NTSB El Faro Report Meeting

This is from the VDR transcript - Around 2000 hrs: First the C/M and captain discuss the weather and change the route to stay further from the center. Then the 3/m arrives in the wheelhouse and the capt tells the C/M and 3/M to do watch change. Once the 3/m has relieved the C/M and the capt tells the third mate to let the new route sink in:

Capt (to the 3/M): give you a (minute/moment) to digest that. * * *. (make sure / you let me
know) if you see anything out of the ordinary to be concerned about.

Then the 3/M brings up the fact the the forecast is changing.

3/M to capt" I just hope it’s not worse than what this is saying because that’s
Weather Underground [weather related website -
www.weatherunderground.com] is– saying it’s a lot. they’re sayin’ it’s–
more like eighty-five– not fifty * wind.

Capt: did you (notice/minus) the wind on the ship.

3/M tries to redirect back to the Weather Underground info:

3/M but what they’re sayin’ they’re– they’re saying this is much more powerful than this is saying
right now. * * so it’s more powerful here– then maybe it’s more powerful

At that point apparently the C/M directs the 3/M attention back to the new waypoints that he and the Capt have laid out.

CM (waypoints) printed here and they’re listed in there * the track.

Third mate drops the subject of the forecast:

3/M okay very well. I understand.

Capt: …we’ll be passing clear on the backside of it. just keep steamin’ our
speed is tremendous right now. the faster we’re goin’ the better. this will
put the wind on the stern a little bit more– it’s givin’ us a push.

3/M okay.

only to the extent that a newer (diesel) ship would have had effective watertight closures for its ventilators and hatches into the holds but more importantly that a diesel ship would not have had a lube oil supply to the propulsion engines which could lose suction with a significant list or heel. of course, a newer ship would also have had modern lifesaving appliances which would have included gravity launched enclosed lifeboats.

in the case of EL FARO, her old hull did not fail nor her old machinery so given no or less water in the holds and no loss of lube oil suction to the turbines the vessel would most likely survived her encounter with Joachim that morning. something as simple as having more lube oil in the supply tank to the turbines might have made the difference between living and dying?

It always points to this guy.

Bell said Davidson was a 24-year maritime veteran who had sailed in bad weather on numerous occasions, although it was clarified that his experience was not with that type of cargo ship and not as a ship’s master. She also noted that some within the company had “dwindling confidence” in his leadership. One employee, in an email, referred to Davidson as a “stateroom captain,” implying that he spent more time in his own room than on the ship’s bridge.

in the end, if he had stayed on the bridge that night and realized he was not going to pass to the south of the center of Joachim, then the loss of the ship would never have occurred. It really ends up being as simple as that but why did TOTE allow him to be so reckless? Why did they not closely monitor his actions and step in when it appeared he was taking the vessel into danger? if there were confidence issues with him, why not ensure you knew he was not taking undue risks with their ship? I have had vessel owners watch me every minute with PurpleFinder and call me to ask what my plan was when bad weather was between my position and the destination.

Davidson was literally asleep at the switch but so was TOTE so in essence they are both at fault. With vessel tracking technology that exists, there is no reason to not stay right on top of things when there is potential danger in play during a vessel’s voyage.

The requirement for the vents is that they be "weathertight. I believe the “2nd Deck” was the freeboard deck. Looks like the vents were designed so that sea water entering the vents would drain out the “drain holes”. The vent louvers are apparently are fixed and can not be closed. Doesn’t seem like a very good design.

Not sure if the fire dampers were also intended to keep sea water out or not. On the El Yunque the fire dampers were found to be in very poor condition as was the plenum, but I’m not sure what the photos in the CG report were showing exactly.

Presumably on the new TOTE ships sea water can not enter directly from the sea in high heel angles like the El Faro experienced. That entry path was a major factor in downflooding of the El Faro.

Secondly there is a requirement for a open/shut display panel to show the watch mate if any watertight opening have been left open at sea. This was first source of the flooding which caused the list. So with the new requirement for a panel more likely that a open scuttle would be discovered by the crew and closed.

My view is a newer ship with open/close indicator and weathertight vents would have a much better chance of surviving. As far as the loss of propulsion, low-speed diesel engines will shut down on low lube oil pressure with heavy rolling / list.

This is from the Marine Executive:

  • The crew were not adequately informed of the importance of securing the fire dampers in the ventilation trunks for El Faro’s cargo holds. Under the vessel’s COI, these dampers must remain open under way. In the vessel’s downflooding calculations, they are assumed to be closed under way. The dampers were open, and on the low side they would likely have begun to admit water about 40 minutes before El Faro sank.

Our (PCTC) cargo vents are over 25 meters from the sea. They are kept closed at al times at sea except during the working day when the holds are ventilated. They are closed at the end of the day and kept closed in bad weather.

1 Like

I was always amazed when I observed ancient steam turbine driven LASH vessels that had been converted to carry containers trading out of West Coast ports to Hawaii. If I had been master of one of these vessels under any other flag but the US I would have had my wrists out ready for the handcuffs following a port state inspection.


Opening Statement - Chairman Robert L. Sumwalt

Recovery of El Faro’s Voyage Data Recorder - Brian Curtis, Director, Office of Marine Safety

Accident Overview Sinking of Cargo Vessel El Faro - Brian Young, Investigator-in-Charge

Sinking of US Cargo Vessel SS El Faro - animation on NTSB YouTube Channel

Engineering Factors - Brian Young, Investigator-in-Charge

Vessel History
Major conversion
Loss of propulsion

Flooding of Cargo Holds - Eric Stolzenberg, Naval Architecture Group Chairman

El Faro simulation at 0330 hours - simulation on NTSB YouTube Channel

Damage Control and Stability Information - Michael J. Kucharski, Nautical Group Chairman

Survival Factors - R. Jon Furukawa, Survival Factors Group Chairman

Electronic Data and Audio - Sean Payne, Electronic Data and Audio Group Chairman

Onboard Weather Information Weather Reporting from Vessels - Mike Richards, Meteorology Group Chairman

Human Performance Factors - Carrie Bell, Human Factors Group Chairman

Captain’s Decision-making and Actions - Michael J. Kucharski, Nautical Group Chairman

Closing Statement - Chairman Robert L. Sumwalt

1 Like

Yes, he needed to be on the bridge for the close encounter with Joaquin and he did in fact tell both the 3/M and the C/M that he planned to be on the bridge for much of the night. Also he did not leave any night orders.

However if the plan required that the captain be on the bridge it was a bad plan. If the encounter with T/C Joaquin was going to so close that the captain’s presence is required it’s too close.

Better write good solid night orders and brief the watch officers the day before.

It’s a matter of margin of error. The plan should be made such that the passage can be made without the assistance of the captain. Then in the case things do not unfold according to plan the captain can be called.

If the captain felt that the skill level required to make a safe passage was such that his presence was required it too risky if safer alternatives are available.

1 Like
  1. that’s mostly what I’ve encountered on unlimited ships.
  2. good, I don’t want the captain on the bridge.

The 2nd Mate and Third Mate sure did want him on the bridge.

I obviously meant during normal operations, like the quote was talking about.

Are we talking stateroom or office? Mine are attached and there is a difference to me from my normal daily routine of emails, emails, emails coupled with paperwork, paperwork, paperwork and sitting on my couch watching a movie. I spend an inordinate amount of time in my office. Not much in my stateroom. The current job description of ships Master has very little to do with pacing the wheelhouse in my opinion.

That being said, a reputation as a “stateroom captain” is not something I am hoping to achieve anytime soon. I’m on the bridge in some fashion or another on every watch for general ships business and coffee but always available if needed. Pulled 14 hours piloting through the North Sea just the other day when the conditions were bad enough to warrant me to do so.

1 Like

I expect the quote was referencing him being in his office doing paperwork as opposed to hovering over the mates on watch on the bridge.

The first reports of Davison being a "stateroom’ captain referred to the belief that he did not spend time on deck during cargo ops.

Not much point in spending time in the wheelhouse on the JAX/SJU run except as D yankee says, a visit for coffee, for wx check ect.

I’m also not used to the captain being involved at all in cargo ops. The few times I was Chief Mate for a captain that was involved was very frustrating.

1 Like

I agree, but it’s a good idea to get out of the office and have hike around the decks (I work RO/RO) at least once per port just to see what happening. Don’t get involved, just hike through the decks with your eyes open.


My involvement with cargo is mostly the stability condition, special case (high value cargoes), or if the mate requires my assistance. I want to be informed but not micromanaging every last detail. That is the mates job.

The fact that Davidson was criticized for not being more involved with cargo is kind of odd to me. It might explain some things about the corporate culture over at tote.

1 Like

I think that’s right. I’ve never been on that class of ship but I know the crews there get hammered.

One thing the struck me was that at the hearing the TOTE captains mentioned that they would relieve the chief mate in the wheelhouse on a routine basis so he could get caught up on his work. I get the impression that the pace there was such that everyone was at 110% all the time.

That’s the setup to take short-cuts because that’s the only way you can get your work done on time.

1 Like

It sounds like they need another 3rd mate on that run.

I agree completely, I reviewed the stability printout and signed it off before it was filed. I walked around the vessel every afternoon at sea and relieved the mate each morning so he could shower before we had breakfast after 0800 at sea. The time on the bridge gave me the opportunity to review and sign off on the various logs as well. On occasions such as renewing crane runners (376 metres and 2.5 tonnes of wire) I kept the morning watch for the mate so he could supervise the job.
In port my office not my stateroom called on more of my time than anything else and the mate generally got on with it.