NTSB El Faro Report Meeting

I noted the starting years of the job on board a ship, there are no voids within the table.
During 2011 - 2015, he upgraded from 3M to C/M on El Yunque.

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This is from Tote’s report.

The E/R logs were lost of course, the lube oil amt that was used came from the stability program. It’s very probable that lube oils may not have been routinely updated as they typically don’t change much.

According to the Machinery Operating Manual for the El Faro, the lube oil sump had a
low level alarm set at 18 inches and the high level alarm was set at 33 inches. (MBI Ex. 320, p.
3).
The off duty Chief Engineer from the El Faro, who departed the vessel on August 11,
2015, began serving as Chief Engineer on the El Faro in 2006. (NTSB 10/8/2015, pp.5-6). The off duty Chief Engineer testified that the main engine lube oil system was normally run at a levelof around 27 inches. (MBI, 2/23/16 at p.97). Another former Chief Engineer testified that he recalled the normal operating level to be 28 to 32 inches, but that operating level is inconsistent with other evidence, particularly the main engine’s approved plans, operating instructions, and historical engine logs. (Appendix A (J.Daly), p.14).
The operating instructions for the main engine lube oil system on board the El Faro state
as follows: “When necessary, add lube oil from the storage settling tank to the sump via purifier
to maintain a normal level at 27 inches. Record the amount added in the logbook.” (MBI Exhibit
384).
b.
Lube Oil Sump Level At Departure - Records
The engine logs for the voyage 185S, which contain the sounding of the lube oil sump at
the time of the loss, were on board and lost with the vessel.
The engine room log book entries for the year preceding indicated a lube oil sump level
predominantly between 25 to 26 inches. Oil was added when the sump level reached
approximately 23 inches. (Appendix A (J.Daly), p.14).
The last available engine log for the El Faro was for September 1, 2015, which shows a
lube oil sump level of 26 inches. (MBI Ex.341). A former Chief Engineer of the El Faro testified
that lube oil levels changed very little over time - approximately 1-2 inches per quarter. (MBI
02/08/17 (draft), p.474).
Information was presented during the MBI investigations using CargoMax to determine
main engine sump levels. (MBI Ex.412, p.3). TOTE expert, Mr. John Daly, determined that this
was not a reliable record to rely on for the purposes of defining the precise level of oil in the lube
oil sump. The volumes of liquids in most engine room tanks, and changes to them, have an
insignificant impact in calculating vessel stability, and, therefore, these records are generally not
maintained with the same level of regularity as engine room logs. (Appendix A (J.Daly), pp.13-
14). We believe the MBI’s use of the assumed lube oil sump operating level of 24.6 inches is
> likely in error and, based on the available evidence, it is more likely that the engine log for the El Faro was for September 1, 2015 (26 inches) provides the most reliable figure. (MBI Ex. 341);
(Appendix A (J.Daly), pp.14-15).
To illustrate this further with regard to the record relied on by the MBI, it appears that the
specific gravity of the lube oil, listed in CargoMax, is apparently based on a default value which is not exactly consistent with the actual specific gravity of the lube oil in the tank. From a
stability standpoint, this is of little overall consequence. However, when the correct specific
gravity of the lube oil is used, the reported 4.2 long tons of lube oil in the sump equates to a
sounding in the lube oil sump of approximately 25.5 inches. Id.

That’s the ticket right there. They were inputting tons, not quantity or sounding. It’s still a level slightly lower than required but not as significant.

Yea, if somebody went to use my CargoMax files as record of the engine room soundings, they would be sorely disappointed. Fuel numbers, yes, but the other small tanks I barely ever update, as they have little to do with the overall stability. It’s also real easy to have the wrong specific gravity in there.

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NTSB and CG interview with the master of the El Yunque is worth a read.

4 - Witness Interview - Transcript of Interview and errata for El Yunque Master, TOTE - 2015-10-9

The interviewers don’t seem very knowledgeable, don’t know tender from stiff, not aware that the CG COTP kicks ships out of port before a TC.

The captain that he was relying on the BVC system entirely and no longer using NOAA products (maybe just not the wx FAXs?) because seeing the conditions as different colors was very convenient. Evidently he was unaware of that systems limitations.

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Yes it is. A few observations:

  • Lack of a follow-up query as to why he wasn’t in the habit of downloading NOAA products; he was on board El Yunque, sailing north, during the development of Joaquin; if he was relying solely on the BVS weather, then his data would have been six hours out of date as well. Did he know that this was the case? If so, why not turn to the latest (NOAA) storm updates?
  • He was asked if he thought the course El Faro took, heading a little west of their usual track, was a reasonable one, based on the forecasts:

MR. KUCHARSKI: Would you have gone towards the west as the El Faro essentially sent further west then a normal track? [sic]
CAPTAIN LOFTFIELD: In the models that I had seen, it looked like west would be a safe place. Furthermore, west is through several of the openings in the Bahamas, which would have dampened the amount of swell that was getting through there.

  • His answers suggest that his perception of the storm’s development was also to treat it as something that could be outmanoeuvred, and not something that had to be avoided outright. Is this indicative of the fact that the weather info that both captain’s were getting was old, and not accurate?
  • It always struck me as inconceivable that two captain’s plying the same route on sister ships, one headed north, the other south, as a hurricane was developing in their vicinity, would not have had a discussion about it. But apparently the two men did not communicate, even though their ships passed so close to each other. The two CM’s talked, but not the Captains. This suggests both of them felt it was not a direct threat. So even if they had talked, they would probably just have confirmed each other’s misconceived assessment of the weather out there.

Which would make it all the more valuable to know what weather info and heavy weather avoidance procedures that other ship, the Curacao Pearl, were operating with that night.

Here is the other El Yunque captain and El Faro C/M interview:

4 - Witness Interview - Transcript of Interview and errata for TOTE El Yunque Master - 2015-10-7

He mentions hand plotting SAT-C weather. Seems less condescending than the first.

Also when the El Yunque left JAX the first time after the loss of the El Faro they dodged down then came back out to the regular route at Hole in the Wall to check for signs of the El Faro.

Interestingly the captain of the El Yunque had the fire dampers in the cargo vents closed which was never done, and had a round of the decks to close scuttles etc. So he knew how the water got in right away.

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OK - got it - Loftfield wasn’t on El Yunque at the time, it was Stith. Thx for the correction!
But the lack of direct communications between the two Captains still seems odd. And the question about BVS and the fact that they were both relying on out of date weather info remains… In fact Stith’s testimony about his VHF conversation with the EF CM emphasises even more that he did not consider Joaquin as a direct threat to El Faro; he was chatting about vacation photos and other stuff…

Narcissism of small differences perhaps, nobody despises a ship captain more than another captain working for the same company.

So even a quick call to Davidson along the lines of we had to close the dampers & scuttles might have been appreciated.

That was done after the loss. Perhaps before everyone thought the ships were near invulnerable.

Oh ok. Got it (again!)

Unfortunately I have seen this to be more the norm than the exception.

My understanding of these particular ships within tote as a whole is that there was a lot of turnover, even at the master’s level. It’s possible the two captains had never met or didn’t have a professional relationship that happens organically at a company where Mates and Masters work together for years. I’d still have reached out but that might just be me.

Personally I enjoy engaging other Captains in the fleet. They’re usually the only ones worth bitching to.

As for the dampers and scuttles not being closed. There is no worse feeling than getting into some heavy weather and knowing you didn’t do everything at your disposal to make the vessel watertight. Inexcusable in my opinion

In fact they had worked together a lot; Stith had been CM under Davidson on El Faro, and they had “a very good working relationship”. (see transcript mentioned above)

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From the crew interview it was evidently the practice to leave the dampers open all the time.
From reading the El Faro VDR transcript I don’t think it occurred to anyone to even considere that having them open was a danger to the ship. They thought that the heel was wind heel.

It was after the El Faro went down, that changes everything. Once you know for a fact that those ships WILL go down in heavy weather then the question is how and the answer evidently was obvious.

Before the lost nobody thought the question of how they could flood was worth considering.

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Thanks. I did not know that detail. A real head scratcher now

well if they were “fire dampers” they likely were not watertight and not being so, no one believed closing them would be for any purpose than to stop the flow of air into a hold should a fire break out below decks. the design of the trunks just below the highest deck are that they will self drain when at sea before any water could migrate down into the ducts. Certainly there was no closing the louvers on those trunks and that it was expected water would get into them when the vessel was at sea.

if however, the dampers were also designed to be watertight, then not closing them before entering a hurricane would be tantamount to a gross lack of professional conduct. On semisubmersible drillrigs and platforms, there are ventilation ducts going down into the pontoons and all those ducts have a damper which is in fact designed to be watertight in order to prevent downflooding from occurring. Those dampers are all checked regularly as part of the PM schedule to ensure they work when remotely actuated and that indicate to the bridge when in fact closed. I do not however believe EL FARO would have any such system

From the CG MBI report it seems that the cargo intake vents were required to be watertight and the exhaust vents were required to be weathertight.

According to the NTSB report the ventilation for the cargo holds was required by the Coast Guard Certificate of Inspection (COI) to be open while at sea and there were required by the ABS International loadline document (ICLL) to be closed while at sea.

Evidently there was no guidance from Tote but from crew testimony the practice was to leave them open. Except the captain of the El Yunque had them closed the first voyage after the loss of the El Faro

STCW Manila requires this but there are grandfather rights for existing officers, however Company rules should dictate…