From gcaptain: > The U.S. National Transportation Safety Board is scheduled to meet next week to determine the probable cause of the October 1, 2015, sinking of the U.S.-flagged cargo ship El Faro.
The major safety issues associated with this accident include the Captain’s actions; the currency of weather information; bridge team management; company oversight; damage control plans; and survival craft suitability.
such as deficient both intact and damage condition righting arm, lack of watertight integrity of ventilators and scuttles, cargo lashing quality for a worst possible case scenario, design of supply of lube oil to turbines…
I honestly do not know how the bridge team failed unless one wants to believe that some officer should have stood before the master and said “NOT ONE MILE CLOSER” and the “ALL OF US ARE TOGETHER ON THIS!”
I have said it before and will continue to say it…Davidson was reckless. He had more than enough warning of what was facing the ship and still pushed towards danger. Why did he? Not a knowledgeable and experienced man with sufficient fear for his ship’s ability to survive or a company man not wanting to face the wrath of management? Either way, his decision to proceed after 2300 the night before as they past San Salvidor took them into a time and place where any major casualty was enough to spell death for them all.
Sinking of the El Faro Subject of NTSB Meeting
The NTSB is scheduled to meet Dec. 12, 2017, to determine the probable cause of the Oct. 1, 2015, sinking of the U.S. flagged cargo ship El Faro.
The 790-foot vessel set sail from Jacksonville, Florida, on a voyage to San Juan, Puerto Rico, Sept. 29, 2015, and sank about 34 hours later near the eye of Hurricane Joaquin. All 33 crewmembers aboard the ship perished in the accident.
The NTSB launched an investigation as soon as the sinking was confirmed and with assistance from the U.S. Navy and U.S. Coast Guard, the wreckage and debris field was located Oct. 31, 2015, more than 15,000 feet under the surface of the sea.
The investigation, that to date has cost $5.6 million and amassed 30,500 hours of investigative work, has produced more than 70 findings and more than 50 proposed recommendations, which will be presented to the board during the meeting.
The major safety issues associated with this accident include:
The Captain’s actions
Currency of weather information
Bridge team management
Damage control plans
Survival craft suitability
The sheer volume of information that needs to be reviewed during the board meeting has necessitated minor modifications to the flow of the board meeting. Unlike other board meetings where the managing director reads all the findings and recommendations following investigative staff presentations, during the El Faro board meeting the investigative staff will present their findings and recommendations during their presentations. Probable cause will still be read by the managing director.
The agenda (subject to change) for the board meeting is as follows:
Chairman’s opening remarks
Flooding and Damage Control
Damage Control Stability
Board Member questions with investigative staff
Company Oversight and Bridge Team Management
Captain’s Decision Making
Board Member questions with investigative staff
Board Member deliberation on findings
Board Member deliberation on probable cause
Board Member deliberation on safety recommendations
Chairman’s closing remarks
When this $5.6 million dollar investigation becomes public nothing will change really. The NTSB has no enforcement ability nor can it make rules. There’s not much US flagged shipping to be concerned with anyway. After the exhaustive examination of the Deepwater Horizon disaster the only real change I see is not as much is put in emails any more. “We’ll go off line with this” “I’ll call and we’ll discuss” are the popular business terms now if there is any question of future accountability.
It was a top-down failure. From reading the VDR transcripts it is apparent that each watch mate was acting as in individual, not as part of a team.
A good example of this is when the third mate came to the wheelhouse for the 2000-2400 watch. The third mate had just watched the latest Joaquin update on the Weather Channel and wanted to discuss this new information with the captain and chief mate. However he was shut down and told to just follow the wayponts as laid out by the C/M.
If the watch mates were working as a team the captain would have, at minimum, explained to the on-coming third mate how the new information from the Weather Channel made sense in the context of the captain’s understanding of the situation.
In other words everyone should be on the same page. Not possible in this case without breaking someone’s understanding as the captain’s perceptions of the situation did not match what was happening outside.
Ever since I read the first report and read the transcript of the bridge recording it was apparent that the entire bridge resource management scheme failed. In my opinion it is a cultural thing. Authoritarianism is still the norm on ships. The bridge resource management idea came from the airline industry and even they were slow to adopt, see Korean Airlines for relatively recent examples.
The mates on board clearly were not comfortable with their route planning. One even contacted home to express concern to a family member. But at no time did any of the mates or ABs contact the DPA or vehemently express their concern to the captain. They went along with the captain’s decision for one of two reasons. 1. They did not trust their own judgement and/or lacked experience. 2. They were afraid of losing their job by questioning the captain or contacting the DPA.
In any case they took no strong action. They died and took others not involved in the decision making process with them. Why?To prove the captain wrong? If so they made their point.
This entire matter cannot be laid at the captains feet. The management of the company, the “regulatory” agencies and some of the dead were all complicit.
but it is the master who builds and fosters the “team”…unless he does this then there is no team to fail. It is only a number of individual mates all taking direction as provided as is their duty however we see that as much unease that might have been felt by the mates not one of them was fearful enough to demand redress of their concerns and thus they all drove on through the night following the track as provided.
one thing to note is that we see how quickly the situation went from doing fine to not doing fine to downright we are in deep shit. Obviously the EL FARO would have survived the encounter with Joachim if the lube oil supply to the turbines was not lost as it was so really they all died because the suction was placed in just a very bad spot for their particular list and the worse luck of hot having enough lube oil in the tank. Really, the loss of the ship comes down to that (and poor watertight integrity of ventilators) however, the way Davidson ran his ship allowed his people no input to voicing their justifiable concerns thus it is the master who is the one to fault, not the people driving the ship…they were only doing their job as asked of them by their boss.
I agree the master should foster and build the team. In this case Davidson clearly was deficient. CRM or BRM has as one of it’s requirements the ability of anyone to report legitimate concerns to the DPA. In this case management failed in not properly overseeing the operation of the vessel as well as the captains lack of proper management of the BRM scheme. Additionally the crew was negligent in reporting the same.
As a practical matter BRM is no better than the company purporting to use it. If the company insists BRM is used it will be. BRM would never be taught if it were not for the IMO who has no enforcement capability. We all know that. Just as we know that “stop the job” authority is a brilliant scheme to put the blame on the lowest person involved in an accident.
Without serious consequences that hits companies in the wallet no real BRM scheme will ever be effective. The aviation industry has more effectively instituted CRM but that industry cannot hide accountability behind FOCs or third world regulatory agencies as the shipping business can. I expect no real changes from the NTSB report nor do I expect regulations to be enacted to prevent a similar loss of life.
With hindsight we know that the ship went down. But the mates did not have that information at the time. Things were much more unclear the night of the 30th/1st.
The crew expected to pass the system in the navigational semi-circle. That was a big ship with a history of taking heavy weather, if things got bad they could just heave to for a bit. Who would expect that ship do go down in those conditions?
The captain planned to pass south of the eye with a max of about 50 kt winds. A risky but not totally unreasonable plan. But there was a failure to have the bridge team monitor the plan. He did not make that plan explicit to the watch mates and did not require a methodical plot of Joaquin.
Had there been an explicit plan, made clear to the mates (ship to pass in the navigational semicircle and avoid more then 50 kt winds ) and methodical plotting, when the forecast changed the mates could have called the captain with a very specific message. The original plan is no longer valid and the ship needs a new plan.
I still don’t understand why they didn’t just head down the Florida coast and down Old Bahama Channel from the get go. Every Captain (tankers) that I’ve talked to since the incident has said the same thing. Yes, I know the forecast wasn’t supposed to be that bad, but why put yourself between a possible hurricane and the Bahamas? I haven’t done the math on the mileage difference/time of schedule, but I would guess at their speed no more than an extra day on the voyage?
I’ve never worked on a container ship with a set schedule, so I don’t know the commercial pressure that comes with that. On every tanker I’ve been on, the charterer has always been understanding when it comes to slowing down for weather or diverting. There might be some questions or further explanation required, but I would say “trying to avoid a hurricane” is a pretty good explanation.
YES RIDICULOUS but he took the Old Bahamas Channel a month earlier and got spanked by TOTE for the delay that caused so being afraid of management and still wanting command of one of the new vessels he did not take the safe route and lost his ship and his life in the bargain. IDIOT!