Final report on El Faro

[Shrew]

^^^ I'm glad someone else sees that. I thought that was getting lost in translation.

Your point is not lost on me. I agree with you completely. I don't care about the opinion of one crew-persons relative either. Further, this argument of allocation of funds is ridiculous. Funds have been allocated and they will get spent. They're not taking food from starving children's mouths here. Asserting this as the basis of an argument only shows lack of understanding of economics.

What we're dealing with is a series of unfortunate events. The boat would have, should have made it through the storm. loose cargo, loose hatches eventually leading to the plant shutting down is what lead to the sinking. It's pretty clear the captain was under tremendous pressure from desk jockies.

The captain more than likely would not have steamed into the storm if truly given the choice, however he did so under pressure without anticipating a series of cascading failures.

To me this is a corporate culture issue. Had Tote given the capt. more discretion, we would not be having this lively discussion.

The argument that the captain reckless steamed into a hurricane with complete disregard is simply ridiculous.

 

[Benthic2]

True....but we have to ask ourselves...how many of those "un-anticipated events" might not have happened if the Captain was more dilligent in his duties.

Consider the following:

There were many human factors involved including issues regarding maintenance, mechanical status, cargo tie down and information reporting. This Master was known as a "stateroom captain" and one of his supervisors said "I'm not even sure he knows what the deck looks like". He was supposed to be written up for finding a watch officer sleeping on mulitiple occiasions and not doing anything about it. He noted in June that the anemometer was not working, but never submitted a work order to fix it. ( important to note that they didn't realize how close they were to the storm because they could not determine the wind direction !) He was supposed to be written up another time for not ensuring other repairs were done in a timely manner.

So if the Master doesn't do his rounds, discipline his crew or take care of the ship.....the officers and crew are likely to do the same.

He was called at 11:05, 11:38 and ( I forget the exact time...but I think around 2:00) with suggestions from the bridge that he should look at the latest weather data. During one of these calls he was told that at 4:00am they would be 22 miles from the center of the hurricane.

While he was "sleeping like a baby" ( his words ) the bridge crew were talking about whether their survival suits fit, the noises they heard were probably things breaking loose in the superstructure, and the ship speed had gone down 20%

He did not come to the bridge until 4:09, and only stayed for 25 minutes and he went to the galley. He had to be called back to the bridge

At 4:45 the barometer indicated 960 mb, and the center of the storm was 950.

The inquiry board determined that at 5:43 he failed to recognize the gravity of the situation. That was almost 2 hours before they abandoned ship

At 6:12 they lost propulsion...if they abandoned ship then they would have had a greater chance to get into suits, get into rafts and get their location out.

( this one seems HUGE to me ) The Captain never notified anyone they were abandoning ship, or provided an updated location. The Coast Guard didn't know there were bodies in the water, and when they did....they didn't know where to look.

The ship left port with less than the required amount of oil, and the engine died because the oil pump couldn't get enough oil when the ship was listing. I don't expect the Master to check the oil, but perhaps his lackadaisical attitude existed in the engine room. They took on water because a scuttle was open for a significant period, after the crew was known to have been inconsistant with securing those scuttles. Perhaps a pre-departure meeting stating that this would be a rough one would have gotten some attention to the cargo tie downs, and oil levels, and the scuttles. I know..that is total speculation on my part, but it doesn't seem unreasonable.

Perhaps the Master gets his attitude from Tote. They had internal memos saying he needs to be written up, but he never was. They know he does not make rounds and check cargo spaces but they don't mention it, and end up promoting him.

As a previous poster said...no, the Capt didn't just recklessly sail straight into a hurricane. He did however, take a ship in less than great condition, into an area very near a tropical storm, did not listen to his officers who tried to alert him to the conditions, and slept as things spiralled down hill. When he finally did show up for work, he failed to realize the danger they were in, and waited until just minutes before the ship went under to give the order to abandon ship, and then never told anyone where they were, or that they were doing so.

Disclaimer: I have never been a professional mariner, so I admit that I do not know what conditions are like for those that are, or the pressure they are under when they work. I also have never played in the NBA, but I know when LeBron James has a bad game. It happens. He's human. A Captain is human too, and he or she is going to make mistakes. But in an environment where mistakes are measured in lives lost, there is a very narrow margin of acceptable performance. Our society holds people like airline pilots, surgeons, and ship captains to a very high standard, and justifiably so. Fair or not, that's just the way it is. If you don't like that, don't take that job. This captain failed to do all he could for his crew and his ship. And he failed in that responsibility on more than one occaision. That doesn't mean that all others involved are blameless by any means, or even that his wrongs were the most severe, but he absolutely deserves to be blamed for this. I suspect many civil suits will follow and support that judgement.

 

[BandB]

I suspect many civil suits will follow and support that judgement.

Most of the victim's families settled early as they needed the money plus TOTE threatened with an old obsolete law which limits the potential amounts.

When something like this happens, everyone is at fault in my opinion. Then it becomes the degree and in civil courts it is often percentages adding up to 100%. However, in my mind and in criminal courts you can have multiple people held completely responsible. Also, fault is not just actions taken but it's omissions as well. I don't think proclaiming that the company or the captain or anyone else is at fault makes others any less so.

Now the next time, I'll toss in the CG and anyone else who fails to take steps after this event as recommended plus some in order to make things safer.

 

[Seevee]

True....but we have to ask ourselves...how many of those "un-anticipated events" might not have happened if the Captain was more dilligent in his duties.

Consider the following:

......................
.

Benthic,

Good summary of events. It sure points to a very incompetent Captain that not only made one mistake, but several.

Had the chain been broken earlier on, we may have never had this post. That ship "may" have sailed through (or close to) the storm without issue if it were in good shape and the crew was prepared for it. (don't know for a fact, but certainly better of with a running engine).

The company was negligent for not keeping the boat in a safe operating condition and the captain for not verifying it.

If the company gets proven criminally negligent, the company should not be fined, it should be the individual responsible and probably starting at the top.

 

[Seevee]

Oh, but the professionals most certainly did know in this case. It's a simple fact that the recorder was as rudimentary as it gets. I've been involved with many aircraft accident investigations. Everything of consequence (what's in the report) was established before the ship went down. The black boxes witnessed nothing not already known, and any investigator who looked at what could possibly be found on that recorder knew it. This was a politically motivated waste instigated by uniformed hysteria to appease a vocal minority. The experts decision not to retrieve the box was reversed by politics. Criminal.

Rufus,

First, I'll agree with you that some political pressure and a congressman should not be the reason the black box is raised.

However, investigative team was incorrect in the decision in not raising the black box, so someone had to tell them to do their job.

And as an aircraft accident investigator you, of all people, should absolutely know this. Did you work for an airline, or the NTSB in your investigations? My experience was with an airline, but did not do on site investigation, and was more of accident analysis than investigation.

 

[Rufus]

Initially FAA engineering test pilot rep with on-scene investigation teams. Activity ranged from the crash site to manufacturer and operator company records and interviews. The overall process is the same...marine or aviation. Over the decades I moved though the management structure to a Senior Executive position on the aircraft engineering certification side. There I deal with the politics. I'm a Naval academy grad with both naval engineering and aero background. Served on large, old ships in early years. Quite familiar with steam power plants and ship systems. I was an engineering test pilot (Navy Test Pilot School @ Patuxent River) both for the military and for the FAA. A career in evaluating and testing new and modified machines and their systems. As a manager (and as a test pilot) I routinely dealt with some of the biggest companies in the world.

The accident investigative team had the whole enchilada in front of them...including the view of some families (more than one) to leave it alone. They knew the black box was archaic with little pertinent information. Turned out they were correct. They made their best judgement regarding cost vs benefits and I trust it was the correct one. Second guessers don't have the whole package in front of them. The decision to raise the box was politically motivated. Doesn't make it right.

I've seen the investigation process from top to bottom. I made decisions regarding safety cost/benefits analysis every day..not just for accidents. Decisions that kept your airplanes from being so heavily laden with safety devices that they can't get airborne. Safety has a cost and not everything you'd like to do gets done, even in an accident investigation. Somebody has to be the gate keeper. Why not raise the ship...there might be a missed clue. We routinely told the NTSB to take a hike because their recommendations were economically prohibitive. As a tax payer you should thank your lucky stars that safety zealots aren't allowed to run amuck or routinely be forced to run amuck. In this case politicians, the press, and unions ran it amuck. Telling me that "you of all people should know...blah, blah blah " is a bit much. You don't know what you don't know. It's not an open checkbook, nor should it be.

 

[Benthic2]

Without the black box we would not have known the following facts:

The converstations regarding cargo floating in the holds that prevented the crew from identifying where the water was leaking into hold 3.

The reason for the engine failure

The fact that the Captain was asleep in his cabin and did not come to the bridge until 4:09

The fact that the officer on the bridge called the Captain 3 times to discuss the weather and suggesting a course change, despite knowing they would be 22 miles from the center of the storm.

The fact that the crew had a history of not securing the scuttles.

The fact that the reduction in speed was not intentional and was due to taking on water.

and the fact that with 4 minutes left before the ship submerged, the captain was asking where the life jackets were. More than 60 minutes had passed since they drafted their distress call....and no one had gotten PFD's or survival suits ?!?!

I'm sure there are more facts that were learned from the black box, but that's all I can recall at the moment, but that should be sufficient to prove that the retreival of that information was vital in knowing what went wrong and when.

 

[Seevee]

Initially FAA engineering test pilot rep with on-scene investigation teams. Activity ranged from the crash site to manufacturer and operator company records and interviews. The overall process is the same...marine or aviation. Over the decades I moved though the management structure to a Senior Executive position on the aircraft engineering certification side. There I deal with the politics. I'm a Naval academy grad with both naval engineering and aero background. Served on large, old ships in early years. Quite familiar with steam power plants and ship systems. I was an engineering test pilot (Navy Test Pilot School @ Patuxent River) both for the military and for the FAA. A career in evaluating and testing new and modified machines and their systems. As a manager (and as a test pilot) I routinely dealt with some of the biggest companies in the world.

The accident investigative team had the whole enchilada in front of them...including the view of some families (more than one) to leave it alone. They knew the black box was archaic with little pertinent information. Turned out they were correct. They made their best judgement regarding cost vs benefits and I trust it was the correct one. Second guessers don't have the whole package in front of them. The decision to raise the box was politically motivated. Doesn't make it right.

I've seen the investigation process from top to bottom. I made decisions regarding safety cost/benefits analysis every day..not just for accidents. Decisions that kept your airplanes from being so heavily laden with safety devices that they can't get airborne. Safety has a cost and not everything you'd like to do gets done, even in an accident investigation. Somebody has to be the gate keeper. Why not raise the ship...there might be a missed clue. We routinely told the NTSB to take a hike because their recommendations were economically prohibitive. As a tax payer you should thank your lucky stars that safety zealots aren't allowed to run amuck or routinely be forced to run amuck. In this case politicians, the press, and unions ran it amuck. Telling me that "you of all people should know...blah, blah blah " is a bit much. You don't know what you don't know. It's not an open checkbook, nor should it be.

Rufus,

Benthic2 said it better that I could. We can agree to disagree.

 

[Blissboat]

I thank my lucky stars that innovations in transportation safety are not left to the purview of bean counters. If that were so, the world would be a much more dangerous place.

 

[diver dave]

The argument that the captain reckless steamed into a hurricane with complete disregard is simply ridiculous.

hmmm, but that's what happened. The captain is the tail end of management. He is part of management. His boss is pressured, and his boss is pressured, etc. All the way up to the investor analysis phone call quarterly. The captain is highly complicit in this "deliver the cargo, no matter what" attitude. To change this corruption, he and other captains need to do what it takes to stay alive. Quit, unionize, find another job, fix the boats, get public backing, but stay alive (and not kill others) through smart actions.
At the end of the day, the captain might as well have had no weather data, if he was willing to drive into this monster.
Others on this thread will have issue with this. I say, if your job security is that marginal, where you have to put yourself and others at high risk to keep it, change needs to be made. It starts with you.

 

[Rufus]

Without the black box we would not have known the following facts:

The converstations regarding cargo floating in the holds that prevented the crew from identifying where the water was leaking into hold 3.

The reason for the engine failure

The fact that the Captain was asleep in his cabin and did not come to the bridge until 4:09

The fact that the officer on the bridge called the Captain 3 times to discuss the weather and suggesting a course change, despite knowing they would be 22 miles from the center of the storm.

The fact that the crew had a history of not securing the scuttles.

The fact that the reduction in speed was not intentional and was due to taking on water.

and the fact that with 4 minutes left before the ship submerged, the captain was asking where the life jackets were. More than 60 minutes had passed since they drafted their distress call....and no one had gotten PFD's or survival suits ?!?!

I'm sure there are more facts that were learned from the black box, but that's all I can recall at the moment, but that should be sufficient to prove that the retreival of that information was vital in knowing what went wrong and when.

Nothing here that changed the conclusions and recommendations. Section 8 begins by stating that the sources of water incursion were impossible to establish, so they made various assumptions for simulations. The recommendations came out of those simulations, not the tapes. The ship wasn't designed for the conditions and the report notably doesn't go off on a tangent suggesting that it should have been, or that new ships should be. The recommendations for warning systems regarding status of selected items was obvious when they looked a the simulations. The audio adds emphasis to the conclusion that the Captain made some fateful mistakes, but that was well established without the audio. Sadly, it also illustrated that the crew was not all that familiar with the ship's systems...a point that didn't really matter in the end, and didn't have to be pushed in front of the families. The team knew it. There are no doubt facts that could be added by raising the ship and it would be a technical feat. Can't be justified by cost versus benefits.

 

[Rufus]

I thank my lucky stars that innovations in transportation safety are not left to the purview of bean counters. If that were so, the world would be a much more dangerous place.

Virtually all safety innovation or improvement is subject to a cost versus benefits analysis. It's the law. Safety is not free...not by a long shot. The analysis is primarily conducted by the engineering community, not bean counters. Large changes that are not in the category of emergency directives typically take place in the form of more stringent minimum required design standards. The recommendations in the El Faro report will be the subject to scrutiny within the world wide shipping community....builders, operators, unions and regulators. They could be adopted wholesale, but more often than not a middle ground will become the law. The NTSB makes recommendations with no regard to cost to the end user. Easy to do, but if in the case of the aviation industry, a recommendation would ground an entire fleet or ultimately drive seat costs through the roof, the FAA (Coast Guard)/industry/user groups would likely look for a way to meet the intent in a less burdensome way. Or they could elect to not implement the recommendation and send a letter to the NTSB stating why. Happens all the time. So again, the law requires that cost be a consideration when imposing more stringent design requirements. Operating restrictions are often used as a workaround. Emergency directives (Airworthiness Directives for aircraft) are handled differently.

 

[Benthic2]

They DO know where at least some of the water was coming from:

From page 30 of the report:

At 5:52 AM, the Master received a call on the house phone informing him that the source of
the flooding was an open scuttle.

 

[Rufus]

They DO know where at least some of the water was coming from:

From page 30 of the report:

At 5:52 AM, the Master received a call on the house phone informing him that the source of
the flooding was an open scuttle.

Included as a possibility in the simulations.

 

[Seevee]

Virtually all safety innovation or improvement is subject to a cost versus benefits analysis. It's the law. Safety is not free...not by a long shot. The analysis is primarily conducted by the engineering community, not bean counters. Large changes that are not in the category of emergency directives typically take place in the form of more stringent minimum required design standards. The recommendations in the El Faro report will be the subject to scrutiny within the world wide shipping community....builders, operators, unions and regulators. They could be adopted wholesale, but more often than not a middle ground will become the law. The NTSB makes recommendations with no regard to cost to the end user. Easy to do, but if in the case of the aviation industry, a recommendation would ground an entire fleet or ultimately drive seat costs through the roof, the FAA (Coast Guard)/industry/user groups would likely look for a way to meet the intent in a less burdensome way. Or they could elect to not implement the recommendation and send a letter to the NTSB stating why. Happens all the time. So again, the law requires that cost be a consideration when imposing more stringent design requirements. Operating restrictions are often used as a workaround. Emergency directives (Airworthiness Directives for aircraft) are handled differently.

Rufus,

Good post. True safety is not free, but most good operators realize that the alternative can be brutally more expensive. One major hull loss could easily put a small company out of business. It's prudent and cost effective to be safe. And safety includes from properly trained people to good operating procedures and equipment with a known safe condition.

But we do have a few operators that want to occasionally cut corners, and often get away with it. Seems like this was the case.

Question for you Captains that have operated an 800 ft boat like this: What weather will the boat handle, and what weather is an absolute no go?

And how often are these boats and their operations inspected for compliance with some standards?

 

[BandB]

Safety isn't free and it seldom comes without being forced by regulations and laws. Businesses feel they can't be competitive if they spend money on safety and their competition isn't forced to.

 

[BandB]

Final report to be released soon but executive summary available plus video of final meeting and animation of the route and events.

The board voted to adopt the probable cause, which cited the captain’s decisions and the shipping company’s inadequate oversight among numerous contributing factors, and concluded the NTSB’s 26-month investigation into the accident. The board also voted to adopt 81 findings, 53 recommendations, along with the NTSB’s entire report. ​

Here is the executive summary.

https://www.ntsb.gov/news/events/Documents/2017-DCA16MM001-BMG-Abstract.pdf

The video animation

NTSB Video Details Sinking of US Cargo Vessel SS El Faro – gCaptain

 

[Blissboat]

El Faro sailed regularly from my home port of Jacksonville, Florida, and so the investigation has received close scrutiny in the local media, as well as in discussions along the waterfront. It's painful to conclude that this ship's master not only made a series of poor decisions, but that he behaved recklessly. His actions (or inactions) veered back and forth across the boundary between complacency and sheer boneheadedness. Sadly, the major portion of blame falls to him.

That said, this vessel was unfit for the service to which it was assigned. One huge shortcoming was the open lifeboats, which would have unusable in the conditions during which the crew had to use them. Other defects appear in the NTSB and CG reports, and as a result the ship's corporate operators are also receiving a portion of blame.

On the other hand, the skipper had options as to routing this voyage. He chose to steam ahead into what any rational person would have regarded as risky conditions, when a more prudent mariner, taking the ship's condition into account, might well have selected a more southerly route to San Juan.

In light of the El Faro tragedy, every maritime professional must confront this basic question: if a vessel is unfit or marginally fit for service, whose is the ultimate responsibility for holding it alongside the pier? Is it the owner's responsibility? The answer seems indisputable. Smart practices like "bridge resource management" notwithstanding, this incident is a reminder to every captain, and to everyone who aspires to be one, of the awesome responsibilities of command at sea.

 

[BandB]

Don't overlook the other part, Bliss. While the captain is absolutely at fault, TOTE is at fault in many ways. While no direct pressure was exercised, the report does reference the indirect pressure that would be felt. It also addresses many safety, training, and management issues and their lack of any monitoring of the ship and route.

You are right that every maritime professional must continually address the situation and their risk and the risk to others. Also, whatever our profession and even with friendships and relationships, we all must set our limits and boundaries. There have to be lines we don't cross, firm limits.

The CG is held accountable on many issues in this as well. Hopefully some new regulations come out that increase the protection to all.

 

[Benthic2]

Thanks for posting that. The report seems to contradict itself in a few places.

It says that improper securing of cargo wasn't a factor....but that the floating cargo damaged the pipe that filled hold #3 and impacted ship stability

It also says the Capt was at fault for delaying the mustering of the crew....but then goes on to say the life boat and life rafts wouldn't have helped ??

The Capt should have listened to the deck officers who suggested course changes.....AND the deck officers should have been more forceful with their recomendations.

Hopefully some good will come of this

 

[SaltyDawg86]

Here we go, telling the professionals what we need to do when you don't actually know what we do.....

 

[Benthic2]

We may not know the details and procedures of what a professional mariner does, but we know what they are supposed to do: Get their crew and their ship from point A to point B without anyone dying or the ship sinking.

It doesn't take a professional mariner to see that didn't happen here.

 

[SaltyDawg86]

 

[Benthic2]

( post deleted )

 

[Fletcher500]

I am half way through this book, and it is excellent. The voice data recorder (VDR) was retrieved from the wreck so the actual conversations from the Bridge and ER are incorporated. The book also does a very good job covering many other aspects related to boats, ships, weather, and the history of maritime commerce. A very sad story.

 

[Civilitas]

Coincidentally, I'm also 1/2 way through this book as of today. And I have to say, it's very much worth the read. As Fletcher500 said, Excellent.

He described some of the solid aspects of the book. I would also add it is much more "meaty" in detail, history, and concept than the average tale of this type. She avoids trying to make heroes or tear-jerk personal back stories of the lost mariners, and really focuses on the issues, events, and context.

I am not familiar with her writing, but I am going to pay attention for her name in the future.