Thing that strikes me is how much the disaster was like the Bounty sinking. One uninspected with serious flaws, other inspected by incompetents with serious flaws, either one capable vessels. Delusional masters not afraid of Hurricanes. Crews with no input on the routings afraid to question decisions.
Except ability to be rescued, situation exactly the same.
Boats3
[QUOTE=Kennebec Captain;195630]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.[/QUOTE]
“Plans are worthless, planning is everything.” – Dwight Eisenhower. His whole speech is worth reading:
http://www.presidency.ucsb.edu/ws/?pid=10951
Cheers,
Earl
[QUOTE=Earl Boebert;195641]“Plans are worthless, planning is everything.” – Dwight Eisenhower. His whole speech is worth reading:
http://www.presidency.ucsb.edu/ws/?pid=10951
Cheers,
Earl[/QUOTE]
It’s out of context but I like this quote:
“… only for the man who, knowing with precision what he should expect, is able to recognize that something has gone wrong.”
― Thomas S. Kuhn, The Structure of Scientific Revolutions”
[QUOTE=Chief Seadog;195603] 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.[/QUOTE]
Though, off topic, thanks for posting that. When Fukushima blew up, I was on that side of the world. I also had quite some time working with Asian culture. I have stated for years, that there was no reason for the explosions to happen (remember, it was days after loss of power that the explosions occurred). They needed power for running pumps. Or they needed to pump water. The entire WORLD was available to assist, and ANYTHING could’ve been flown in within 24 hours.
OR, I also said a ship or two could’ve been pulled up and extension cords run. And now you have proof that this is viable scenario. Thank you. Meanwhile, radiation pours into the ocean…
But they saved face, though.
It’s somewhat ironic that we comment so confidently about someone else’s presumed overconfidence.
When we read about a CEO’s failed strategy in Business Week, or analyze the actions of the manager profiled in a case study at Harvard Business School, we often ask ourselves: How could that individual make such a stupid decision? My students ask themselves this question on numerous occasions each semester as they read about companies that falter or fold. Perhaps we think of others’ failures in these terms because of our hubris, or because we might need to convince ourselves that we can succeed when embarking upon similar endeavors fraught with ambiguity and risk. Jon Krakauer, a member of Rob Hall’s 1996 Everest expedition, wrote, "If you can convince yourself that Rob Hall died because he made a string of stupid errors and that you are too clever to repeat those errors, it makes it easier for you to attempt Everest in the face of some rather compelling evidence that doing so is injudicious."
Rob Hall was the leader of the expedition that become the subject of Krakauer’s “Into Thin Air”
In May 1996, Rob Hall and Scott Fischer, two of the world’s most accomplished mountaineers, died on the slopes of Everest along with three of their clients during the deadliest day in the mountain’s history.
Exactly. What Diane Vaughan called “our luxurious retrospective position.” Coulda, shoulda, woulda in ordinary terms. I made it a practice to reread Chapter 10 (Lessons Learned) of her Challenger book every year when I was engaged in risky business.
Cheers,
Earl
[QUOTE=Earl Boebert;195675]Exactly. What Diane Vaughan called “our luxurious retrospective position.” Coulda, shoulda, woulda in ordinary terms. I made it a practice to reread Chapter 10 (Lessons Learned) of her Challenger book every year when I was engaged in risky business.[/QUOTE]
obviously, casualties occur often because the decision maker failed to do a mental risk analysis. I have been guilty of several times in my career of failing to look at what the potential for disaster to occur before making my decision to proceed but kind providence by God prevented the situation from going from just fine to all collapsing down around my ears. I also can say that these times were not always when I was young and had not yet earned the wisdom of age. I recently wrote about how just the other day I was towing a trailer heavily loaded without having secured the load on it properly. I lost part of that load on I-5 but no other vehicles became involved which only God was responsible for. When I left with the equipment only secured with webstraps and not chain, I did not say to myself “but what if one of these straps breaks”? what might happen if that occurs? how bad might that be? if I had, I would have gone to buy four cargo chains and binders but I was being cheap and didn’t want to because I already had plenty of chain at my shop but had not brought them with me that day. Instead I told myself that the webstraps were in good shape and “should” hold the load secure which they likely would have except that the trailer was fishtailing while I was towing it home and the accelerations over strained the lashings. I never stopped to ask myself “is this really safe”…I just went and almost made it home before the straps failed and I lost the load. If I had really looked at the potential for a failure of the lashings I would never have left with them not lashed to the best possible level of security. However, I was lucky and did not end up with a massive insurance claim against my insurance which could have bankrupted me if there had been injuries to other drivers or their passengers. God had my back that afternoon and once it was all over and I had my load recovered and all home safe did I say to myself, “WHAT THE FUCK WERE YOU THINKING”?
A screen shot of the BVS (Bon Voyage System)
Bon Voyage System screenshot showing Joaquin forecast center position, storm wind fields, sea level pressure, surface wind, and significant wave height valid 8AM October 1st. Part of the main BVS weather file emailed to El Faro about 5AM October 1st.
If this came in a 5am EDT it may have never been looked at.
This is a link tothe BVS package emailed to the EL FARO around 2300EDT 29SEP15. This package contains the nominal 1700EDT NHC Tropical Cyclone Forecast/Advisory 8, valid for the time of release
If the screen shot at the linkcame out at 29/2300 ETD likely it was looked at the morning of the 30th. - If this program is similar to what I use the blue (?) wind barbs are the current time and the green wind barbs on the track-line are the forcast winds for the time the ship will be at that postion.
Homing in on one point which has had me confused: why is an anemometer not a required piece of navigational equipment? Nowhere in SOLAS, the MCA, or even the latest World Sailing Offshore Special Regulations can I find any requirement for a vessel to possess a working anemometer. Is this an oversight? I’m sure it is assumed that any sea-going vessel would carry one.
There is a contradiction otherwise in the recommendation in Solas Chapt. V for ships to do the following:
"REGULATION 5 - Meteorological services and warnings
SOLAS Chapter V – 1/7/02
7 - when in the vicinity of a tropical cyclone, or of a suspected tropical
cyclone, ships should be encouraged to take and transmit their
observations at more frequent intervals whenever practicable, bearing
in mind navigational preoccupations of ships’ officers during storm
conditions….
…9 - to encourage masters to inform ships in the vicinity and also shore
stations whenever they experience a wind speed of 50 knots or more
(force 10 on the Beaufort scale).”
How does the bridge know when the wind speed is over 50 knots, and how can they supply wind speed & direction data if they don’t have an anemometer?
Likewise, how can a ship effectively make an informed, independent assessment of a tropical cyclone’s motion & intensification, if they don’t have the means to make accurate observations? The NOAA document “Mariner’s Guide for Hurricane Awareness in the North Atlantic Basin” states:
"Changes in wind direction and speed along with changes to shipboard barometric pressure are the
fundamental guides to locating a vessel within the tropical cyclone’s circulation. “
Surely the equipment & meteorological awareness to make these calculations should be mandatory on any vessel operating in tropical waters?
Perhaps if the Officer on watch had been able to demonstrate with the ship’s own observations that they were heading for trouble, the Captain might have been persuaded to return to the bridge?
CAPT
07:13:51.6
07:13:54.8
[B]if our anemometer worked.[/B]
CM
07:13:55.2
07:13:59.2
yeah we’d be able to * *.
CAPT
07:13:59.4
07:14:01.5
be like * old school.
CM
07:14:00.9
07:14:08.5
it’s– is– is– the– is the– is anybody played with it enough to know the
number’s good? just not…obviously the direction’s not good. is that
number any good?
CAPT
07:14:09.4
07:14:11.1
I wouldn’t trust it.
CM
07:14:11.0
07:14:16.8
and they’re– they’re (not gunna) buy a new one for it.
=======================
CAPT
14:03:39.6
14:03:48.5
umm @CAPT-EY said he saw a hundred gust to a hundred knots. they
were going in to it.
2M
14:03:47.9
14:04:05.1
========================
SUP-1
05:10:40.7
05:10:47.1
gunna (look the cable looks) down the on second deck by the bunker
station (things are) slappin’ around.
SUP-1?
05:10:51.1
05:10:53.0
what’s the wind speed?
CAPT
05:10:52.6
05:10:57.4
[B]we don’t know. we don’t have (any) anemometer[/B]
Exactly. So if it had been required by law, it would have been fixed/replaced, and they would have had accurate wind data.
This is 5 a.m on the 1st. - Capt does not know where the center of the system is.
CAPT
05:03:30.8
05:03:54.8
That– that’s fine– but here’s the thing– you got two G-P-Ss– you got
five G-P-Ss– you gunna get five different positions. you got one
weather program (and I use/and use) B-V-S and that’s what I (sent) up
here * we’re gettin’ conflicting reports as to where the center of the
storm is.
Buys Ballot Law:
The law outlines general rules of conduct for masters of both sail and steam vessels, to assist them in steering the vessels away from the center and right front (in the Northern Hemisphere and left front in the Southern Hemisphere) quadrants of hurricanes or any other rotating disturbances at sea. Prior to radio, satellite observation and the ability to transmit timely weather information over long distances, the only method a ship’s master had to forecast the weather was observation of meteorological conditions (visible cloud formations, wind direction and atmospheric pressure) at his location.
Included in the Sailing Directions for the World are Buys Ballot’s techniques for avoiding the worst part of any rotating storm system at sea using only the locally observable phenomena of cloud formations, wind speed and barometric pressure tendencies over a number of hours. These observations and application of the principles of Buys Ballot’s Law help to establish the probability of the existence of a storm and the best course to steer to try avoid the worst of it—with the best chance of survival.
CAPT
05:05:05.4
05:05:08.8
our biggest enemy here right now is we can’t see.
CAPT
05:05:13.6
05:05:15.4
that’s our biggest enemy
And from the NOAA/NHC Mariner’s Guide…
“Winds veering over time indicate that the ship is in the right semi-circle (with respect to tropical cyclone motion) of the
system. Conversely, backing winds over time indicate that a vessel is in the left semi-circle of a system. If wind direction remains steady but continues increasing in speed, a vessel is likely located
ahead of the tropical cyclone. Additionally, in those instances where a vessel is caught ahead of a
tropical cyclone, the barometric pressure will also continue to fall, in some cases quite rapidly as the
system center moves closer.”
Since the previous afternoon they had been casually monitoring changes, but without the ability to record exact wind direction & speed data to go with the pressure changes, it would have been difficult to get a fix on the centre of Joaquin. The most important need was to determine their [B]relative[/B] position to the centre, and monitor whether that was changing, or not.
Some edited weather related extracts…
AB: 14:25:25.3 - "it’s all whitecaps now. and the swell’s growing. "
2M: 15:46:36.6 - “…wind is increasing. we’re doing weather every hour. “
2M: 15:46:42.2 - "still comin’ right for us or we’re headed right for
it. um the swell has been about the same – about eight feet – six to eight feet. from
the east. “
2M: 15:46:57.7 - "umm but the wind has started to pick up more. “
CM: 15:48:16.2 - "(gettin’/the) wind on the stern?”
AB: 15:48:18.1 - “naww – it’s (all) it’s outta here. “
CAPT: 16:08:44.3 - "that’s a pretty healthy swell buildin’ there chief mate. “
CM: 16:08:52.4 - "it’s on the port quarter *. "
Wind speed / direction by observation or “feel” at night is going to be very subjective. Few mariners have very much experience of the “feel” of the wind at wind speeds over 40 or 50 kts.
The issue than is confirmation bias. The ambiguity in the information increases the chance that it will be interrupted to conform to what the observer expects. In this case they clearly expected the wind to shift aft (as would be the case in the "navigable semicircle) even as they approached the eyewall.
Hourly observation taken by anemometer and recorded would have been much less subjective.
Confirmation bias, also called confirmatory bias or myside bias,[Note 1] is the tendency to search for, interpret, favor, and recall information in a way that confirms one’s preexisting beliefs or hypotheses, while giving disproportionately less consideration to alternative possibilities.[1] It is a type of cognitive bias and a systematic error of inductive reasoning. People display this bias when they gather or remember information selectively, or when they interpret it in a biased way. The effect is stronger for emotionally charged issues and for deeply entrenched beliefs. People also tend to interpret ambiguous evidence as supporting their existing position.
[QUOTE=Mat;195684]Exactly. So if it had been required by law, it would have been fixed/replaced, and they would have had accurate wind data.[/QUOTE]
Been a long time since I went through USCG inspection on a US flag vessel but regardless of specific equipment requirement, I seem to remember them enforcing a “if it is there, it has to work” rule at OCMI discretion. However, even that would have varying effect on a specific organization’s motivation to maintain a ship. If the company culture and port engineers did not view that as important they could easily conclude to ignore it until forced to correct it. Not the way it is supposed to be but from the few corp guys I watched on the hearing streaming they sure seemed disengaged from deep concern or caring.
The quote is from one of hearings in february 2016.
Later, the board asked Mr. Baird about the condition of the El Faro’s anemometer, and he responded that when he was last aboard, it was not working; he had informed the captain of it. For recording logbook entries of weather conditions, the bridge team would estimate wind based on visual observations. The anemometer was broken for “at least 2-3 months,” he said; in followup questioning from TOTE, he allowed that it could have been repaired after his last rotation on the vessel.
It is true that if such a non compulsory instrument is on board that it must work and if not, should be repaired at the first possible opportunity or replaced. What I cannot find in the hearings is the fact whether Tote was queried about the repair or rather the non repair including a replacement of the anemometer. As we know now from the transcripts this instrument was not working properly.
With the law of Buys Ballot it is possible, together with the barometric pressure, wind speed, wind and wave directions as well as ship’s speed and course to estimate to a certain extent the hurricane’s path and to take proper action accordingly, staying away from the dangerous semicircle. A reliable weather instrument is then very helpful, especially at night.
Hurricane navigation is an art at which already Columbus was skilled, always observing the sky, wind and waves.
Columbus read the signs of an approaching storm from the appearance of a southeasterly swell, the direction of the high cirrus clouds, and the hazy appearance of the atmosphere. He directed his vessels to shelter. The commander of another group, who did not heed the signs, lost most of his ships and more than 500 men perished.
I guess I would mildly disagree with the applicability of your quoted definition of confirmation bias, or “go fever” as my astronaut boss used to call it, to this particular situation. I think it can arise in cases of ambiguous evidence even when the individual does not have an existing or prejudged position. The light flickers now green, now red. Stop or go? Lots of cultural and organizational pressure to go; so much so that rolling the dice becomes the default option and stopping must be justified – especially if the individual has rolled the dice in the past and won. Not quite the same thing as cognitive bias, IMHO, and more seductive and dangerous.
“Superior pilots use their superior judgement to avoid situations requiring their superior skill.” – Attributed to Ed White, and a favorite quote of my boss.
Cheers,
Earl
I thought this was of interest.
It’s been reported that the captain has a reputation for dotting the i’s and crossing the t’s but here the C/M is entering the new waypoints into the GPS and the captain says this:
CAPT
all I need is a navigation calculator and I will make up the waypoint
sheet– courses– rhumb line distances and then chart. (don’t need none
of) that fancy stuff. oh it’s nice to have– don’t get me wrong.
CAPT
a friendly reminder that you’ll have a route to deal with.
Having the waypoints entered is standard practice, of course it’s not necessary but it’s a good way to double check the chart work. Says he doesn’t need fancy stuff but is using the BVS program instead of hand plots for tracking Joaquin. Not a big deal but a little odd.
Here’s the full exchange.
CAPT:
you heavy in thought over there chief mate?
CM
06:56:57.4
06:57:02.2
uh no captain I’m just now puttin’ in uh– a new route.
CAPT
well back in the day we didn’t have that stuff. throw that right over the
side.
CM
I know but I– I like to look at the numbers and have everything line up
and match up and—
CAPT
I agree– I agree. that’s that type a personality you have.
CM
yeah I like to I like to have my little thing following the little purple line…
CAPT
yup.
CM
and my course to waypoint matching my course over ground.
CAPT
yup.
CM
and then the only– if it’s not then you have to take another look.
CAPT
ya.
CM
you know so. I mean I understand what we’re doing why and of course
it could change.
CAPT
sure.
CM
pretty quick and easy.
CM
okay. now.
M1
[sound of quick electronic chirp]
CM
Wind speeds are ‘subjective’ when not taken with a properly working anemometer, sure, but the precision of the number clearly means less than his ability to determine the ‘data’ of the wind effect in sufficient detail in relation to decision points. The Captain knew what the winds were doing well enough to know he had to ride to weather (which was his plan) vice make good his course based on how the ship was responding. While some more visibility would have improved subjective evaluation of wind/seas/swell, having a ‘number’ clearly didn’t mean much, nor did the lack of functioning anemometer in his plan. The faulty anemometer was known before sailing, so the Captain accepted this uncertainty–more properly ‘imprecision’–as one more bit of risk.
I believe the Captain was relying on barometer more than wind data (degraded as it was). CM also was watching and the Captain clearly is relying on this data in making a key decision to attempt to get back on course suggesting he was using this data to ‘fix’ his position in relation to the storm more than wind data.
01OCT/0445: CM ‘down to nine sixty millibars’
It is clear the Captain is relying on his impression of the trend when he queries the CM at 0503AM. CM notes he is “watching millibars (come up)”. (FWIW: If Captain or CM saw the 5AM EDT public advisory update (unlikely) from NOAA, the minimum central pressure was reported as 948 mBar and the Forecast Advisory from 2300/30Sep (EDT) was estimating central pressure of 951mBar. Previous updates and advisories called for 988mBar. This should worry him severely if the CM reading is correct and logs reflect drops below last advisories. But he’s committed to his position and is dealing with what’s in front of him, and any trend up following the downward trend noted in earlier discussion is a positive indicator in his decision making that the worst may be over.)
Captain Davidson again confirms with CM. The CM notes ‘yes [coming up] six-zero and its (now/still) (nine-six-zero/nine-sixty)’.
Again, 0503 Capt: “(comin’ up)?” an unknown reply follows then the Captain orders ‘let’s put (the rudder) hard right’.
0506 Capt: "(come)***(tryin’ to get on) our course.
0510: Capt: ‘now we’re on the back side of the storm’. (which he repeats at 0518)
but at 0514 he had already dropped attempt to get on course and decided to ‘steer up into it a little’
Some 19 minutes later, 0522, Captain asks ‘what’s the barometer doin’ now @CM?’
CM replies ‘nine fifty (one)’ Maybe this was an error in transcription since it should be alarming. If accurate, this is a drop of 10mBar in 20 minutes which should frighten the crap out of the Captain (or anyone) indicating increasing proximity to the center and that his earlier supposition on his location being on the back side of the storm is an error. Captain is already riding the weather, so his lack of any action is his only move anyway so no comment on the possible significance may seem necessary. Still, I wonder if it was ‘nine sixty one’ since 961mBar, up from 960mBar would be further confirmation that the worst may be over. Captain & CM opine about the storm being slow moving, or stalled.
There are two other inquiries for barometer reading i saw. ‘What’s the millibars’, first by the 3M at 0631, transcript doesn’t have the answer. At 0710, after the loss of prop, the Captain asks for the millibars to relay over the phone, answer is 958.8 from 2M. Whatever his earlier estimations and plan, he must know he’s in it now, noting the drop and is thinking about survival in the face of a closing hurricane.
For overall decision-making though, his use of wind or barometer data may be irrelevant. In his voyage planning decision-making, his consideration of weather impacts were clearly minimized based on history, experience and believing in his controls over any possible vulnerability to weather on the intended voyage. His pre-voyage stated intentions (duck under the storm and sneak by) are confirmed by his actions. His estimation of what to do when things get fierce is matter of fact. See 1418 on 30th: speaking to 2M “…get us through the storm. weather ride–and then in the morning when we can see what’s going on (we decide) to steer back”. He has a plan, and a contingency plan. Regardless of the wind speed/direction and barometer data and forecasts, he placed himself into a situation where he is riding to weather, dealing with the wind as he knew he would have to if he held to his plan. He was clearly willing to run the risk of sailing into heavy weather and that meant exercising his contingency plan for heavy weather. His observation of wind and barometer data appear to have been serving as means to let him know when it would be over more than precisely maintaining a safe distance in response to storm movement. Unfortunately teh success of his plan and contingency relied on propulsion and ability to hold a heading and he shows a serious lack of understanding of a propulsion vulnerability at 0511.
0511 Capt: ‘now (how-how) is this list’.
SUP-1 (Alternate Chief Engineer sailing Supernumery) "I’ve never seen it list like this…I’ve never seen it hang like this"
Capt: “(never?)- we certainly have the sail area”
…
Capt:“how does that affect below your operations as far as lube oil(s) and*”
The answer from SUP-1 notes the low pressure LO alarm, but this is all that is necessary to identify that the Captain didn’t know himself already. His initial inquiry to SUP-1 on list gauges an expert engineer assessment meaning he may be reaching out for possible vulnerability (more likely looking for good news about resilience of the plant). SUP-1 answer and (lack of) experience with such a list indicates the Capt may not be able to have total faith in the engineering team’s experience in this severe a list, possibly. He asks a further probing question on impact to the plant. If he doesn’t know about the alarm, unlikely he knows about the shutdown and vulnerability to 15 degree permanent list (if sump is properly filled). It isn’t clear SUP-1 communicates it. At 0515 Capt: “uh its CE,- you know he’s got a problem like you said a low level [alarm]”. Nothing about loss of plant being a possibility. He’s already doing all he can do, whatever is going on below deck is the CE’s problem, so presumably why no new actions are ordered, no new inquiries, it either all works out now or it doesn’t. 0521: Captain: ‘right now I’m just waitin’ for wind shift’.
After this comment, he goes on to note he figured it would be really “#” (presumably euphemism for ‘bad’) between two and eight o’clock"— the weather is going according to his estimate, his plan is executing according to his estimates–riding to weather to wait it out. One might imagine him considering the later problems as outside his planning or bad luck more than having undertaken a risky plan without a full awareness of the vulnerabilities. His comments and actions express a confident reliance in his engineers as much as in the ship’s “good steel”–both no doubt satisfactorily proven (to his mind) in prior experience.
