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Old 10-21-2015, 10:13 PM   #161
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Originally Posted by psneeld View Post
Seriously?
Regarding that comment, The industry is being inundated with new 'catchphrases' in this 'risk management' topic.

The concept in modern risk management is 'error trapping'. Meaning in the cycle of an error (as the El Faro sinking will be included) in the entire error chain, if you can just eliminate ONE part of the error chain (of events) you would eliminate the entire error.

To put it simply, in the case of fire, removing one aspect of fire (either heat, fuel or air) removes the possibility of a 'fire error'.

Similarly, in the case of El Faro, removing one of the causes (poor steel, failing engine, or.... more predictably changing route) would have eliminated the incident.

In this case, the ship wasn't going to be changed. The engines were already suspect, as they had outside engineers doing (Unknown) repairs, modifications, and then they headed in straight line towards San Juan.

Sounds like just NOT going directly into an oncoming hurricane would have solved a whole lot of issues.

The voyage was in all expected to be about 1000 NM. They had traveled about 550 miles to sinking. They had passed their 'way out' (Providence Channel Bahamas) about 200 miles previous (the previous day.)

Bad error chain, NO error trapping, and poor judgement in age of vessel, known problems, and going TOWARDS instead of along the fringe of a hurricane.

Professional Mariners are trained in this stuff. It ain't magic. It ain't a mystery. What is a mystery is why the error chain wasn't seen, stopped or altered.

A previous mention was made: Would you invite 33 people on a boat with you under these circumstances. This is a red herring.

The true question would have been: Would the Master take a vessel with known issues INTO the path of a hurricane? If so, why? If so, under what directive? Would a prudent mariner put his vessel in this predicament? Us 'outsiders' don't know a lot about the actual conditions of the El Faro. However, having sailed on vessels similar to her, of like age, and knowing how design changes (have you looked at the pictures of her?) alter stability I am more than suspect on many things surrounding this incident. However, the evidence needed to come to conclusions may rest not on ElFaro (or be retrievable), but on her sistership that is still afloat.
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Old 10-21-2015, 10:34 PM   #162
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Cappy--- Very interesting post, thank you. A similar situation to "error trapping" exists in aviation, although I have yet to hear that term used here (which doesn't mean it isn't, just that I haven't heard it).

The big challenge, particularly for the people here involved in training our customers, is recognizing the chain to begin with. The recent crash of the Asiana 777 at SFO is a classic case of a chain of events or an error chain. Breaking the chain at any one of several points during the descent would have avoided the accident. The problem was, nobody recognized there was an error chain.

Well, that's not strictly true. Apparently one of the four people on the flight deck did realize at one point what was happening but was stymied by his culture from bringing it to the attention of the captain.

Breaking an error chain can certainly change an outcome. But only if the chain is recognized by someone in a position to break it or is willing to act on someone else's recognition of the chain. In aviation, at least, therein lies the problem, particularly in cultures where taking action to break a chain when it's recognized, particularly in the case of a subordinate flight crew member, is very, very difficult to do.
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Old 10-22-2015, 07:11 AM   #163
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They only took the ship into the path of a hurricane IF....


1. You knew what everyone else didn't...the path of that hurricane was virtually unpredicted (or not agreed upon) till the turn north and the turn time was very uncertain.


2. You knew that it was going from barely a CAT 1 or tropical storm to a CAT 4 hurricane when everyone else didn't till it happened. One reference is the Weather Channel
"Rapid Intensification

At one point Joaquin saw a pressure drop of 57 millibars in about 39 hours, going from a strong tropical storm to a Category 4 hurricane in the process.


So yes it happened...but based on my readings...much of what happened wasn't out of the question...but the hurricanes actual path and intensification did surprise most forecasters.


Had the ships engines failed at any point other than one 24 hr stretch..maybe less...we wouldn't even have this thread.
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Old 10-22-2015, 07:21 AM   #164
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Quote:
Originally Posted by cappy208 View Post
Regarding that comment, The industry is being inundated with new 'catchphrases' in this 'risk management' topic.

The concept in modern risk management is 'error trapping'. Meaning in the cycle of an error (as the El Faro sinking will be included) in the entire error chain, if you can just eliminate ONE part of the error chain (of events) you would eliminate the entire error.

To put it simply, in the case of fire, removing one aspect of fire (either heat, fuel or air) removes the possibility of a 'fire error'.

Similarly, in the case of El Faro, removing one of the causes (poor steel, failing engine, or.... more predictably changing route) would have eliminated the incident.

In this case, the ship wasn't going to be changed. The engines were already suspect, as they had outside engineers doing (Unknown) repairs, modifications, and then they headed in straight line towards San Juan.

Sounds like just NOT going directly into an oncoming hurricane would have solved a whole lot of issues.

The voyage was in all expected to be about 1000 NM. They had traveled about 550 miles to sinking. They had passed their 'way out' (Providence Channel Bahamas) about 200 miles previous (the previous day.)

Bad error chain, NO error trapping, and poor judgement in age of vessel, known problems, and going TOWARDS instead of along the fringe of a hurricane.

Professional Mariners are trained in this stuff. It ain't magic. It ain't a mystery. What is a mystery is why the error chain wasn't seen, stopped or altered.

A previous mention was made: Would you invite 33 people on a boat with you under these circumstances. This is a red herring.

The true question would have been: Would the Master take a vessel with known issues INTO the path of a hurricane? If so, why? If so, under what directive? Would a prudent mariner put his vessel in this predicament? Us 'outsiders' don't know a lot about the actual conditions of the El Faro. However, having sailed on vessels similar to her, of like age, and knowing how design changes (have you looked at the pictures of her?) alter stability I am more than suspect on many things surrounding this incident. However, the evidence needed to come to conclusions may rest not on ElFaro (or be retrievable), but on her sistership that is still afloat.
+1 Best post so far.
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Old 10-22-2015, 07:49 AM   #165
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Updates from early investigation....

Q. What do we know about the captain’s route?

A. On Sept. 30, the captain emailed a company safety official to say that he planned to take a route south of the hurricane’s predicted path, passing about 65 miles from its center, the safety board said. But by 7 a.m. on Oct. 1, he made a recorded satellite call saying there was a maritime emergency: A hull had been breached, a hatch had blown open, the ship had lost propulsion and there was water in hold No. 3, the investigative update said. An electronic alert system signal sent by the vessel at 7:17 a.m. that day said that the ship’s last reported position was about 20 miles from the edge of the eye of the hurricane.

At that time I am sure he was planning on altering course a bit here or there depending on updates...

Q. What have we learned about the ship’s condition?

A. About two weeks before the shipwreck, the company that owned the ship, Tote Maritime Puerto Rico, received permission from the Coast Guard to shut down one of the ship’s two boilers so it could be inspected by an independent boiler service, the safety board said. The inspectors recommended service to both boilers, which was scheduled for Nov. 6, the safety board’s update said. A spokesman for the board said that as far as investigators know now, the ship left Jacksonville with both boilers working. Investigators did not say whether boiler problems caused the engine failure.

So did the captain know he had a questionable ship or not? Sure problems ...but were they resolved enough to not expect a total failure? Plenty of voyages have been and are made with temporary repair where the expectation is they will hold for the voyage.

Risk management ultimately involves taking some risks...so again...without A LOT MORE INFO THAN WHAT IS AVAILABLE NOW ONLINE THAT I CAN FIND...how can fingers be pointed with any certainty?
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Old 10-22-2015, 08:20 AM   #166
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completing that sentence:
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They only took the ship into the path of a hurricane IF.....
they observed the 'recommended service life' to which the vessel was originally designed. From my experience commercial industry doesn't do 'service life extensions' as good as the military does. Something about $$$$$.
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Old 10-22-2015, 10:49 AM   #167
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And I will venture a guess that he only ones to even have a remote idea about the condition of the vessel just prior to sailing were probably the captain, a handful of engineers, maybe a rep or two in the company and possibly the last set of inspectors.....

certainly no one on TF that I can tell......
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Old 10-22-2015, 11:10 AM   #168
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A democratic process.... Yuck yuck yuck.

It just don't work that way. There's only one chief. The rest are just indians. (so to speak).

Regarding past incidents, Of course there are many. This is the only way the industry changes.
...
My bad but I was THINKING, but not stating, recent losses. I can remember quite a few losses, but not in the last 30 years or so, with the exception of the Edmund Fitzgerald.

My point with the question is that there does not seem to be that many US flagged cargo ship sinkings which, if true, implies the system is working safely.

To put it another way, what is the loss rate of US flagged ships compared to other first world countries? How many sailors die per miles traveled or similar metric on US flagged ships. Is the number increasing, decreasing or the same? Cappy, I don't expect you to have the answers, they are just questions that seem relevant but I don't know the answers either.

Recently, I was reading a story written by Tom Colvin when he was a sailor on a sailing ship. Long story short, he and a friend were aloft in a storm when the ship was knocked down. Colvin saw the wave coming, shouted a warning but his large and very strong Swedish friend could not hold on to the spar and fell to his death. Sometime scat just happens...

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Old 10-22-2015, 12:19 PM   #169
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I think the part that is equally misunderstood is that some of us understand it but still don't like when it's excessive. This isn't a unique industry in terms of pressure being applied nor is it unique in pressure being applied to do things one shouldn't. From Wall Street to Corporate America to Commercial Ships to Little League Coaches to College professors. It is everywhere in life and I know some commercial mariners and former ones and have heard all their stories. I also have talked about those pressures to an acquaintance, who is an owner of a large commercial fleet of 200+ boats.

Everyone in every walk of life has to decide their limits. What they're push others to do, what they'll allow others to do, or what they will do when pushed or ordered by others. I'm not saying any of that is easy. I've known people to walk out on jobs under pressure to do things they felt they shouldn't and have no idea how they were going to explain it to their family or take care of their family. I've competed against it. I've been to manufacturing facilities around the world and been appalled. I've seen my competitors use those we would never consider with unsafe conditions and child labor. I've seen manufacturing in buildings that any reasonable authority would condemn.

As to El Faro, I don't know what was going on in the mind's of the decision makers. What I do know is only a small part of the actions. I believe personally, regardless of what additionally is found and whether or not the tragedy had occurred, that the risk undertaken was too great. That's a personal belief, but don't for one moment think I don't understand the way the industry works and the pressure.

There are other industries, such as off shore oil drilling, with worse risks too and while I'm glad someone works in them, I can't imagine doing so.

I'm just saying that all of you can feel free to disagree with my opinion on this, but don't think for one moment I don't understand the pressures in the industry.
Yes, well stated and I do agree.

I think as Salty Dawg mentioned eons ago, the real the tragedy of El Faro will probably be shown to be the engine failure.
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Old 10-22-2015, 12:24 PM   #170
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Ship and boating accidents involving US flagged vessels can get to be a long, sad and tedious list to work through. One (and only one) that I will mention is the US sub that struck the tour boat in Hawaii when performing a rapid surfacing test. Many were lost. Yes scat happens.

An interesting and sad read are the WWII happenings when part of the US fleet decided to ignore weather warnings and steamed through a typhoon. Big ships were lost.

Spy, psneeld, Sailor of Fortune etc are the real TF seagoing experts to listen to on matters such as this with the rest of us just gum flappers keeping the internet hopping.
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Old 10-22-2015, 12:41 PM   #171
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The most recent American ship casualty was the Marine Electric 1983.

As I alluded, it is only after one of these serious marine casualties is change proffered by the USCG. Prior to the Marine Electric NO regulations existed requiring exposure suits aboard commercial vessels! None!!!!

Now exposure (survival) suits are required. And, truth be told, they should be required for any vessel venturing offshore.

The other three incidents I referred to (Mauvilla, The Barberie and Bay Titan) were in the inland industry, which although is not exactly the same as the ship industry, it has some similar needs and points that coincide between the two. Radar Certification, physical health review and Applicable licensing and experience between differing careers respectively. NONE of these incidents had anything to do with the actual age of the vessels.

The biggest change in the industry as a whole has been OPA 90. This was brought about by the Exxon Valdez. This got us mandatory drug and alcohol testing on ALL commercial vessels, and double hull oil tanks.

The take away from this is: Since last January there are almost NO US flag Barge, or ship transporting oil in bulk that is greater than 25 years old. There were a few exceptions that were built around 1988 to 1990 that 'saw the writing on the wall' and built double hulls, but they number in the single digits. OPA 90 also put a 30 year drop dead restriction on hulls also. (then we can sell them to companies who can use them in less stringent countries like Nigeria and China!) ;-)

So the 'oil industry' cleaned up it's act. The El Faro may provide the impetus to clean up the Ro/Ro dry bulk, container fleet by raising standards.

I do not know of any way to get (to the open public) the data you want to know. I am sure the USCG has info on hand, but I don't know who to ask, or where to go to get it. Companies surely don't want any evidence out in public. They don't want the competition to be able to use any info to sabotage their contracts and prices.
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Old 10-22-2015, 12:53 PM   #172
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Not in the US, but a BC Ferry went down a few years ago not too far from Hartley Bay with luckily only one life lost as I remember. Rescue craft from Hartley Bay were able to evacuate passengers before the ferry sank. Reason, titillating stuff going on at the helm.

Was the Bounty a US flagged vessel?
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Old 10-22-2015, 12:58 PM   #173
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...

I do not know of any way to get (to the open public) the data you want to know. I am sure the USCG has info on hand, but I don't know who to ask, or where to go to get it. Companies surely don't want any evidence out in public. They don't want the competition to be able to use any info to sabotage their contracts and prices.
Yep, I suspect the USCG, insurance companies, and/or trade groups have the data.

Ah, Marine Electric, Wxx3 mentioned the book which I put it in my read list.

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Old 10-22-2015, 01:02 PM   #174
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I believe the Marine Electric incident was also the event that mandated the USCG to upgrade its rescue swimmer program.
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Old 10-22-2015, 01:07 PM   #175
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...
Was the Bounty a US flagged vessel?
She was HMS Bounty so she must have been British!

She did appear to be US flagged in spite of her name and heritage.

I did not realize how close to NC she was when she sank. I thought she was much farther out. The Wikipedia page says the USCG C130 was from RDU which does not seem correct to me. I would have thought they were from Elizabeth City.

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Old 10-22-2015, 01:15 PM   #176
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The Bounty was only named HMS for theatrical purposes. She was American flagged. But built in Canada. Since she was foreign built she could not carry passengers for hire and was classified as a 'Dockside Attraction'.
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Old 10-22-2015, 01:21 PM   #177
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Assuming that anyone here is smarter than those that made this miscalculation based on a lot of info/requirements is insane.

There's a very good chance that the people involved were way smarter and more experienced than the few monday morning quarterbacks here or anywhere.

While I like my track record in safely executing hundreds of dangerous trips/missions...I know I will never have enough info to want to second guess these guys.

If you must..be prepared for others to second guess your monday morning quarterbacking...

Me personally...I have better things to do. Let the souls rest in peace and the NTSB and court systems have their way. When all is said and done and ALL the facts are in. (even if not enough fact are found)...then open the proverbial "big mouth".....
"Assuming everyone here is smarter ...." The implication clearly that we're not very smart ... And then "Me personally .. I have better things to do. Really .... Then what are you doing here posting?
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Old 10-22-2015, 01:36 PM   #178
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The Bolivian flagged cargo ship Minouche was near Haiti when Joaquin came through. It too sank, reportedly due to cargo shifting. All on board were saved.

Does anyone know when and if El Faro called CG for help? Is there a time line between when cargo shifted and mayday sent out?
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Old 10-22-2015, 02:00 PM   #179
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...
Does anyone know when and if El Faro called CG for help? Is there a time line between when cargo shifted and mayday sent out?
The best time line and information I have seen so far is from the NTSB Update which was posted on gCaptain:

Quote:
Before El Faro departed Jacksonville, Tropical Storm Joaquin was predicted to become a hurricane and a marine hurricane warning was issued by the National Hurricane Centerís Advisory #8 at 5:00 pm EDT on Sept. 29.

At about 8:15 pm EDT on Sept. 29, El Faro departed Jacksonville, Fla., for San Juan, Puerto Rico.

At 1:12 pm EDT on Sept. 30, the captain emailed a company safety official that he intended to take a route south of the predicted path of the hurricane and would pass about 65 miles from its center.

In an advisory issued at 2:00 am EDT on Oct. 1, the National Hurricane Center predicted seas of 30 feet with sustained winds of 64 knots (74 mph), increasing to 105 knots (121 mph) as the El Faro approached the wall of the eye of the hurricane.

The Last Communication

In a recorded satellite phone call to the companyís emergency call center at 7:00 am EDT, the captain told the call center operator that he had a marine emergency. He reported that there was a hull breach, a scuttle had blown open, and that there was water in hold number 3. He also said that the ship had lost its main propulsion unit and the engineers could not get it going. The operator then connected the captain with the Designated Person Ashore (DPA). The DPA told investigators that the captain had communicated similar information to him that was provided to the call center operator, and also that the captain had estimated the height of the seas that El Faro was encountering to be 10 to 12 feet.

The USCG received electronic distress alerts from three separate sources on El Faro: the Shipís Security Alert System (SSAS), the Inmarsat-C Alert, and the Emergency Position Indicating Radio Beacon (EPIRB).

According to electronic alert system data sent by the vessel at 7:17 am EDT on Oct. 1, its last reported position was about 20 miles from the edge of the eye of the hurricane.

The USCG did not have direct voice communications with El Faro, only electronic distress alerts
At 0700 the Captain called out an emergency to his office but the distress alerts went off 17 minutes later at 0717 but there was no voice communications to the USCG. No mention of cargo shifting which was reported but 0700ish is a good guess.

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Old 10-22-2015, 03:31 PM   #180
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The updates are also available directly on the NTSB site.

DCA16MM001

The report referenced above can be found on the upper right part of the page labeled "October 20, 2015". Any additional reports will be published here although I'd bet gcaptain will immediately pick them up too.
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