It’s not a pretty picture, no matter what angle you view it from. The findings from the U.S. Coast Guard and the National Transportation Safety Board after concluding their separate investigations of the now infamous sinking of the 790′ El Faro in the Bahamas on Oct. 1, 2015, are sobering stuff.
In spite of the fact that various parties representing various interests will continue to dispute portions of the Coast Guard and NTSB reports, the many failures and shortcomings that led to the disaster leave no one untouched.
Poor situational awareness, aided and abetted by inadequate professional training, an ineffective safety culture afloat and ashore, and an unwillingness to consider worst-case scenarios and possible alternatives to avoid them, led directly to a series of clearly bad operational decisions. But these decisions did not occur in a vacuum. A complete lack of checks and balances, both on the water and ashore, resulted in the voyage gradually snowballing into a mass-fatality disaster. Insufficient safety support and oversight from every level — corporate, regulatory, etc. — laid the foundation for it all to unravel, resulting in the deaths of 33 crewmembers for no good reason at all.
There is much to think about, but I’ll point first to remarks made by NTSB Chairman Robert Sumwalt at one of the hearings in Washington, D.C. Referring to the El Faro’s captain, Michael Davidson, he said, he “had a mental model that the hurricane would be in one place, and based on that mental model and based on his previous experience he thought they were going to be OK.”
That mental model proved to be wrong, and with fatal consequences. Since we all build mental models for everything we do (even if you’re unaware of it) and no one is immune from building a bad one, you might want to consider the serious ramifications of that fact.
As for the value of experience, consider this: Davidson’s previous experience did not help him and probably pushed him further into a corner from which there was no escape.
in all honesty…is there any more that need be said about this sad and needless loss? is it now time to move on from this and just make damned sure our ship is not going to go there too?
I would be more interested in the outcome of this investigation. “Coast Guard to hold public hearing for Bouchard barge explosion”.
A leaking cargo tank, that had been reported many times, documented on paperwork I am told, and was blown over by the company in the name of pushing oil, maintaining a schedule in the name of profits. Two guys died, I think one of the bodies was never found, because of product from this tank and a sparking windlass if I remember correctly.
“The Coast Guard has established an e-mail address for the public and interested parties to provide information, ask questions and make comments related to ongoing investigation and scheduled hearing. This e-mail will be checked regularly and all correspondence will be acknowledged. The e-mail is: Bouchard255@uscg.mil.”
Its never good when your company barged that exploded is in front of the email address @uscg.mil
I hope they livestream these meetings. If Bouchard is anything like I remember it’s not going to be pretty once (and a big if) they find out that they have not been doing proper repairs and hiding things during inspections.
Yes, we all want it to end. Yet it keeps going and will likely continue untill the movie is made 5 years from now and we become viscerally sick with the images.
The better question is why. Why do we all continue to want to scratch this itch.
I believe it’s because during the 4 long years at the academy (or more for Hawsepipers), and the yars spent studying for liscense and at every BS safety meeting and in response to wvery complaint over SMS paperwork the same atory is told… we have to do this hard work because there are a lot of leasons to be learned and all leasons about safety where written in the blood of our brother sailors.
But what leasons have we learned here? Not many we already didn’t know.
Those of us who have attended the trial and read every document published will tell yoh there are MANY leasons to be learned (e.g. the mental
Models Joe writes about). But most disagree with those either in principal or at least as they pertain to this incident.
In short, we have been told for decades (centruries even) to oay close attention to disasters and learn our leasons… and people will continue to be interested in this untill that happens.
Plus… we like fair endings. This is not a fair ending. If executives are sent to jail for misconduct far worse (worse because it was deliberate and long term) than killing a few birds which has landed lesser men in jail (e.g. John Cota)… if that happens then people will move on.
But it won’t so don’t expect interest to wane anytime soon.
I am just a retired mariner on the other side of the Atlantic but I have been kept awake after I learnt yesterday that witnesses to the investigation had been got at, and it makes me more certain that the loss of the El Faro should remain a topic here as long as the contributors want it to be one. Who would like it to be nothing but a dim memory? The Company, the Classification Society and probably the Coast Guard, for whom it was also not a good day. It is admirable that people are sufficiently motivated to get into the transcripts of the witness statements to find out what is in them worth exposing to the scrutiny of everybody else, and to research and exchange views about the stability of the ship (creating much more clarity about that aspect of the disaster for me at least). I have been analysing marine accidents for 20 years; they are always a combination of factors and, no matter how it appears, it was true in this case as well. If it had not been so there would have been no reason to “prepp” the witnesses.
In the first couple El Faro threads there was hyper vigilance for imaginary conspiracies and cover-ups. Now everyone is bored? What happened? Maybe a lot of the posts in early threads was just trolling.
I believe there is a limit to what can be done through the vehicle of a public forum, valuable though they may be.
If you really believe that the official investigation was inadequate (for whatever reason) then you don’t need the MAIB to do a peer review. Get a group with the necessary expertise together, download all the evidence (before the docket disappears) and grind through it, detail by detail. Then publish your results. It’s been done before
Looking at some of the MBI transcripts for the first time looking for stability info that’s not in the reports. A lot of time spent getting the board up to speed on basic stuff and pitching soft balls to the ABS.
Wow! There were a brief piorid of time that the El Faro was absent from the media. Rehashing the facts can be boring and unproductive. Yet I believe that those of you who continue discussing,and honor the crew of the SS El Faro, only want to preserve their legacy. Thank You