NTSB El Faro Report Meeting


This is from the MBI hearings, the second mate who was with Davison is being interviewed about the diversion for Erika.

2 CDR Denning: Have you ever proposed an alternate route from Jacksonville to San
23 Juan?
WIT: Yes I have, many times.
2 CDR Denning: So just a minute ago we had up Exhibit 2, we don’t need to bring it up
3 again unless you feel there would value in that, we can if you would like, but regarding
4 that particular exhibit and it showed in the green line the alternate route taken in August,
5 August 25 th to 28 th for Tropical Storm Erika, do you recall that particular voyage?
6 WIT: Yes I do.
7 CDR Denning: In order to take that alternate route through the Florida Straits and Old
8 Bahama Channel, was it your suggestion or was it Captain Davidson’s suggest to take
9 that particular route?
10 WIT: It was my suggestion, sir.
11 CDR Denning: And why did you prefer that particular route under those
12 circumstances?
13 WIT: Well under this particular situation we had six Polish laborers and we had two
Chief Engineers riding with us who were doing work converting, you know working on
15 the El Faro to convert it to the Alaska trade. If we were going to go through a tropical
16 storm we would rolling and pitching and nobody would be able to do any work. So I
17 suggested to the Captain that we take an alternate route where we could – where the
18 eight people could actually work as opposed to not being able to work on the way to
19 San Juan.
20 CDR Denning: What weather information were you utilizing to help you make that
21 suggestion?
WIT: I was using a, called BVS, it’s our weather, our ready – weather routing service. I
2 also looked at the weather channel while we were in port, we have satellite TV. And we
3 have telexes that come in with the weather for the tropical areas.
4 CDR Denning: Do you recall what the forecast were for Erika at that point and time
5 that helped you lead – helped lead you to this decision?
6 WIT: I think it was forecasted as a tropical storm, it was hurricane class 1, maybe 1 to
7 2, but it was in our line of position. We would have to go right through it or close to it
8 and it would have been too rough to really to do any work. And the alternate route
9 doesn’t add that much time to your trip, maybe 150 miles.
10 CDR Denning: How much level of protection do the Islands, the Bahamas provide
11 you? If there was a storm that did proceed along, let’s say your normal track such that
12 you would have to go directly through it and you chose to take the Old Bahama
13 Channel, would the Islands provide you a lee?
14 WIT: The Islands are our savior, yes. We would still get the winds, but we wouldn’t get
the high seas. We wouldn’t get the roll.
16 CDR Denning: Did Tropical Storm Erika acting the way the forecast predicted?
17 WIT: For the most part yes. We were able to avoid all the heavy weather. We got
18 some high winds, but the ships made to sustain that.
19 CDR Denning: When you made the suggestion for the alternate route to Captain
20 Davidson, how did he – how was that received by him?
21 WIT: It was received well. We always discussed our – what route we were going to
22 take, especially if there was weather involved.
CDR Denning: Was there any push back from him, any hesitation to take that route
2 versus the most economical route?
3 WIT: No. He didn’t give me a decision right away. He thought about it, but within an
4 hour or so I had my alternate route planned and entered into our GPS’s.
5 CDR Denning: Do you happen to know if he consulted with Tote before making the
6 final decision?
7 WIT: No I do not know that.
8 CDR Denning: Did he mention anything to you about how the company might feel
9 about taking an alternate route?
WIT: No, not at all.
11 CDR Denning: Did you hear anything after the fact from Captain Davidson about any
12 reaction from Tote on taking the alternate route?
13 WIT: No, I heard no repercussions.
14 CDR Denning: To your knowledge since the El Faro incident, has Tote issued any
15 guidance, whether it’s informal or formal, to the Masters and Mates regarding voyage
16 planning? Well let’s go back. Since Erika, since this voyage where you deviated for
17 Tropical Storm Erika, let’s go back to there. Did Tote issue any guidance to vessels
18 after the deviation voyage?
19 WIT: I don’t recall anything more or less than what they would normally send us. They
20 would send us tropical storm updates just to keep us informed.
21 CDR Denning: So you say they normally sent tropical storm updates, is that in addition
22 to the safety alert that was received in August


WIT: We always discussed our – what route we were going to
take, especially if there was weather involved… It was my suggestion, sir…
So I suggested to the Captain that we take an alternate route where …eight people could actually work as opposed to not being able to work on the way to San Juan…It was received well…

Similar weather and Polish rider circumstances but quite a different response to 2nd mate’s input on ill-fated voyage.


my only thought is that the flooding before the change in heading was not of a rate that possibly it would not cause the capsize before the passage of the eye of Joachim provided that the ventilators were still high enough above the sea.

also why would Davidson not know the eye was toward the east of their position still? further there is no way to do anything to steer the ship out of the path of the storm’s center but heaving to with wind just on the port bow not worked provided the flooding not rise to a level that the pumps could cope with? putting the wind on the starboard bow did truly kill them.


It’s also an odd argument to have to make to convince a captain to avoid a tropical cyclone. It might be a good argument for staying a away from a mid-latitude, it’s not for a valid argument for a tropical system. Being close to a tropical system is high risk

The forecast track for Erika was very different from Joaquin.

Also the topology of the avoidance/routing problem was different, with Joaquin, once the error of not using the OBC was made it was no longer possible to have made the right move as a double back was required. Adding miles required for lower risk is one thing, added unnecessary miles for a routing error is another. It means there is going to be more reluctance to divert.


Could still have done a 180 but it would have meant exposing a gross error in judgment and fear of getting fired over it might have been justified.
Here is another puzzle: Instead of advising the office while southbound that he wanted to deviate in order to avoid a developing weather system, he elected to tell them he wanted to return from PR via the OBC. By his own reckoning, the system would have been long gone by then.


Yes, that’s the logic I see, gross error and fired seems too strong. Like Earl says, likely more in the captain’s own mind more than actual repercussions

It’s the layout of the problem. Using OBC seems like a no-brainer but what if they use that route and Joaquin turns as expected. Looks like an unnecessary precaution Maybe by appearance not high-risk enough for the existing culture.

Next is Hole in the Wall but the cost of that route is a bit higher as is the risk. So it’s a bit of an Escalation of commitment trap.

Escalation of commitment is a human behavior pattern in which an individual or group facing increasingly negative outcomes from some decision, action, or investment nevertheless continues the same behavior rather than alter course. The actor maintains behaviors that are irrational, but align with previous decisions and actions


if we are talking about the final 3 hours then there was no way the ship could wear around without the same hideous consequences. concerning the time up to 0400 then there were several options to prevent what occurred however the comment that once into the inner bands of circulation with the downflooding happening the only hope would have been to head into it and to pray that the storm center begins to track away.

since we do see that the center still did not begin to move north until later the 1st, the master would have had to fight like hell to keep the ship afloat but without the turn to put the wind on the opposite bow he might have had a small chance to win that fight if cargo did not shift and if downflooding could be limited to a rate the pumps might be able to keep up with. KC was right when he said that it was the turn to go from a starboard list to a port which was the final act in a tragic play ensuring there could be no survival for the ship. the shifted cargo, the increased flooding due to the ruptured firepump suction line, ventilators gone underwater with the increased list and with the loss of propulsion, no way to turn the heading back into the wind was the very end of the saga.

if only the crew could have gotten off into something which might have given them a chance to live…maybe that is the biggest takeaway from this as seems to be what the USCG sees. Ships can sink no matter now well designed, operated, fitted and maintained but regardless, a crew should be able to count on a means to escape which might actually work as opposed to what the EL FARO people had which was worse than nothing at all.


I’ve always been curious about that, it makes no sense.


See Page 2-3, Items 10-15 of the NTSB Abstract, specifically No. 11.

“10. The port list, coupled with the vessel’s motion, most likely caused air to enter the bellmouth of the suction pipe to the lube oil service pump, which resulted in a loss of oil pressure that caused the main engine to shut down.
11. The level of lube oil in the main engine sump was not maintained in accordance with the vessel’s operations manual, which increased the propulsion system’s susceptibility to loss of oil pressure.
12. If the company had provided guidance to the engineers about the list-induced operational limitations of the engine as well as about raising the level of lube oil in the main engine sump before or during heavy weather, the additional quantity of oil in the sump would
have kept the suction pipe submerged at greater angles of inclination and increased the likelihood of maintaining propulsion.
13. Increasing the minimum athwartships angle of inclination requirements for both static and dynamic conditions would provide an additional margin of safety for vessels exposed to high winds and large sea states.
14. The crew was most likely unaware of the operational limitations on the main engine from a sustained excessive list.
15. If the ship’s officers had known the maximum static list angle at which the main propulsion engine would operate, they would most likely have attempted to reduce the initial list sooner and possibly avoided the loss of propulsion.”

I’m not trying to say that if the engine hadn’t shut down they would have definitely made it through, but having to deal with one less major issue in the face of all of that certainly couldn’t have made it any worse.


I read that also but the question arises why didn’t they immediately begin adding oil to the sump once oil pressure began to fluctuate. No brainer to me.


Agreed. I can’t answer that either. Still doesn’t answer the question of why the tank wasn’t maintained at the proper level though, especially if it was stated in the ops manual.


I would imagine they were trying to but the clock ran out on them. remember the ship was heeling further and further over while the engineers would have been attempting this last act to save themselves


Gotta agree with that … the first indication of fluctuating oil pressure coincident with rolling should have instantly lead to dumping oil from the LOST to the sump.

I remember many times in bad weather with exteme rolling watching the bullseye and beginning to worry when it seemed like forever with nothing flowing, but the lube oil pressure was not fluctuating so all was good. Scary but good.

How could they have missed a low sump level on top of loss of lube oil pressure and not done anything at the first indication?

To answer my own question, It must have been hell in that engine room for those guys, between the horror of cascading events and loss of the throttle I can see how they were overwhelmed and cannot place any blame on them.


That doesn’t seem like the right approach, sure, evidently the ship left port with a low level. For one, it may have gotten filled at any point, we don’t know.

But that is not really the point. If the crew turnover in increased, training is reduced, redundancies are eliminated, ops tempo increased and so forth, at some point, something is going to break. And in almost every case when something does goes wrong almost certainly someone will find what broke and it’s going to be some procedure, instruction or check list that wasn’t followed.

For example the ship went through 4 chief mates in two months. How rapidly can you turn over chief mates and still legitimately be able to point at something in a manual when something goes wrong?

Anyway propulsion was lost because the ship was sinking, not the other way around.


I don’t think anyone is trying to say loss of propulsion sank the ship but it certainly made saving it impossible.

There is a fair to good probability that if propulsion was not lost the ship might not have been lost.

If propulsion had been restored they might have have more chances at damage control.


Of course it’s impossible to say for sure but the sequence was the water was initially entering from the open scuttle. The C/M went to close the scuttle at just before 0600 hrs but couldn’t because the water on deck was too deep from the stbd list. To solve that problem the Captain put the wind on the stbd side but evidently as soon as the ship’s head crossed the eye the ship flopped over to port. That was the “bad” side for the lube oil suction bell and the propulsion was tripped out.

The other event from flopping from stbd to port was cars floating in the hold likely (CG and NTSB differ) wiped out the fire main.

When the ship went over to port it had a reported about a 15 (maybe 18) degree list. Assuming propulsion could be restored would it been possible to steer somehow to avoid a list with that much water in the holds? I don’t see how. Every time the ship rolls in the sea she’s going to go over.


I think it would be useful to have had the transcript from the VDR of that other vessel, the Curacao Pearl, which left from a similar place (Charleston) at a similar time, normally sailed a similar route via PR (Mona Passage), but at some point on that particular voyage made the decision to take the OBC instead. What specific procedures/experience/storm tactics were driving them, that were lacking on the El Faro bridge? That is worth knowing surely?


the sequence was the water was initially entering from the open scuttle. The C/M went to close the scuttle at just before 0600 hrs but couldn’t because the water on deck was too deep from the stbd list. To solve that problem the Captain put the wind on the stbd side but evidently as soon as the ship’s head crossed the eye (of the wind) the ship flopped over to port. That was the “bad” side for the lube oil suction bell and the propulsion was tripped out.

Another thing regarding the changing sides, when the ship first heeled over to stbd the captain had ballast shifted in the “ramp tanks” to reduce the list, that would means when the ship heeled over to port it would have been an increased list, plus the effect of the asymmetrical lube oil sump.

From looking at the righting arm, it looks like about 8 degrees of the list was from wind heel, the rest of the 15-18 degrees had to have been flooding. So presumably had they been able to steer straight into the wind they could have reduced the list by less then about 8 degrees.

Maybe in theory this would have helped, it would be required that the amount of water ingress be less than the amount they were able to pump out. Seems similar to the calculation that the Sully flt US 1649 could have made it back to the airport.


By the time of the investigation, the VDR was certainly overwritten.
However, interviews with the crew would probably have helped to understand.


About the crew’s experience on the JAX-SJU route, on El Faro or on a similar ship:

2013 Captain El Morro, then El Faro

2011 3M > 2M > C/M El Yunque
2015 (May) C/M El Faro

2005 3M > 2M El Morro
2015 (July) 2M El Faro

2010 3M El Morro
2014 3M El Faro
(in 2014 Davidson evaluated him as “has the knowledge and skills to sail as
second mate if he chooses to do so”

2011 1E El Yunque
2014 C/E El Faro

(from TOTE’s 2017/10/01 Party Submission to the NTSB, in the docket)