Third and final hearing into loss of SS El Faro scheduled Feb. 6, 2017

Professional Mariner Forum
101

[QUOTE=freighterman;195295]

To avoid accidents caused by a systemic or momentary lack of good judgement on the part of the captain or the company, we create policies. Or standing orders.[/QUOTE]

This should be the lesson learned. Captains often have access to “master’s cash” for incidental expenses but with a limit. This is obviously to avoid self-dealing.

Likewise if a captain gets himself in jam he can sometimes get himself out by putting the ship in a higher risk situation. For example literally cutting corners on a track-line to make up lost time. Just like the cash limit there needs to be a limit on how much risk the captain is allowed without authorization.

Before putting the ship inside the 34 kt wind field of a hurricane (for example) there should be a requirement to notify the company, take weather routing or some similar procedure to limit risk to the ship.

102

I think you and c.captain both pointed out the obvious: no ship, much less that old ship, (or El Yunke) should have been taken into close proximity of that hurricane when a much safer alternative route down the Old Bahama Channel was available. That alternate route would have only added a few extra hours to the voyage. Obviously, too much unnecessary risk taking here for an attempt at saving a few hours.

As c.captain asked: why did Davidson do it? Was Davidson threatened or pressured by shoreside management?

Those seem like good questions to me. Questions that may lie quite a bit closer to the root cause. Put another way, El Faro had no business being there. So, why was it there?

103

During the final round of testimony, the panel learned that the El Faro had little room for troubles on its final voyage, operating with a minimal stability margin. (Reporting by Letitia Stein; Editing by Colleen Jenkins and Alistair Bell)

© Copyright Thomson Reuters 2017.

The above is the last para on today’s gCaptain post of the last day of the El Faro hearing but does highlight a couple of queries I have as follows.

Firstly I have tried unsuccessfully to find a general arrangement for the El Faro and likewise a tank plan which frustrating and secondly I appreciate that she was originally constructed as a ro/ro vessel and later converted to carry containers -no doubt someone will correct me if I have got that wrong!

Having spent time on container vessels larger than the El Faro, I do find it curious that there was an acceptance that the initial list was put down to windage. Now I may be a bit of a wuss but a soon as a list gets beyond a few degrees, things down below start playing up and so the first action is to ring the mate and ask to bring the vessel upright either by transferring fuel or ballast. However on El Faro, there did not seem to be any reference to correcting the list by the mate or the captain or have I missed something? A steam vessel of El Faro’s size would be burning what 150 metric tonnes a day so fuel transfer would be a daily if not twice daily event so there would have been a number of opportunities to correct the windage -on the Tokyo Bay we transferred 3 times a day but that’s for another day. In correcting the windage, any flooding due to the emergency fire pump pipe work damage would also have been more noticeable.

Also, in my time, hold bilge alarms were taken extremely seriously but there doesn’t seem to be to much info being reported to El Faro’s bridge and given that she was ro/ro originally I would have thought that any water in the hold would have gone immediately from a warning to critical action in a nano second. I also assume that in common with vessels of that age the ballast and hold bilge control system would be under the control of the engineering staff but the superintendent engineer didn’t seem to mention anything about pumping bilges or pumping problems unless again I’ve missed something.

The third curiosity is that access to the holds was via the main deck rather than side passageway but again without a GA it’s impossible to comment as to whether there was an alternative access arrangements to the holds.

Any comments, please be gentle, as I am merely a superintendent engineer!

104

[QUOTE=tugsailor;195338]I think you and c.captain both pointed out the obvious: no ship, much less that old ship, (or El Yunke) should have been taken into close proximity of that hurricane when a much safer alternative route down the Old Bahama Channel was available. That alternate route would have only added a few extra hours to the voyage. Obviously, too much unnecessary risk taking here for an attempt at saving a few hours.

As c.captain asked: why did Davidson do it? Was Davidson threatened or pressured by shoreside management?

Those seem like good questions to me. Questions that may lie quite a bit closer to the root cause. Put another way, El Faro had no business being there. So, why was it there?[/QUOTE]

Why did the Boeing 747 pilot in the Tenerife Airport Disaster decide to take off when there was another 747 on the runway? The answer is to be found in the science of human decison making, cognitive biases and so forth, nobody thought to search for a message from KLM demanding that the plane not be delayed.

Likewise the story that TOTE was putting direct pressure on the Captain Davidson strikes me as very unlikely. In the case that there is pressure, a captain can just lay out the reasons that the risk is too high. If the captain lays out a good case no shoreside person will want the responsibility of countermanding the master of a vessel, especially regarding routing near a hurricane.

Looking into cognitive dissonance, motivated reasoning, loss aversion, sunk cost fallacy and so forth is far more likely to yield answers than a search for emails or whatever coercing the captain.

105

[QUOTE=Ffinn;195347]During the final round of testimony, the panel learned that the El Faro had little room for troubles on its final voyage, operating with a minimal stability margin. (Reporting by Letitia Stein; Editing by Colleen Jenkins and Alistair Bell)

© Copyright Thomson Reuters 2017.

The above is the last para on today’s gCaptain post of the last day of the El Faro hearing but does highlight a couple of queries I have as follows.

Firstly I have tried unsuccessfully to find a general arrangement for the El Faro and likewise a tank plan which frustrating and secondly I appreciate that she was originally constructed as a ro/ro vessel and later converted to carry containers -no doubt someone will correct me if I have got that wrong!

Having spent time on container vessels larger than the El Faro, I do find it curious that there was an acceptance that the initial list was put down to windage. Now I may be a bit of a wuss but a soon as a list gets beyond a few degrees, things down below start playing up and so the first action is to ring the mate and ask to bring the vessel upright either by transferring fuel or ballast. However on El Faro, there did not seem to be any reference to correcting the list by the mate or the captain or have I missed something? A steam vessel of El Faro’s size would be burning what 150 metric tonnes a day so fuel transfer would be a daily if not twice daily event so there would have been a number of opportunities to correct the windage -on the Tokyo Bay we transferred 3 times a day but that’s for another day. In correcting the windage, any flooding due to the emergency fire pump pipe work damage would also have been more noticeable.

Also, in my time, hold bilge alarms were taken extremely seriously but there doesn’t seem to be to much info being reported to El Faro’s bridge and given that she was ro/ro originally I would have thought that any water in the hold would have gone immediately from a warning to critical action in a nano second. I also assume that in common with vessels of that age the ballast and hold bilge control system would be under the control of the engineering staff but the superintendent engineer didn’t seem to mention anything about pumping bilges or pumping problems unless again I’ve missed something.

The third curiosity is that access to the holds was via the main deck rather than side passageway but again without a GA it’s impossible to comment as to whether there was an alternative access arrangements to the holds.

Any comments, please be gentle, as I am merely a superintendent engineer![/QUOTE]

Hi Ffinn,

Thank’s for joining the forum. The below link is the transcript from the VDR audio section factual report. After you bring the pdf up on your browser - search the document for the word ballast. I hope this info helps this part of your question.

https://dms.ntsb.gov/public/58000-58499/58116/598645.pdf

Cheers,

DSD

106

[QUOTE=Kennebec Captain;195348]Why did the Boeing 747 pilot in the Tenerife Airport Disaster decide to take off when there was another 747 on the runway? The answer is to be found in the science of human decison making, cognitive biases and so forth, nobody thought to search for a message from KLM demanding that the plane not be delayed.

Likewise the story that TOTE was putting direct pressure on the Captain Davidson strikes me as very unlikely. In the case that there is pressure, a captain can just lay out the reasons that the risk is too high. If the captain lays out a good case no shoreside person will want the responsibility of countermanding the master of a vessel, especially regarding routing near a hurricane.

Looking into cognitive dissonance, motivated reasoning, loss aversion, sunk cost fallacy and so forth is far more likely to yield answers than a search for emails or whatever coercing the captain.[/QUOTE]

Here’s a quote from a past BP Vice-President of Exploration and Production in the Gulf who is well-regarded in the industry for his devotion to safety (and who was abruptly fired by BP four months before the Deepwater Horizon went down):

“The ‘elephant in the room’ is all the mixed or unintended messages we send the crews when we are behind schedule, over cost, or behind on production. If we don’t clearly keep personal and process safety as an unyielding value in our words and more importantly visible behaviors and decisions, we ultimately will not withstand the risk or test of time, and we will certainly suffer a fatality or major incident."

His point, which I think is well taken, is that it is not enough just to say “we never ordered them to hurry.”

And since you mentioned Tenerife, here’s the NASA report on the 1979 workshop that kicked off the Crew Resource Management movement:

https://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/19800013796.pdf

People have been studying this problem for a long time, and coming up with answers – answers the spreadsheet jockeys don’t want to hear :frowning:

Earl

107

[QUOTE=Earl Boebert;195359]Here’s a quote from a past BP Vice-President of Exploration and Production in the Gulf who is well-regarded in the industry for his devotion to safety (and who was abruptly fired by BP four months before the Deepwater Horizon went down):

“The ‘elephant in the room’ is all the mixed or unintended messages we send the crews when we are behind schedule, over cost, or behind on production. If we don’t clearly keep personal and process safety as an unyielding value in our words and more importantly visible behaviors and decisions, we ultimately will not withstand the risk or test of time, and we will certainly suffer a fatality or major incident."

His point, which I think is well taken, is that it is not enough just to say “we never ordered them to hurry.”

And since you mentioned Tenerife, here’s the NASA report on the 1979 workshop that kicked off the Crew Resource Management movement:

https://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/19800013796.pdf

People have been studying this problem for a long time, and coming up with answers – answers the spreadsheet jockeys don’t want to hear :frowning:

Earl[/QUOTE]

From what I saw of the hearing TOTE’s safety culture likely is not going to come out of this with high marks. Little doubt that the culture at TOTE raised the risk. However the focus here on the forum seems to be on a single smoking gun which I doubt will be the case.

One detail of the Tenerife disaster was the captain’s decision to refuel, while refueling the airport reopened so some 35 minutes were lost. Unlike all the other factors the captain “owned” this decision. This may have increased his anxiety about being delayed.

Likewise Capt Davidson may have felt like he “owned” the delay once the chance to divert down OBC was missed.

108

[QUOTE=Ffinn;195347]

Any comments, please be gentle, as I am merely a superintendent engineer![/QUOTE]

Have you read through this REPORT?

109

I agree that there is no smoking gun email.

I seem to recall reading awhile ago that Davidson was in the doghouse with TOTE for causing the delay on the prior voyage where he did go down the Old Bahama Channel. After that it was very doubtful whether he would be master of the new ship. If so, this put him in a position where he may have felt that he had to super perform to TOTE’s expectations in order to redeem himself to get the new ship. And, he may have quite reasonable felt that he might well be fired, much less not get the new ship, if he disappointed TOTE again by diverting down the Old Bahama Channel.

I have watched TOTE operate in Alaska for a long time. I know people who have worked for TOTE in Alaska. I started out approaching this issue with a lot of respect for TOTE. Things appear to be quite different at TOTE Jacksonville. Now, I’m very disappointed in TOTE.

110

[QUOTE=tugsailor;195367]I agree that there is no smoking gun email.

I seem to recall reading awhile ago that Davidson was in the doghouse with TOTE for causing the delay on the prior voyage where he did go down the Old Bahama Channel. After that it was very doubtful whether he would be master of the new ship. If so, this put him in a position where he may have felt that he had to super perform to TOTE’s expectations in order to redeem himself to get the new ship. And, he may have quite reasonable felt that he might well be fired, much less not get the new ship, if he disappointed TOTE again by diverting down the Old Bahama Channel.

I have watched TOTE operate in Alaska for a long time. I know people who have worked for TOTE in Alaska. I started out approaching this issue with a lot of respect for TOTE. Things appear to be quite different at TOTE Jacksonville. Now, I’m very disappointed in TOTE.[/QUOTE]

With regards to using Old Bahama Channel, it make sense that being in the dog house very well might increase Davidson’s willingness to accept more risk, the other factor of course was the forecast.

111

[QUOTE=Kennebec Captain;195371]With regards to using Old Bahama Channel, it make sense that being in the dog house very well might increase Davidson’s willingness to accept more risk, the other factor of course was the forecast.[/QUOTE]

Unlikely, if such was a possibility he would have taken a different opinion of 3M call on CPA and 3M suggested further deviation S—Indicative of choosing speed over avoidance.

112

[QUOTE=tugsailor;195367]…he may have quite reasonable felt that he might well be fired, much less not get the new ship, if he disappointed TOTE again by diverting down the Old Bahama Channel…[/QUOTE]

This does not conform to the discussions on the VDR-transcript; surrealistic with hindsight:

They often discussed taking the Old Bahama Channel for the coming return trip SJU >> JAX; e.g. at 13:20:10 EDT.
The captain asked for it at home, but did not yet have the permission.

113

[QUOTE=Jamesbrown;195374]Unlikely, if such was a possibility he would have taken a different opinion of 3M call on CPA and 3M suggested further deviation S—Indicative of choosing speed over avoidance.[/QUOTE]

It does seem likely the Old Bahama Channel was never considered.

The forecasts worsened considerably the night of the 30th. From the transcripts the captain seems to have only discussed seriously routing decisions with the C/M. To make sense of the lack of an appropriate response I’ve more or less been assuming that the captain simply disregarded the calls from the 2nd and 3rd mates.

The investigators have weather hindcasts as well as screen shots of the Bon Voyage program. Perhaps when this is all put together fewer assumptions will be requred to make sense of the incident.

114

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OMG. Looking at that curve sends shivers up my spine. Just inside the USCG criteria, no room at all for mistakes or things like running into bad weather or the occasional hurricane. And that with an overaged rust bucket. This is pure cargo over safety. American nautical academies are top notch in their field, I wish I could say the same of the tandem USCG/ABS who bitterly failed at safeguarding the lives of mariners.

No wonder Tote will scrap the El Yunque in a hurry now. They cannot afford another mishap as that will expose the present situation. Did they check that ship’s ventilation holes for wastage? They better hurry or the evidence is lost!

115

Thanks for this as it had eluded me but it does explain some of my queries but leads to more especially the lack of concern on the bridge.

David

116

Just out of curiosity, how many of our members here have worked ashore in the office for Maritime or “Shipping” companies. I am including Tug and Barge Companies. This may just have been for a couple of months or could have been a career change.

Once some reply, I will ask the questions that I have. There is a point to me asking this question and also putting for it here rather than starting a new thread.

To be fair, I did work ashore for six +/- as a PE when my company came up with an idea to rotate Captains and Chiefs through the office.

117

Volumetric greed has a nice ring to it. Everyone whistled past the graveyard as long as the ship was level and the numbers could be made to come up on the right side of the curve. As mentioned plenty of times here after a while it’s routine and not given a second thought. We all know the companies will keep operating ships this way as long as crews are willing do it.

The only reason the El Yunque is being scrapped is to make the situation disappear. This is just TOTE’s way of putting concealer on a black eye. If the El Faro hadn’t of sank they would’ve still operated both of these old shit boxes as long as they could bang a buck out of them.

118

[QUOTE=Fraqrat;195397]Volumetric greed has a nice ring to it. Everyone whistled past the graveyard as long as the ship was level and the numbers could be made to come up on the right side of the curve. As mentioned plenty of times here after a while it’s routine and not given a second thought. We all know the companies will keep operating ships this way as long as crews are willing do it.

The only reason the El Yunque is being scrapped is to make the situation disappear. This is just TOTE’s way of putting concealer on a black eye. If the El Faro hadn’t of sank they would’ve still operated both of these old shit boxes as long as they could bang a buck out of them.[/QUOTE]

It is a total mystery to me, and I realize I am not the only one, why Davidson persisted in his head on course with Joaquin as he must have been aware of his limited options with this GZ curve and a hardly seaworthy ship with boiler problems. If you want to commit suicide do it alone but donot bring others into the equation.

119

[QUOTE=Tugs;195396]Just out of curiosity, how many of our members here have worked ashore in the office for Maritime or “Shipping” companies. I am including Tug and Barge Companies. This may just have been for a couple of months or could have been a career change.

Once some reply, I will ask the questions that I have. There is a point to me asking this question and also putting for it here rather than starting a new thread.

To be fair, I did work ashore for six +/- as a PE when my company came up with an idea to rotate Captains and Chiefs through the office.[/QUOTE]

I have, most of my experience is ashore. Coast Guard out of high school + 20 years Reserve. Off active duty various unlicensed and Operators License jobs, all small tonnage. Then 46 years with 4 ship owners. Two American one European one Asian in that order.

Boats3

120

A classic case of “standardization of deviation.” It becomes the new “normal” unless and until events occur that are extreme enough to force a change. The resistance to that change is always uniformly fierce. This event, though extreme for those that went through it, is probably not nearly extreme enough and the general public has already long since moved on, if it ever even registered at all. I see no modern-day Capt. Domenic Calicchio (USCG) riding to the rescue this time.

The inertia in this case is surely aligned to brush all of the obvious institutional failures under the rug and ignore the ever-popular fake-safety-culture window dressing that we’re all too familiar with. There’s no easy answer: it was never an equipment problem, or an unavoidable Act-of-God, it was and remains a people problem at all levels, with all the usual suspects: fear, greed, pride, ego, cluelessness, ignorance, apathy, etc. Try as we might, we historically have always had a great deal of trouble getting past them. Other than self-preservation, the incentives to do the right things when it really mattered the most just weren’t there, or else were way too weak.

And like any carcass, the longer it sits putrefying out in the sun, the more it stinks.