in the routing of the ship?
[/QUOTE]

This is a good point. The captain just had a route created, little room for disscussion. The mates evaluated the plan after the captain left the bridge.

Instead the goal of the plan needed to be explicitly stated. Need to avoid moving the goalposts. When the 60 miles from the center was violated the plan needed to be changed. Otherrwise there is risk of erosion of margins.

19

An analysis of the Korean ferry disaster using Prof. Leveson’s approach can be found here:

http://sunnyday.mit.edu/papers/Kwon-Thesis.pdf

I warn you, it makes for horrifying reading.

Earl

20

[QUOTE=Slick Cam;195590]If anything, my overall feeling was the guy was eerily calm throughout the whole ordeal. I mean the guy just seemed to fear nothing. Maybe he was in shock, I don’t know. Its been a little while since I read the transcript and I don’t care to read it again, but didnt he basically wake up and come to the bridge maybe an hour or two before their deaths? I mean damn…sleeping the night away while everyone on board is terrified.[/QUOTE]

It’s kinda like the guy committed suicide and took his crew with him.